Dr.S.Venkatesan MD

Up to 24 hours

• Failed thrombolysis and persistent infarct related chest pain
• Prolonged  Infarct pain  in spite of successful thrombolysis (Rare)
• Dual STEMI and Dual ACS ( Combination of STEMI/NSTEMI)  *

* Generally  until   after  24 hours one should not make a second coronary syndrome  though  logically  it is possible ( Dual acute coronary syndrome)

After 24 hours -up to 2 weeks

• Post MI angina  – IRA related (Re-occlusion, Threatened reocclusion)
• Post MI angina -Non IRA related ( Critical  non -IRA lesion)
• Thrombus migration /Side branch occlusion
• Re infarction -Same territory
• Re-infarction-Remote territory
• Infarct extension, Infarct expansion , Dyskinetic segments  ( Acute ventricular  remodeling  has a potential to generate pain )
• Combinations of the above

Caution

24 hour is  arbitrary cut off .There can be spill overs and over laps

*Refractory non ischemic  chest pain often atypical not relieved by anti anginal  medication   – Pericardits, Coronary dissections , myocardial /Pap muscle  tears .

After thought

Do we need to break our brain  to  find  the source of angina  following STEMI ?

Principles of scientific medicine  would demand it  . However   in this era of  hyper active interventional  cardiologists  there is little purpose  as they  tend to  open up all occluded arteries   guided by the  their  ignorance about the source of chest pain.

Reference

Video on Dual  coronary syndrome