A 64-year-old man comes to the emergency department due to substernal chest pressure for the last 2 hours and associated mild nausea. Two weeks ago, he underwent right coronary artery stenting for stable angina. He also has hypertension and hyperlipidemia. His blood pressure is 92/60 mm Hg and pulse is 48/min. He is diaphoretic, and his extremities are cold. Lungs are clear on auscultation. There are no heart murmurs. ECG shows sinus bradycardia with 2-mm ST-segment elevation in leads II, III, and aVF. Which of the following additional history is most helpful in diagnosing the cause of this patient's condition?
A)Alcohol abuse
B)Dietary habits
C)High-intensity exercise
D)Illicit drug use
E)Medication compliance

Question

A 64-year-old man comes to the emergency department due to substernal chest pressure for the last 2 hours and associated mild nausea.  Two weeks ago, he underwent right coronary artery stenting for stable angina.  He also has hypertension and hyperlipidemia.  His blood pressure is 92/60 mm Hg and pulse is 48/min.  He is diaphoretic, and his extremities are cold.  Lungs are clear on auscultation.  There are no heart murmurs.  ECG shows sinus bradycardia with 2-mm ST-segment elevation in leads II, III, and aVF.  Which of the following additional history is most helpful in diagnosing the cause of this patient's condition?
A)Alcohol abuse
B)Dietary habits
C)High-intensity exercise
D)Illicit drug use
E)Medication compliance

Quizplus · Accepted Answer

Explanation: This patient's presentation is consistent with an acute, inferior wall myocardial infarction (ST-segment elevation in leads II, III, and aVF). The history of recent right coronary artery stenting suggests possible subacute stent thrombosis leading to abrupt vessel occlusion. Stent thrombosis is an uncommon but potentially fatal complication of coronary artery stenting, with most events (myocardial infarction or death) occurring within 30 days of stent placement. The premature cessation of dual antiplatelet therapy with aspirin and platelet P2Y₁₂ receptor blocker (ie, clopidogrel, prasugrel, ticagrelor) is the most important risk factor for stent thrombosis. ₁₂ (Choices A, B, C, and D) Dietary habits, exercise, and alcohol use are not associated with an increased risk of stent thrombosis. Cocaine use is associated with a small risk of early stent thrombosis. Educational objective: Premature discontinuation of dual antiplatelet therapy (aspirin and P2Y₁₂ receptor blocker) is the strongest predictor of stent thrombosis after coronary stent placement. Patients should be aggressively screened and counseled for medication compliance to reduce the risk of stent thrombosis. ₁₂ References: Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. (http://www.ncbi.nlm.nih.gov/pubmed/19371823) Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. (http://www.ncbi.nlm.nih.gov/pubmed/15870416)

A 64-Year-Old Man Comes to the Emergency Department Due to Substernal