A 62-year-old man comes to the emergency department due to chest pain. The patient had occasional episodes of chest heaviness yesterday. Two hours ago, he had burning midline chest pain that lasted 30 minutes. The patient took aspirin on the way to the hospital; he currently has no chest pain or other issues. Medical history is significant for diet-controlled type 2 diabetes mellitus. The patient is an ex-smoker with a 20-pack-year smoking history. He has no known drug allergies. Blood pressure is 135/80 mm Hg, and pulse is 82/min and regular. Oxygen saturation is 95% on room air. BMI is 32 kg/m². The lungs are clear on auscultation. There are no heart murmurs. Peripheral pulses are full and symmetric. ECG shows normal sinus rhythm with T-wave inversions in leads aVF and III. Cardiac troponin I level is 2.1 ng/mL (normal:

Question

A 62-year-old man comes to the emergency department due to chest pain. The patient had occasional episodes of chest heaviness yesterday. Two hours ago, he had burning midline chest pain that lasted 30 minutes. The patient took aspirin on the way to the hospital; he currently has no chest pain or other issues. Medical history is significant for diet-controlled type 2 diabetes mellitus. The patient is an ex-smoker with a 20-pack-year smoking history. He has no known drug allergies. Blood pressure is 135/80 mm Hg, and pulse is 82/min and regular. Oxygen saturation is 95% on room air. BMI is 32 kg/m². The lungs are clear on auscultation. There are no heart murmurs. Peripheral pulses are full and symmetric. ECG shows normal sinus rhythm with T-wave inversions in leads aVF and III. Cardiac troponin I level is 2.1 ng/mL (normal: <0.01 ng/mL). This patient would benefit most from which of the following?

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Explanation: 11ec25c8_d187_135c_bc81_91efd2b21e4b_MD0003_00 This patient with risk factors for acute coronary syndrome (ACS) (male, age >55, diabetes, smoking history) has chest pain that resolved, with an ECG showing inverted T waves and an elevated troponin level. This presentation is concerning for non-ST-segment elevation myocardial infarction (NSTEMI), typically characterized by partial thrombus occlusion. He does not meet criteria for emergent coronary revascularization (eg, hemodynamic instability, cardiogenic shock). Medical management is appropriate, and he should be admitted for early coronary revascularization (within 24 hr). The cornerstone of NSTEMI medical management is dual antiplatelet therapy (DAPT) with aspirin (which the patient already took) and a P2Y12 receptor blocker (eg, clopidogrel, prasugrel), which should be given to all patients with no contraindications (eg, allergy, bleeding). DAPT is directed at limiting platelet adhesion and aggregation, the early steps of thrombus formation. Compared to aspirin therapy alone, long-term DAPT reduces the risk of recurrent MI and cardiovascular death in NSTEMI. It also reduces the risk of stent thrombosis following drug-eluting stent placement. Patients with NSTEMI should also receive anticoagulants (eg, heparin) to inhibit clot formation (typically for 48 hr). In addition to DAPT, other medications that reduce morbidity and mortality rates in coronary artery disease include: Beta blockers (reduce myocardial oxygen demand) Statins (anti-inflammatory effects) ACE inhibitors or angiotensin II receptor blockers (facilitate cardiac remodeling) Aldosterone antagonists (in select patients) (Choice A) Apixaban (direct factor Xa inhibitor) is used for anticoagulation in nonvalvular atrial fibrillation and for management of deep venous thrombosis and pulmonary embolism. In ACS, its use has been associated with increased bleeding, so it is not recommended. (Choice B) Ibuprofen and colchicine are used to treat pericarditis (pleuritic chest pain, diffuse ST-segment elevation and PR depression, pericardial rub), which can develop after an MI. They are not used in NSTEMI management. (Choice C) Oxygen is recommended in patients with oxygen saturation <90% or respiratory distress. In normoxic patients, oxygen supplementation has no added benefit, and hyperoxia may be associated with harm due to direct vasoconstrictor effect on coronary arteries (possibly free radical-mediated). (Choice D) Nitroglycerin (a vasodilator) is used to treat chest pain in patients with ACS but has no added mortality benefit. Sublingual formulations can be administered for immediate relief, and infusion is sometimes used for persistent chest pain. This patient is chest pain-free. Educational objective: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor lowers morbidity and mortality rates in non-ST-segment elevation myocardial infarction. It should be administered to all patients with no contraindications.

A 62-Year-Old Man Comes to the Emergency Department Due to Chest