A 62-year-old man is brought to the emergency department with substernal pain and mild shortness of breath over the last 2 hours. En route he was given sublingual nitroglycerin twice with significant relief of pain. He also received chewable aspirin. The patient currently rates the pain as 1-2 out of 10. His past medical history is significant for hypertension and active smoking. He has no history of bleeding. The patient's father died of a heart attack at age 56. Blood pressure is 154/90 mm Hg and pulse is 110/min. He is not in respiratory distress. No murmurs are heard. Lungs are clear to auscultation. The initial electrocardiogram (ECG) is shown in the Exhibit. Which of the following is the best next step in management of this patient?

Question

A 62-year-old man is brought to the emergency department with substernal pain and mild shortness of breath over the last 2 hours.  En route he was given sublingual nitroglycerin twice with significant relief of pain.  He also received chewable aspirin.  The patient currently rates the pain as 1-2 out of 10.  His past medical history is significant for hypertension and active smoking.  He has no history of bleeding.  The patient's father died of a heart attack at age 56.  Blood pressure is 154/90 mm Hg and pulse is 110/min.  He is not in respiratory distress.  No murmurs are heard.  Lungs are clear to auscultation.  The initial electrocardiogram (ECG) is shown in the Exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's clinical presentation - substernal chest discomfort, relief with nitroglycerine, and electrocardiogram (ECG) findings of ST-segment depression in leads II, aVF, and V3-V6 - is consistent with acute coronary syndrome ([ACS] - unstable angina/non ST-elevation myocardial infarction [NSTEMI]). All such patients should be managed with: (ECG) findings Dual antiplatelet therapy with aspirin and platelet P2Y12 receptor blockers (clopidogrel, prasugrel, or ticagrelor) Nitrates Beta blockers Statins Anticoagulant therapy (unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux) In multiple randomized trials, treatment with dual antiplatelet therapy and anticoagulant therapy has been shown to significantly reduce the risk of nonfatal MI and cardiovascular death in patients with ACS. (Choice B) Emergency cardiac catheterization and revascularization within 90 minutes from the first medical contact is the goal of treatment in patients with ST-elevation myocardial infarction. (Choice C) CT scan of the chest with contrast is the modality of choice for the diagnosis of acute aortic dissection. It usually presents with sudden onset of severe "tearing" chest and back pain in patients with uncontrolled hypertension. (Choice D) Intravenous adenosine causes a transient atrioventricular node block and is used for the acute termination of paroxysmal supraventricular tachycardia. This patient's ECG shows sinus tachycardia, and adenosine would not be beneficial. paroxysmal supraventricular tachycardia (Choice E) Transthoracic echocardiogram is useful to assess left ventricular function and wall motion abnormalities in patients with ACS. However, the patient should be treated with optimal medical therapy prior to further noninvasive or invasive evaluation. Educational objective: Patients with acute coronary syndrome should be treated with guideline-directed medical therapy, including dual antiplatelet therapy with aspirin and platelet P2Y12 receptor blockers (clopidogrel, prasugrel, or ticagrelor), beta blockers, statins, and anticoagulant therapy to reduce the risk of recurrent nonfatal myocardial infarction and cardiovascular death. References: 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22800849) Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315274)

A 62-Year-Old Man Is Brought to the Emergency Department with Substernal