Hemodynamically complicated ST-segment elevation myocardial infarction: presentation and treatment

Abstract

When ST-segment elevation myocardial infarction is complicated by hemodynamic instability, clinical evaluation alone cannot be relied upon for accurate assessment. Invasive hemodynamic monitoring with a pulmonary artery catheter and intra-arterial catheter should, therefore, be performed to gauge impaired hemodynamics in such patients and make necessary changes in therapy. There are several hemodynamic disturbances that can occur after ST-segment elevation myocardial infarction including pulmonary congestion, cardiogenic shock and mechanical complications such as left-ventricular free-wall rupture, ventricular-septal defect or papillary muscle rupture. Patients with hemodynamic compromise should be admitted to the coronary care unit and therapy should be initiated with drugs such as vasodilators, diuretics and positive-inotropic agents, based on hemodynamic data provided by the invasive catheter. Intra-aortic balloon counterpulsation should be used for those who fail to achieve hemodynamic stability with medical therapy. Coronary angiography should be considered for all patients who are hemodynamically unstable provided they are candidates for aggressive care, followed by coronary revascularization in those with suitable anatomy. Operative repair should be performed promptly when a surgically correctable mechanical lesion is identified.