A 62-year-old man comes to the emergency department with 2 episodes of retrosternal pressure-like chest pain over the last 6 hours. Medical history is significant for type 2 diabetes mellitus, hypertension, and end-stage renal disease. He undergoes hemodialysis 3 times a week through a left arm arteriovenous fistula.
Blood pressure is 152/89 mm Hg and pulse is 88/min. The chest is clear on auscultation. There are no heart murmurs.
Bedside finger-stick glucose level is 134 mg/dL. ECG shows normal sinus rhythm with 1-mm horizontal ST-segment depressions in leads II, III, aVF, and V4-V6. The initial troponin I level is 1.5 ng/mL (normal:

Question

A 62-year-old man comes to the emergency department with 2 episodes of retrosternal pressure-like chest pain over the last 6 hours.  Medical history is significant for type 2 diabetes mellitus, hypertension, and end-stage renal disease.  He undergoes hemodialysis 3 times a week through a left arm arteriovenous fistula.
Blood pressure is 152/89 mm Hg and pulse is 88/min.  The chest is clear on auscultation.  There are no heart murmurs.
Bedside finger-stick glucose level is 134 mg/dL.  ECG shows normal sinus rhythm with 1-mm horizontal ST-segment depressions in leads II, III, aVF, and V4-V6.  The initial troponin I level is 1.5 ng/mL (normal: <0.01).
He is treated with aspirin.
Which of the following is the most appropriate additional treatment for this patient?

Quizplus · Accepted Answer

This patient's clinical presentation - recurrent substernal chest pain, ST-segment depression, and elevated cardiac biomarkers - is consistent with non-ST elevation myocardial infarction (NSTEMI). The acute pharmacologic management of unstable angina/NSTEMI in patients with end-stage renal disease (ESRD) is similar to that in other patients. In the absence of specific contraindications, patients who have ESRD with NSTEMI should receive aspirin, a P2Y₁₂ receptor blocker (eg, clopidogrel), a beta blocker, and anticoagulation therapy. Nitrates may also be given for active chest pain. The benefit of high-intensity statin (eg, atorvastatin) therapy is not clear in patients with ESRD. ₁₂ This patient has no contraindication to beta blocker use (eg, decompensated heart failure, bradycardia) and should be started on metoprolol to reduce infarct size and lower the risk of reinfarction and early mortality. (Choices A and E) Calcium channel blockers (eg, amlodipine) and aldosterone antagonists (eg, spironolactone) are not indicated in the acute management of unstable angina/NSTEMI. (Choice B) Anticoagulant therapy is indicated for patients with unstable angina/NSTEMI. However, enoxaparin, a low-molecular-weight heparin, is renally cleared and is not recommended in patients with ESRD due to increased risk of bleeding complications. Anticoagulation with unfractionated heparin is more appropriate in patients with ESRD. (Choice C) Glycoprotein IIb/IIIa inhibitors are sometimes used in acute coronary syndrome at the time of percutaneous coronary intervention if there is heavy clot burden or high-risk features (eg, elevated troponin). However, in patients with ESRD, their use is associated with increased risk of bleeding complications; abciximab is preferred (no renal dosing adjustment required) whereas eptifibatide is contraindicated. Educational objective: Patients with unstable angina/non-ST elevation myocardial infarction and end-stage renal disease (ESRD) should be managed with pharmacologic therapy similar to that for patients without renal failure. However, enoxaparin and the glycoprotein IIb/IIIa inhibitor eptifibatide are contraindicated in patients with ESRD. __________ References: Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. (http://www.ncbi.nlm.nih.gov/pubmed/19996401) 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)

A 62-Year-Old Man Comes to the Emergency Department with 2