A 75-year-old man comes to the emergency department with 6 hours of intermittent chest pain. He has no nausea, vomiting, syncope, shortness of breath, or diaphoresis. His medical problems include type 2 diabetes mellitus, hypertension, and hyperlipidemia.
The patient's blood pressure is 142/78 mm Hg and pulse is 82/min. Cardiac and pulmonary examinations are within normal limits.
Electrocardiogram shows normal sinus rhythm with 1.5-mm horizontal ST-segment depression in leads II, III, and aVF. Initial troponin I level is 2.2 ng/mL (normal

Question

A 75-year-old man comes to the emergency department with 6 hours of intermittent chest pain.  He has no nausea, vomiting, syncope, shortness of breath, or diaphoresis.  His medical problems include type 2 diabetes mellitus, hypertension, and hyperlipidemia.
The patient's blood pressure is 142/78 mm Hg and pulse is 82/min.  Cardiac and pulmonary examinations are within normal limits.
Electrocardiogram shows normal sinus rhythm with 1.5-mm horizontal ST-segment depression in leads II, III, and aVF.  Initial troponin I level is 2.2 ng/mL (normal <0.012 ng/mL).
The patient receives antiplatelet agents, nitroglycerin, and anticoagulation.  He reports complete resolution of symptoms.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_96c0_ae46_853d_d1fc4756a7e6_MD0002_00 This patient's clinical presentation with angina, electrocardiogram abnormalities, and elevated troponin is consistent with acute coronary syndrome. Unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) are part of the spectrum of acute coronary syndrome (ACS). They are differentiated by the presence (NSTEMI) or absence (UA) of elevated cardiac biomarkers. ACS patients with high-risk features, ST-segment depression, and/or positive cardiac biomarkers should be managed with an early invasive approach using coronary angiography and primary percutaneous coronary intervention. Multiple randomized trials have shown better outcomes with lower rates of recurrent MI and all-cause mortality with an early (within 24 hours) invasive approach as compared to a conservative strategy in high-risk ACS patients. (Choice A) Emergency cardiac catheterization and revascularization within 90 minutes (of first contact with medical personnel) is the goal of treatment in patients with acute ST elevation myocardial infarction. (Choice C) Coronary calcium score is occasionally used for screening for coronary atherosclerosis in asymptomatic patients with multiple risk factors for coronary artery disease. It has no role in the acute management of patients with NSTEMI. (Choices D and E) A conservative approach, including medical therapy and further risk stratification with noninvasive stress testing, may be appropriate for patients at low risk of cardiac events (no troponin elevation, no ST-segment depression, and a Thrombolysis in Myocardial Infarction [TIMI] score of 0-2). Patients with NSTEMI have a high risk of recurrent MI and death and should be managed with an early invasive strategy with coronary angiography and revascularization. [TIMI] score Educational objective: Acute coronary syndrome patients with high-risk features, ST-segment depression, and/or positive cardiac biomarkers should be managed with an early invasive approach using coronary angiography and primary percutaneous coronary intervention to reduce the rate of recurrent myocardial infarction and all-cause mortality. __________ References: Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. (http://www.ncbi.nlm.nih.gov/pubmed/17010789)

A 75-Year-Old Man Comes to the Emergency Department with 6