Background: Wellens' syndrome is a potentially life-threatening condition, characterized by biphasic or deeply inverted T-waves changes in electrocardiographic (ECG) precordial leads, which associated with critical stenosis of left anterior descending (LAD) coronary artery and impending anterior myocardial infarction in patients presenting with unstable angina. This syndrome is an important sign for clinicians because delay in coronary angiography and revascularization may lead toanterior myocardial infarction, left ventricular dysfunction, and even death. Case presentation: A 50-year-old woman came to emergency department in a hospital in Bontang, with new onset intermittent typical chest pain lasting since 3 days. She had history of hypertension without regular medication. Physical examination was in normal ranges. An ECG obtained during chest pain-free period showed Wellens' type A with biphasic T waves in V2-V6 and preserved R-wave progression. Troponin T was slightly elevated. During observation, the ECG pattern changed from Wellens' type A to Wellens' type B with deep T-wave inversions in V2-V6 and preserved R-wave progression. Results:The patient was initially treated with conservative treatment. On the next day, she was referred to percutaneous coronary intervention-capable hospital in Samarinda. Coronary angiography revealed 90% stenosis of mid LAD. A drug-eluting stent was successfully implanted with restoration of LAD flow. She was discharged on the following day in good condition with medication of dual antiplatelet therapy, angiotensin-converting enzyme inhibitor, beta-blocker, and statin. Conclusion:Clinicians should be aware of the ECG changes in Wellens' syndrome, which may occur during pain-free period. Early recognition is crucial to avoid the development of anterior myocardial infarction. Immediate coronary angiography and revascularization is needed.

COVID-19 has a wide spectrum of clinical presentations, from asymptomatic cases to severe respiratory distress, multi-organ dysfunction, and death. Pulmonary embolism (PE) is the most feared and severe complication of venous thromboembolism (VTE). We present a case of a 25-year-old nonsmoker pregnant woman (gravida 2, no history of abortion/miscarriage), who underwent an elective cesarean section at 39 weeks of gestation after uneventful pregnancy. She exhibit clinical presentation of pulmonary embolism (PE) overlapping with severe COVID-19 pneumonia. The diagnosis was made based upon severe oxygen desaturation, McConnel sign finding on POCUS and elevated D-dimer level (34.19 µg/mL). Alteplase and low-molecular-weight heparin were used, which resulted in rapid clinical improvement. We should be warned about high or extremely elevated D-dimer levels and severe oxygen desaturation, as markers of severe COVID-19 pneumonia in patients with high clinical suspicion of PE. Thrombolysis could be an effective and safe therapy for PE in ARDS secondary to COVID-19. Furthermore, we underline that POCUS, despite its inherent limitations, could be a flexible diagnostic and management tool in refractory ARDS due to COVID-19. Key words: COVID-19; SARS-CoV-2; Pulmonary Embolism; Thrombolysis; Postpartum; POCUS Abbreviations: ARDS - Acute respiratory distress syndrome; PE - Pulmonary embolism; VTE - Venous thromboembolism; BPM – Beats per minute Citation: Rotua SH, Arilaksono DG, Hutajulu SV. Systemic thrombolysis and anticoagulation in postpartum patient with acute respiratory distress syndrome, COVID-19 and acute pulmonary embolism: a case report. Anaesth. pain intensive care 2022;26(1):115-118. DOI: 10.35975/apic.v26i1.1777 Received: September 13, 2021, Reviewed: November 06, 2021, Accepted: November 10, 2021

<p>Background. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are novel inflammatory markers in cardiovascular diseases. Global Registry of Acute Coronary Events (GRACE) risk score is a scoring system to predict risk of mortality in acute coronary syndrome. Objective. To investigate the association between NLR and PLR with GRACE risk score in acute myocardial infarction (AMI) patients. Method. A cross-sectional study using data from medical records of AMI patients. Spectrum of AMI includes ST-segment elevation myocardial infarction (STEMI) or non-STEMI. Data analysis was performed using SPSS 20. Results. A total of 136 patients were included, 72.1% male with mean age 56.1 ± 10.5 years. NLR (p&lt;0.001) and PLR (p&lt;0.001) among GRACE risk score groups were significantly different. Mean NLR in low, intermediate, and high GRACE risk score groups were 3.5 ± 2.4, 6.0 ± 4.8, and 7.9 ± 3.9, respectively. Mean PLR in low, intermediate, and high GRACE risk score groups were 117.2 ± 62.3, 183.7 ± 95.8, and 209.9 ± 83.4, respectively. NLR (r=0.527; p&lt;0.001) and also PLR (r=0.496; p&lt;0.001) was significantly positively correlated with GRACE risk score. Conclusion. NLR and PLR are simple and cost effective inflammatory markers to predict GRACE risk score and an additional prognostic tool in AMI.</p><p>Pendahuluan. Rasio neutrofil-limfosit (RNL) dan rasio platelet-limfosit (RPL) merupakan petanda inflamasi penyakit kardiovaskular baru. Skor risiko Global Registry of Acute Coronary Events (GRACE) digunakan untuk prediksi risiko mortalitas sindrom koroner akut. Tujuan. Menyelidiki hubungan antara RNL dan RPL dengan skor risiko GRACE pada pasien infark miokard akut (IMA). Metode. Studi potong lintang atas data rekam medis pasien IMA. Spektrum IMA meliputi IMA dengan Elevasi Segmen ST (IMA-EST) dan IMA Non-elevasi Segmen ST (IMA-NEST). Analisis data menggunakan SPSS 20. Hasil. Sebanyak 136 pasien diteliti, 72.1% laki-laki dengan usia rerata 56.1 ± 10.5 tahun. Terdapat perbedaan signifikan nilai RNL (p&lt;0.001) dan RPL (p&lt;0.001) di antara kelompok skor risiko GRACE. Rerata RNL kelompok skor risiko GRACE rendah, sedang, dan tinggi adalah masing-masing 3.5 ± 2.4, 6.0 ± 4.8, dan 7.9 ± 3.9. Rerata RPL kelompok skor risiko GRACE rendah, sedang, dan tinggi adalah masing-masing 117.2 ± 62.3, 183.7 ± 95.8, dan 209.9 ± 83.4. RNL memiliki korelasi positif signifikan dengan skor risiko GRACE (r=0.527; p&lt;0.001). RPL juga memiliki korelasi positif signifikan dengan skor risiko GRACE (r=0.496; p&lt;0.001). Simpulan. RNL dan RPL merupakan petanda inflamasi sederhana dan hemat biaya yang dapat memprediksi skor risiko GRACE dan memberikan nilai prognostik tambahan pada IMA.</p><p> </p>