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  #1  
Old 11-03-2011
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Heart MI; Next step in management

You are seeing a 68-year-old bus driver who came to the emergency department with excruciating retrosternal chest pain for the last 3 hours. The pain is substernal and dull in nature, with no relation to respiration or position. The pain does not radiate and is accompanied by weakness, lightheadedness, and nausea. He was placed on 2 L of oxygen by nasal cannula and has already received 2 baby aspirin. He denies any significant past medical history. Physical examination reveals a blood pressure of 190/105 mm Hg, pulse of 102/min, respiration rate of 18/min, and temperature of 38.1 C (100.6 F). Examination shows no jugular venous distension; chest auscultation reveals no rales or wheezes; pain is not reproduced with palpation; and heart auscultation shows no gallop. Abdominal examination reveals no ascites, and extremities do not have edema. Chest x-ray is normal and an electrocardiogram shows 2 mm ST segment elevation in leads II, III, and aVF. Which of the following is the most appropriate next step in the management?
A. Send him for cardiac catheterization immediately because of his safe-sensitive job
B. Send him for coronary artery bypass graft
C. Start a heparin drip and follow PTT in 6 to 12 hours
D. Start thrombolytic therapy immediately
E. Control his blood pressure
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  #2  
Old 11-03-2011
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this is a case of hypertension with acute MI, we should first control the blood pressure then proceed to cardiac revascularization so i'm going with choice E control his blood pressure. thrombolytics are also contraindicated in these settings.
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Old 11-03-2011
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control the blood pressure with nitro..
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  #4  
Old 11-03-2011
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another pitfall .... i was about to sent the pt for angio untill i saw sam88 mentioned his BP... damn kaplan lecture of 1min for 1 question is not applicable for every questions
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Old 11-03-2011
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E. Control his blood pressure
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Old 11-04-2011
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The correct answer is E. Clearly, this patient is having an acute myocardial infarction, which would make us consider thrombolytic therapy. But he has a relative contraindication to thrombolytics at this time because his blood pressure is uncontrolled. First, control his blood pressure by giving him analgesics and using nitroglycerin and other measures necessary, including beta-blockers. Once his blood pressure is less than 180/110 mm Hg, proceed with thrombolytics.

Sending him for cardiac catheterization immediately because of his safe-sensitive job (choice A) is incorrect. Patients with chest pain other than myocardial infarction who work in safe-sensitive jobs—such as pilots, air traffic controllers, bus drivers, etc.—should go directly to cardiac catheterization to evaluate their chest pain without having a stress test.

Starting a heparin drip (choice C) in this patient would be appropriate if we were not considering thrombolytics. But controlling the BP is of our first priority so we can give him thrombolytic therapy as soon as possible.

Immediate thrombolytic therapy (choice D) is not appropriate at this time because there is a relative contraindication to thrombolytics: uncontrolled hypertension or a blood pressure greater than 180/110.

CABG (choice B) is appropriate in patients with indications such as triple-vessel disease or with significant occlusion of the left coronary artery, but not during an acute myocardial infarction presentation.
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