A 65-year-old man comes to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. The pain radiates to his left arm and does not remit with sublingual nitroglycerin. The patient has vomited twice since the pain started. ECG shows 2-mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9 C (98.4 F), blood pressure is 110/70 mm Hg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4 L/min oxygen by nasal canula. Cardiac examination shows an S3. Lung examination shows basilar crackles that extend halfway up the lung fields bilaterally. He is given 325 mg of aspirin, 600 mg of clopidogrel, and 80 mg of atorvastatin. Which of the following is the best next step in management of this patient?

Question

A 65-year-old man comes to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago.  The pain radiates to his left arm and does not remit with sublingual nitroglycerin.  The patient has vomited twice since the pain started.  ECG shows 2-mm ST elevations in the anterior leads.  On physical examination, the patient's temperature is 36.9 C (98.4 F), blood pressure is 110/70 mm Hg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4 L/min oxygen by nasal canula.  Cardiac examination shows an S3.  Lung examination shows basilar crackles that extend halfway up the lung fields bilaterally.  He is given 325 mg of aspirin, 600 mg of clopidogrel, and 80 mg of atorvastatin.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d35a_4d2a_bc81_15a559e41099_MD0003_00 This patient has ischemic heart failure secondary to an acute anterior wall ST-elevation myocardial infarction (MI) causing acute pulmonary edema ("flash pulmonary edema") (eg, dyspnea, crackles, hypoxia). A loop diuretic such as furosemide is the drug of choice in this setting. Furosemide rapidly relieves pulmonary edema by decreasing the cardiac preload, thereby decreasing pulmonary capillary pressure. Furosemide also causes venodilation, which further decreases the preload. However, diuretics should be given carefully in this setting as many of these patients may be normo- or hypo-volemic, and aggressive diuresis may lead to hypotension and acute kidney injury. Other appropriate treatments in this situation include intravenous vasodilators (eg, nitroglycerin), though these should also be avoided if the patient is hypotensive. Morphine may be considered for persistent pain treatment as it has both anxiolytic and preload-reducing effects but should not be used routinely due to a possible increase in mortality. Ultimately, emergency revascularization (percutaneous coronary angioplasty or thrombolysis) is needed for definitive management of ST-elevation MI. (Choice A) Amlodipine is a dihydropyridine calcium channel blocker indicated for hypertension. However, vasodilation can result in reflex tachycardia and increased myocardial oxygen demand. As a result, it is not preferred in the acute management of MI or congestive heart failure (CHF). (Choice B) Digoxin is used for rate control in patients with rapid atrial fibrillation and to improve symptoms in patients with CHF. It is relatively contraindicated in acute MI as it may increase myocardial oxygen demand. (Choice D) Intravenous fluids would likely worsen this patient's pulmonary edema. (Choice E) Although beta blockers such as metoprolol improve mortality in acute MI, they are contraindicated in the presence of pulmonary edema (acute decompensated heart failure). (Choice F) Spironolactone is sometimes used in the chronic management of CHF and has been shown to have a mortality benefit. However, it is a weak diuretic and this patient needs more substantial preload reduction. (Choice G) Verapamil is a calcium channel blocker used in the management of hypertension and supraventricular arrhythmias. It is a second-line drug for management of angina pain (stable or unstable). However, it is not indicated for acute MI or CHF. Educational objective: Diuretics are recommended for acute pulmonary edema (acute myocardial infarction). Beta blockers are a standard therapy in myocardial infarction but should be avoided in patients with decompensated congestive heart failure or bradycardia. References: Acute heart failure with dyspnoea: initial treatment. Furosemide and trinitrine, despite the lack of a proven survival benefit. (http://www.ncbi.nlm.nih.gov/pubmed/21678708)

A 65-Year-Old Man Comes to the Emergency Department with Substernal