A 60-year-old man comes to the emergency department due to substernal chest discomfort over the past 3 hours. He has had no shortness of breath, lightheadedness, or palpitations, but he had an episode of profuse sweating when the discomfort started. The patient has a history of diet-controlled type 2 diabetes mellitus. ECG shows normal sinus rhythm with ST-segment depression in leads V4-V6. His initial troponin I level is 0.5 ng/mL (normal,

Question

A 60-year-old man comes to the emergency department due to substernal chest discomfort over the past 3 hours.  He has had no shortness of breath, lightheadedness, or palpitations, but he had an episode of profuse sweating when the discomfort started.  The patient has a history of diet-controlled type 2 diabetes mellitus.  ECG shows normal sinus rhythm with ST-segment depression in leads V4-V6.  His initial troponin I level is 0.5 ng/mL (normal, <0.01 ng/mL), and a second level 6 hours later is 1.1 ng/mL.  He is taken to the cardiac catheterization laboratory.  Coronary angiogram shows near-total occlusion of the left circumflex artery, which is treated with an everolimus-eluting stent.  The rest of the coronary vessels show mild, nonobstructive atherosclerosis.  In addition to aspirin, beta blocker, statin, and an ACE inhibitor, which of the following should be part of this patient's medical regimen at discharge?

Quizplus · Accepted Answer

This patient had a non-ST elevation myocardial infarction (NSTEMI) (chest pain, ST depression, troponin elevation) and underwent revascularization of the culprit coronary artery with a drug-eluting stent. Long-term medical therapy in such patients is aimed at prevention of recurrent coronary events (secondary prevention) and reduction of overall cardiovascular events. Medical therapy shown to improve morbidity and mortality in patients with known coronary heart disease includes: Dual antiplatelet therapy (DAPT) with aspirin and P2y12 receptor blockers (eg, clopidogrel, prasugrel, ticagrelor)Beta blockersAngiotensin-converting enzyme inhibitors or angiotensin II receptor blockersHMG-CoA reductase inhibitors (statins)Aldosterone antagonists (eg, spironolactone, eplerenone) in patients with left ventricular ejection fraction ≤40% who have heart failure symptoms or diabetes mellitus Dual antiplatelet therapy (DAPT) with aspirin and P2y12 receptor blockers (eg, clopidogrel, prasugrel, ticagrelor) Beta blockers Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers HMG-CoA reductase inhibitors (statins) Aldosterone antagonists (eg, spironolactone, eplerenone) in patients with left ventricular ejection fraction ≤40% who have heart failure symptoms or diabetes mellitus DAPT with aspirin and a P2y12 receptor blocker leads to a significant reduction in recurrent MI and cardiovascular death compared to aspirin alone in patients with NSTEMI. Long-term DAPT also reduces the risk of stent thrombosis and is currently recommended for at least 6-12 months in all patients following drug-eluting stent placement. (Choice A) Dihydropyridine calcium channel blockers (eg, amlodipine) are occasionally used as adjunctive therapy (in addition to nitrates and beta blockers) in patients with angina. They have not been shown to provide any mortality benefit in patients with NSTEMI. (Choice B) Anticoagulation (eg, with a heparin product) is part of the initial acute management of NSTEMI but is not required for longterm management. Apixaban, a direct factor Xa inhibitor, is used for longterm anticoagulation in nonvalvular atrial fibrillation and for management of deep venous thrombosis and pulmonary embolism. Its use in acute coronary syndrome is associated with an increased risk of major bleeding and is not recommended. (Choice C) Nitrates may be used in the initial, acute management of acute coronary syndrome to reduce myocardial oxygen demand and ischemic chest pain. Isosorbide mononitrate, a long-acting nitrate providing rapid, symptomatic relief in patients with recurrent angina, has no mortality benefit in patients with coronary heart disease. Routine use in asymptomatic patients is not indicated. (Choice D) Postinfarction pericarditis (pericardial rub, chest pain) sometimes develops after an MI and can be treated with the tubulin inhibitor colchicine. Colchicine is not routinely prescribed to asymptomatic patients. (Choice F) Phosphodiesterase-5 inhibitors are vasodilators used for erectile dysfunction and are contraindicated in patients on nitrates (risk of hypotension). Milrinone is a selective phosphodiesterase inhibitor that increases contractility (by increasing cyclic AMP concentrations); oral milrinone therapy is associated with increased mortality in patients with heart failure. Educational objective: Dual antiplatelet therapy (aspirin and a P2y12 receptor blocker) leads to a reduction in recurrent myocardial infarction (MI) and cardiovascular death compared to aspirin alone in patients with non-ST elevation MI. It also reduces the risk of stent thrombosis and is recommended in all patients for at least 12 months following drug-eluting stent placement. References: 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/25249586) Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. (http://www.ncbi.nlm.nih.gov/pubmed/11519503)

A 60-Year-Old Man Comes to the Emergency Department Due to Substernal