Owing to the decrease in STEMI presentations during this time, there is anecdotal evidence of late presentations, many of which have complications from the pre-lytic era. For patients with chest pain, shortness of breath, or weakness, please be especially vigilant for

1. delayed myocardial infarctions

2. new heart failure

3. new mechanical defects such as left ventricular thrombus, (along with limb ischemia / stroke) ruptured papillary muscles / acute valve failure, ventricular aneurysms and ventricular / septal ruptures, pericarditis and pericardial effusion

4. cardiogenic shock

It is important to realize that such complications typically preclude the use of cardiac catheterization.

Please be careful, have an index of suspension for conditions you have only read about, and consider routine bedside ultrasound and early referral for any suspicious cases. Also keep encouraging patients to attend the ED for worrisome symptoms.