A 62-year-old man comes to the emergency department because of nausea and abdominal pain. He describes the pain as a pressure located in the epigastric area which feels like it is "pushing up" into his chest. It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before. The pain initially improved while leaning forward, but it is now present in any position. The patient has no shortness of breath or palpitations. He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin. He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more.
His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min. Pulse oximetry shows 98% oxygen saturation on room air. The patient is in moderate pain and is diaphoretic. There is a 2/6 systolic murmur at the apex which radiates to the axillae. The lungs are clear to auscultation. The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

A 12-lead electrocardiogram is shown in this exhibit.

Which of the following is the most appropriate next step in the management of this patient?

Question

A 62-year-old man comes to the emergency department because of nausea and abdominal pain.  He describes the pain as a pressure located in the epigastric area which feels like it is "pushing up" into his chest.  It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before.  The pain initially improved while leaning forward, but it is now present in any position.  The patient has no shortness of breath or palpitations.  He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin.  He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more.
His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min.  Pulse oximetry shows 98% oxygen saturation on room air.  The patient is in moderate pain and is diaphoretic.  There is a 2/6 systolic murmur at the apex which radiates to the axillae.  The lungs are clear to auscultation.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

A 12-lead electrocardiogram is shown in this exhibit.

Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

11ec193a_95c0_a34e_853d_c92e0af6ec37_MD0002_00 This patient has epigastric discomfort, diaphoresis, and ST segment elevation in leads I, aVL, and V1 to V5 along with reciprocal ST segment depression in leads II, III, and aVF. This is consistent with acute anterolateral ST-segment elevation myocardial infarction (STEMI) due to occlusion of the left anterior descending (LAD) artery. The most appropriate next step in management is to proceed with emergency coronary angiography and primary percutaneous coronary intervention (PCI). ST segment elevation left anterior descending (LAD) artery Prompt coronary reperfusion restores blood flow, limits myocardial damage, and reduces mortality. Current guidelines recommend primary PCI for patients with acute STEMI as follows: Within 12 hours of symptom onset ANDWithin 90 minutes from first medical contact to device time at a PCI-capable facility ORWithin 120 minutes from first medical contact to device time at a non-PCI-capable facility (to allow time for transport to a PCI-capable facility) Within 12 hours of symptom onset AND Within 90 minutes from first medical contact to device time at a PCI-capable facility OR Within 120 minutes from first medical contact to device time at a non-PCI-capable facility (to allow time for transport to a PCI-capable facility) All such patients referred for emergency PCI should be pretreated with antiplatelet (aspirin and P2Y₁₂ receptor blocker) and anticoagulant therapy. ₁₂ (Choice B) A CT scan of the aorta is indicated for suspected aortic dissection. Acute dissection involving the ascending aorta can occasionally cause occlusion of the right coronary artery. These patients typically have ST segment elevation in leads II, III, and aVF with reciprocal ST segment depression in the anterior leads. (Choice C) An exercise stress test should be performed in patients with chest pain and intermediate probability of coronary artery disease. However, this patient has acute STEMI and should be referred for emergency coronary angiography. (Choice D) Non-steroidal anti-inflammatory drugs and colchicine are used in patients with acute pericarditis. Pericarditis is characterized by pleuritic chest pain which is relieved by leaning forward and associated with diffuse ST elevation and depression of PR segment in the limb and left precordial leads. left precordial leads (Choice E) Proton-pump inhibitors are useful in patients with peptic ulcer disease or gastroesophageal reflux disease. But this patient's electrocardiogram confirms a cardiac source of pain. Educational objective: Primary percutaneous coronary intervention is recommended emergently for acute ST-segment elevation myocardial infarction. All such patients referred for emergency PCI should be pretreated with antiplatelet and anticoagulant therapy as soon as possible. __________ References: Delaying primary percutaneous coronary intervention for computed tomographic scans in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/22534052) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23247304)

A 62-Year-Old Man Comes to the Emergency Department Because of Nausea