title: Delayed thrombolysis in a patient presenting after 12 hours of chest pain, cardiogenic shock and life-threatening arrhythmias.
abstract: This 63 years old man presented to the emergency room with chest pain of more than 12 hours duration. The initial electrocardiogram showed as ST segment elevation inferior and right ventricular infarction. He developed signs and symptoms consistent with cardiogenic shock, followed by life threatening ventricular fibrillation and cardiac arrest. After repeated cardio-respiratory resuscitations and successful cardiac defibrillation, thrombolytic therapy was administered followed by clinical and hemodynamic improvements. One-week later cardiac catheterization and coronary arteriography were performed. The study showed 93% obstructive lesion in the proximal right coronary artery, an angioplasty was performed and a stent was placed. After appropriate re-adjustment of medical therapy, the patient was discharged and followed in the outpatient clinic. Although the time frame to administer thrombolytic therapy was over the 12 hours window as suggested by the AHA guidelines1, the potential risks benefits in the casepresented justifed the used of fibrinolytic therapy. Considering the multiple complications that the patient presented, fibrinolytic therapy needs to be considered even after 12 hours of symptoms initiation, particularly when facilities for primary percutaneous coronary interventions are not readily available.
authors.affiliation: Department of Emergency Medicine, UPR School of Medicine, Puerto Rico Health Science Center, San Juan, PR. jfalconc@gmail.com
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Falcon-Chevere
authors.forename: Joanna J
authors.initials: JJ
authors.lastname: Mercado-Alvarado
authors.forename: Yadira
authors.initials: Y
authors.lastname: Ramos-Arias
authors.forename: José G
authors.initials: JG
authors.lastname: Cabañas-Rivera
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D015906:Angioplasty, Balloon, Coronary; D002637:Chest Pain / Q000209:etiology*; D000075202:Contraindications; D023921:Coronary Stenosis / Q000150:complications / Q000628:therapy; D004298:Dopamine / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004562:Electrocardiography; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D005440:Fluid Therapy; D006327:Heart Block / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000188:drug therapy / Q000628:therapy; D015425:Myocardial Reperfusion / Q000379:methods; D005996:Nitroglycerin / Q000627:therapeutic use; D012770:Shock, Cardiogenic / Q000188:drug therapy / Q000209:etiology* / Q000628:therapy; D015607:Stents; D015912:Thrombolytic Therapy; D013997:Time Factors; D014693:Ventricular Fibrillation / Q000188:drug therapy / Q000209:etiology*
chemical_list: D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents; D005996:Nitroglycerin; D004298:Dopamine