A 29-year-old man comes to the emergency department due to sudden-onset chest pain over the past hour. He says, "I have this pressure and squeezing in my chest that does not go away." He has never before had such symptoms. His medical history is insignificant. The patient smokes 2 packs of cigarettes daily and consumes alcohol occasionally. He uses cocaine and had "one shot" several hours ago. His family history is significant for a stroke in his father and a heart attack in his mother. Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, pulse is 112/min, and respirations are 24/min. ECG shows 2-mm ST-segment elevation in leads I, aVL, and V4-V6. The patient receives oxygen by mask, aspirin, and diazepam. He is given sublingual nitroglycerin and started on nitroglycerin infusion. Portable chest x-ray reveals a normal heart contour and clear lung fields. Twenty minutes later, he still has chest pain and his ECG is unchanged. The patient requests that he be given something to alleviate his chest discomfort. His initial troponin I level is undetectable. What is the best next step in management of this patient?

Question

A 29-year-old man comes to the emergency department due to sudden-onset chest pain over the past hour.  He says, "I have this pressure and squeezing in my chest that does not go away."  He has never before had such symptoms.  His medical history is insignificant.  The patient smokes 2 packs of cigarettes daily and consumes alcohol occasionally.  He uses cocaine and had "one shot" several hours ago.  His family history is significant for a stroke in his father and a heart attack in his mother.  Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, pulse is 112/min, and respirations are 24/min.  ECG shows 2-mm ST-segment elevation in leads I, aVL, and V4-V6.  The patient receives oxygen by mask, aspirin, and diazepam.  He is given sublingual nitroglycerin and started on nitroglycerin infusion.  Portable chest x-ray reveals a normal heart contour and clear lung fields.  Twenty minutes later, he still has chest pain and his ECG is unchanged.  The patient requests that he be given something to alleviate his chest discomfort.  His initial troponin I level is undetectable.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be49_c9bf_8f63_addd43df77eb_MD0005_00 This patient with an ECG demonstrating >1-mm ST elevation in >2 contiguous leads has an acute ST elevation myocardial infarction (STEMI) related to cocaine ingestion. The initial management of myocardial ischemia due to cocaine intoxication focuses on reduction of myocardial oxygen demand and improvement in myocardial oxygen supply. Because beta blockers are contraindicated in the setting of acute cocaine ingestion, intravenous benzodiazepines are given as needed to reduce sympathetic outflow and to alleviate hypertension, tachycardia, and coronary vasoconstriction. Nitroglycerin is also given to reduce blood pressure and left ventricular wall stress. Because cocaine stimulates platelet activity and encourages thrombus formation, thrombotic occlusion of coronary arteries can occur (even in young patients). Therefore, aspirin should be given early. In patients with persistent ST elevation despite initial medical therapy, coronary angiography with percutaneous coronary intervention (PCI) should be performed without delay. Prompt recognition and restoration of myocardial blood flow is critical to minimize myocardial necrosis and to reduce cardiac morbidity and mortality. (Choice A) PCI has been shown to improve survival in patients with STEMI and has a lower rate of recurrent infarction and intracranial hemorrhage compared to intravenous fibrinolysis (eg, alteplase). Fibrinolytic therapy is recommended only in patients with STEMI for whom PCI cannot be performed within 2 hours of first medical contact. (Choice B) Beta blockers (eg, metoprolol) can lead to unopposed alpha-1 receptor-mediated vasoconstriction in patients with acute cocaine ingestion and are contraindicated in this setting. Several retrospective studies that suggest the safety of beta blockers in the setting of acute cocaine ingestion are poorly reliable due to design flaws (eg, selection bias). (Choice C) Oral calcium channel blockers (eg, amlodipine) can be added to benzodiazepines and nitroglycerin to relieve myocardial ischemia in patients with cocaine intoxication and minimal ECG changes. However, patients with persistent ST elevation following initial medical therapy should have immediate PCI. (Choice E) Reassurance alone is not appropriate in this patient with ongoing chest pain and persistent ST elevation on ECG. In addition, the presence or absence of a history of opioid use does not affect the need for immediate PCI. Educational objective: The initial management of myocardial ischemia due to acute cocaine intoxication includes intravenous benzodiazepines and nitroglycerin to improve the mismatch of myocardial oxygen supply and demand. Patients with persistent ST elevation despite medical therapy should undergo coronary revascularization without delay. References: Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. (http://www.ncbi.nlm.nih.gov/pubmed/18347214) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23247303) ST-segment elevation in the electrocardiogram: a sign of myocardial ischemia. (http://www.ncbi.nlm.nih.gov/pubmed/10728321)

A 29-Year-Old Man Comes to the Emergency Department Due to Sudden-Onset