A 59-year-old man comes to the emergency department due to chest pain beginning 2 hours ago and profuse sweating 1 hour ago. He feels weak. Past medical history includes type 2 diabetes mellitus and hypercholesterolemia. The patient's medications include metformin, glipizide, and simvastatin. Blood pressure is 165/98 mm Hg in the right arm and 160/90 mm Hg in the left, pulse is 78/min, and oxygen saturation is 98% on room air. He appears mildly uncomfortable. Lungs are clear to auscultation. His ECG is shown in exhibit. Which of the following is the best next step in management of this patient?

Question

A 59-year-old man comes to the emergency department due to chest pain beginning 2 hours ago and profuse sweating 1 hour ago.  He feels weak.  Past medical history includes type 2 diabetes mellitus and hypercholesterolemia.  The patient's medications include metformin, glipizide, and simvastatin.  Blood pressure is 165/98 mm Hg in the right arm and 160/90 mm Hg in the left, pulse is 78/min, and oxygen saturation is 98% on room air.  He appears mildly uncomfortable.  Lungs are clear to auscultation.  His ECG is shown in exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d184_c969_bc81_698479fd9d7e_MD0003_00 This patient's clinical features and ECG findings (ST-segment elevation in leads I, aVL, and V2-V6 with reciprocal ST-segment depression in leads II, III, and aVF) suggest acute anterolateral ST-segment elevation myocardial infarction (STEMI) due to left anterior descending artery occlusion. In patients with a typical presentation, STEMI can be diagnosed even without cardiac biomarkers (can be normal early on). Immediate coronary reperfusion therapy is indicated following initial stabilization measures, which include: oxygen, full-dose aspirin (chewed to enter the bloodstream quickly), platelet P2Y₁₂ receptor blocker (eg, clopidogrel, ticagrelor), nitroglycerin (relieves ischemic pain; morphine if nitroglycerin is inadequate), beta blocker, and anticoagulation (ie, heparin). ₁₂ Prompt coronary reperfusion with primary percutaneous coronary intervention (PCI) or fibrinolytic therapy (eg, alteplase) 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 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) Multiple randomized trials have shown lower rates of recurrent MI and intracranial hemorrhage, and improved survival with primary PCI compared to fibrinolytic therapy. This patient who is within 12 hours of symptom onset (onset 2 hours ago) and at a PCI-capable facility should ideally undergo PCI within 90 minutes of first medical contact. Fibrinolysis is recommended for STEMI patients arriving within 12 hours of symptom onset who cannot undergo PCI (eg, PCI is not available within the recommended time frame). (Choices A and B) Patients with acute STEMI should go directly to coronary angiography from the emergency department and are usually managed in an intensive care unit rather than a standard telemetry unit following urgent coronary intervention. (Choice D) Acute, type A aortic dissection (ascending aortic dissection) can occasionally cause occlusion of the right coronary artery by the dissection flap, leading to inferior MI. These patients are typically hypotensive. More commonly, patients with aortic dissection have sharp or tearing chest or back pain and nonspecific ECG changes. Patients with pulmonary embolism usually have dyspnea, tachypnea, tachycardia, and hypoxia. (Choice E) Nonsteroidal anti-inflammatory drugs are used in the management of acute pericarditis. Patients typically have sharp and pleuritic chest pain that is worse with deep inspiration or when supine and relieved with sitting up and leaning forward. ECGs classically show diffuse ST-segment elevation and PR-segment depression in the limb and left precordial leads. acute pericarditis Educational objective: Primary percutaneous coronary intervention (PCI) is recommended within 90 minutes for acute, ST-segment elevation myocardial infarction (STEMI). Additional stabilization measures include oxygen, full-dose aspirin, platelet P2Y₁₂ receptor blockers, nitroglycerin, beta blockers, and anticoagulation. Fibrinolysis may be administered within 12 hours of symptom onset for STEMI patients who cannot undergo PCI but is associated with higher rates of recurrent myocardial infarction, intracranial hemorrhage, and mortality compared to PCI. ₁₂ References: Delaying primary percutaneous coronary intervention for computed tomographic scans in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/22534052) Reperfusion strategies in ST-segment elevation myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/24008602)

A 59-Year-Old Man Comes to the Emergency Department Due to Chest