In a patient post‑primary anterior‑wall STEMI treated with PCI (drug‑eluting stents) to the left anterior descending artery and a major obtuse‑marginal branch who now has sweating and a single episode of palpitations, what is the urgent evaluation and management?

Urgent Evaluation and Management of Post-PCI STEMI Patient with Sweating and Palpitations

This patient requires immediate 12-lead ECG within 10 minutes, continuous cardiac monitoring, and urgent assessment for acute stent thrombosis, recurrent ischemia, or life-threatening arrhythmia. 1

Immediate Assessment (Within 10 Minutes)

• Obtain 12-lead ECG immediately to evaluate for new ST-segment elevation, ST-segment depression, or T-wave changes indicating acute stent thrombosis or ischemia in a different territory 1, 2
• Place patient on continuous cardiac monitoring with defibrillator capacity, as 80% of life-threatening arrhythmias occur within the first 12 hours post-MI and 90-92% of ventricular arrhythmias occur within 48 hours of PCI 1
• Assess hemodynamic stability: measure blood pressure, heart rate, and evaluate for signs of cardiogenic shock (systolic BP <90 mmHg, cool extremities, altered mental status) 1
• Obtain high-sensitivity troponin immediately to detect rise or fall pattern compatible with recurrent MI 1

Critical Differential Diagnosis

The combination of sweating (diaphoresis) and palpitations in a post-PCI STEMI patient represents a high-risk presentation that demands urgent evaluation for:

• Acute stent thrombosis: Although rare with drug-eluting stents (0.65% early/late risk), this is a life-threatening emergency requiring immediate return to catheterization laboratory 3
• Recurrent MI in a different territory: The LAD and OM1 were treated, but other vessels may have progressed; recurrence within hours of initial STEMI, though extremely rare, carries up to 50% 5-year mortality 4
• Ventricular arrhythmia: Palpitations may represent non-sustained ventricular tachycardia or other malignant arrhythmias 1
• Autonomic dysfunction: Diaphoresis with palpitations may indicate ongoing ischemia or sympathetic activation 5

Urgent Interventions Based on ECG Findings

If New ST-Segment Elevation Present:

• Activate catheterization laboratory immediately for emergent coronary angiography to evaluate for stent thrombosis or occlusion of non-intervened vessel 6, 1
• Administer aspirin 162-325 mg (if not already on maintenance dose) and ensure P2Y12 inhibitor compliance 2
• Continue anticoagulation with unfractionated heparin or bivalirudin during transport to catheterization laboratory 6, 2

If ECG Shows Ongoing Ischemia Without ST-Elevation:

• Perform urgent coronary angiography within 2 hours as hemodynamic instability, ongoing chest pain, or life-threatening arrhythmias mandate immediate invasive strategy 1
• Verify dual antiplatelet therapy compliance: confirm patient has taken prescribed P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) 6, 2

If ECG Normal or Non-Specific Changes:

• Continue continuous monitoring for minimum 12-24 hours as patient remains at risk for delayed arrhythmias 1
• Serial troponins every 3-6 hours to detect delayed rise indicating peri-procedural MI or late stent thrombosis 1
• Assess for medication-related causes: beta-blockers can cause bradycardia with compensatory palpitations; verify no second-degree type II or third-degree heart block present 1

Medication Verification and Adjustment

• Confirm dual antiplatelet therapy: Patient must be on aspirin 81-325 mg daily plus P2Y12 inhibitor (ticagrelor 90 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily) 6, 7
• Avoid IV beta-blockers if patient has bradycardia, heart failure signs, or increased shock risk, as this may be harmful 1
• Restart or continue oral beta-blockers only if hemodynamically stable and no high-grade AV block present 1

Risk Stratification

• Calculate GRACE score: If >140, this mandates early invasive strategy within 24 hours even if initial presentation appears stable 1
• Assess for high-risk features: anterior wall location (LAD territory), reduced left ventricular function, or multi-vessel disease all increase risk of complications 6

Critical Pitfalls to Avoid

• Never discharge without 12-24 hours of continuous monitoring after any intervention, as the majority of serious arrhythmias occur within this window 1
• Do not attribute symptoms to anxiety without objective evidence excluding ischemia or arrhythmia; sweating and palpitations are classic ischemic equivalents 5
• Do not delay angiography if any evidence of hemodynamic instability, ongoing ischemia, or life-threatening arrhythmia is present 1
• Verify stent type and dual antiplatelet therapy duration: Drug-eluting stents require minimum 12 months of dual antiplatelet therapy; premature discontinuation dramatically increases stent thrombosis risk 6

Disposition

• Admit to coronary care unit with continuous telemetry monitoring for minimum 24 hours 1
• Maintain NPO status until stent thrombosis and need for urgent catheterization are definitively excluded 6
• Ensure uninterrupted monitoring until patient has been event-free (no chest pain, no arrhythmias, no hemodynamic instability) for 12-24 hours 1