SAQ 90 – Cardiology – inferior STEMI with pacemaker malfunction
Model Answer
Question 5. inferior STEMI with pacemaker malfunction.
a. ECG abnormalities
- Atrial flutter, visible in V1 and/or inferior rhythm strips.
- Failure to sense with inappropriate pacing spike after a native QRS.
- Inferior ST elevation, particularly aVF.
- ST depression in aVL, V2, and/or lead I.
- Biphasic T waves in I and aVL.
- Possible failure to capture in limb leads.
b. Significance
- Symptoms plus ST elevation/depression pattern should be treated as inferior STEMI.
- The permanent pacemaker may be malfunctioning, likely related to underlying ischaemia.
- Expect further rhythm disturbance because of pacemaker malfunction, inferior STEMI, and the patient's baseline pacing requirement.
c. Immediate treatment
- Activate STEMI pathway and obtain urgent cardiology involvement.
- Give aspirin 300 mg unless contraindicated.
- Give a P2Y12 inhibitor such as ticagrelor or clopidogrel according to local protocol.
- Give heparin bolus according to local protocol.
- Use cautious opioid analgesia and consider RV involvement.
- Give IV fluid bolus if hypotensive and RV infarction suspected.
- Facilitate urgent PCI; thrombolysis if PCI cannot be delivered in time and no contraindications.
- Prepare for transcutaneous pacing and consider obtaining a pacemaker magnet.
- Repeat ECG while arranging definitive reperfusion.
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