An 81-year-old woman comes to the emergency department due to shortness of breath that has worsened over the past hour. It is associated with nausea. The patient does not have chest pain. Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus. Temperature is 36.7 C (98 F), blood pressure is 92/64 mm Hg, pulse is 90/min, and respirations are 22/min. Oxygen saturation is 94% on room air. On examination, the patient is diaphoretic and appears to be in mild respiratory distress. Bilateral crackles are heard on lung auscultation. No heart murmurs are heard. An ECG is obtained and is shown in the exhibit. Blood samples are sent for testing. Intravenous furosemide is administered. Which of the following is the best next step in management?

Question

An 81-year-old woman comes to the emergency department due to shortness of breath that has worsened over the past hour.  It is associated with nausea.  The patient does not have chest pain.  Medical history is significant for hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Temperature is 36.7 C (98 F), blood pressure is 92/64 mm Hg, pulse is 90/min, and respirations are 22/min.  Oxygen saturation is 94% on room air.  On examination, the patient is diaphoretic and appears to be in mild respiratory distress.  Bilateral crackles are heard on lung auscultation.  No heart murmurs are heard.  An ECG is obtained and is shown in the exhibit.  Blood samples are sent for testing.  Intravenous furosemide is administered.  Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d186_500b_bc81_4b4b0f9e55e2_MD0003_00 This elderly patient with dyspnea and risk factors for coronary artery disease (ie, diabetes mellitus, hypertension, hyperlipidemia) has ST-segment elevation myocardial infarction (STEMI) and should go to the cardiac catheterization laboratory immediately. Diagnosing acute coronary syndrome (ACS) is challenging in elderly patients because they often have atypical symptoms (eg, dyspnea, nausea, diaphoresis), particularly if they have comorbid diabetes mellitus. An ECG should be obtained early to avoid diagnostic delay. STEMI criteria include new ST-segment elevation in 2 contiguous leads. This patient's ECG shows ST-segment elevation in leads V1 through V6 (and possibly I and aVL) indicative of a large anterolateral wall MI (left anterior descending artery occlusion). Large areas of myocardial ischemia can cause left ventricular failure and cardiogenic shock (eg, hypotension, pulmonary edema). Furosemide can be administered to improve pulmonary vascular congestion but should be used judiciously because cardiac output and systemic blood pressure could drop. Early reperfusion therapy to salvage myocardial muscle is the most effective treatment for STEMI. Emergency cardiac catheterization with percutaneous coronary intervention (PCI), ideally within 90 minutes of presentation, is preferred over fibrinolysis. Antithrombotic (eg, aspirin, P2Y12 inhibitor) and anticoagulation (eg, heparin) therapy should be administered in preparation for the procedure. percutaneous coronary intervention (PCI) (Choice A) Dopamine was used historically to treat cardiogenic shock, but it is associated with more arrhythmias and possibly a higher mortality rate than its preferred counterpart, norepinephrine. In addition, this patient should undergo PCI. (Choices C and D) Metoprolol, a beta blocker, is generally indicated for ACS but is avoided when acute heart failure is suspected (eg, pulmonary edema). Oral beta blockers are preferred to intravenous beta blockers, which have not consistently shown benefit prior to PCI and worsen outcomes in patients with hemodynamic instability (eg, hypotension, respiratory distress). Nitroglycerin, a potent vasodilator, is given intravenously to patients with STEMI who have persistent pain, hypertension, or heart failure. It can cause hypotension. Neither therapy is indicated in this patient, who should be transferred to the catheterization laboratory rather than remain in the emergency department. (Choice E) Admission to a telemetry ward is not the appropriate disposition for this patient with acute MI and cardiogenic shock. There is a high likelihood her condition will deteriorate suddenly, so she should undergo PCI and be placed in an intensive care unit. Educational objective: ST-segment elevation myocardial infarction (STEMI) can present with atypical symptoms in elderly patients. Criteria for diagnosing STEMI include ST-segment elevation in 2 contiguous leads. Patients with STEMI should undergo emergency cardiac catheterization and percutaneous coronary intervention. References: ST elevation myocardial infarction in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/22916055)

An 81-Year-Old Woman Comes to the Emergency Department Due to Shortness