You better watch out! Acute management of transient shock secondary to the Bezold-Jarisch reflex following reperfusion of an inferior wall stemi.

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Journal of the American College of Cardiology


Background: An often forgotten complication of acute myocardial infarction is the Bezold-Jarisch Reflex. It is imperative that operators react swiftly in order to stabilize a patient when such activity takes place. Inhibitory cardiac receptors are present in the inferoposterior wall of the left ventricle which often receives its blood supply from the right coronary artery. Stimulation of these receptors physically or chemically can result in an increase in parasympathetic activity and an inhibition of sympathetic activity. This results in profound hypotension and bradycardia. Case: A 52 year old man with no medical history but an everyday smoker, presented to the hospital complaining of severe substernal chest pressure. His vital signs were unremarkable, but electrocardiography noted ST segment elevation in leads II, III and aVF. The patient was emergently taken to the cardiac catheterization laboratory. Coronary angiography noted an acute total occlusion of the mid-segment of the right coronary artery. Following positioning of a balloon over a guidewire across the occlusion, balloon angioplasty was performed. This led to reperfusion of the artery, but immediately upon deflation of the balloon the patient suffered vasomotor collapse. Decision-making: Hemodynamic compromise immediately after reperfusion of the right coronary artery should lead one to consider the triggering of the Bezold-Jarisch Reflex as a potential etiology. Immediate administration of intravenous atropine, intravenous fluid boluses, transvenous pacing and vasopressor support should be undertaken. This then allows for the insertion of temporary percutaneous mechanical circulatory support which can slowly be weaned as the patient again becomes hemodynamically stable. Conclusion: The Bezold-Jarisch Reflex is a potentially life-threatening, but transient, complication of reperfusion in the setting of an inferior wall ST segment myocardial infarction. Prompt recognition of this disorder can be life-saving when operators in the cardiac catheterization laboratory quickly take steps to stabilize patients during this transient phase of autonomic dysfunction.




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