We know prompt reperfusion of infarct related artery( IRA) by any means constitute the specific management of STEMI .However, It needs to be emphasized , treatment process of STEMI is not over after primary PCI or thrombolysis .Early hours after a PCI or thrombolysis is vital as well .The ill-fated coronary arteries are as vulnerable as before. In the setting of multi-vessel CAD (Which usually is the case) the unpredictability is still more.
When a patient complaints of chest pain 24 hours after a STEMI . Think about any of the possibilities and act accordingly.
- Infarct related pain ( Dull aching pain from residual neural signals from infarct zone, till type C un-medullated nerve endings die of hypoxia )
- Post infarct angina –From IRA zone (Residual ischemia)
- Post infarct angina-From Non IRA zone(New Remote ischemia)
- Infarct expansion/ Extension /mechanical stretch
- Intra coronary dissection adjoining a plaque (Plaque fissures are same as dissections if they extend into media ! But plaque fissures are painless since they lack nerve endings )
- Myocardial tear /Rupture (Generates severe pain , usually transmit to back , patient often become violent and poorly respond even to narcotics)
- Post resuscitation/DC shock / chest wall contusion . ( I know at least one patient who was rushed to cath lab for a suspected acute stent thrombosis , it was indeed a rib fracture during an earlier resuscitation at ER on his arrival !)
- Finally ,when the pain is refractory and atypical non cardiac chest pain which might have been pre existing to be considered as remote possibility .