zaki
Forum Guru
Topics: 92
Posts: 398
|
A 54-year-old man presents to the emergency room with 2½ hours of chest discomfort. He appears to be hemodynamically stable, and an electrocardiogram (ECG) shows an acute inferolateral myocardial infarction. The patient is treated with aspirin, intravenous beta-blockers, and thrombolytics. He is admitted to the coronary care unit, where serial cardiac enzymes confirm an infarction with a peak creatine kinase of 900 U/L (normal is less than 250 U/L). Five days later the ECG shows T-wave inversion in the inferolateral leads but no Q waves. A predischarge exercise test reveals no angina or ECG changes.
What is the most appropriate medication at the time of hospital discharge?
A) Aspirin
B) Angiotensin-converting enzyme (ACE) inhibitor
C) Beta-blocker
D) Warfarin
E) Oral nitrate
___________________
Maverick
|
| guest
|
Choice A
|
| peace
|
both aspirin & beta blockers should be given, but if I have to choose, I go/w aspirin.
|
| zaki
Forum Guru
Topics: 92
Posts: 398
|
Answer: A
The patient has sustained an uncomplicated non–Q-wave myocardial infarction. Aspirin therapy at doses of 160 mg daily or greater has been clearly shown to reduce the risk of subsequent myocardial infarction and overall cardiovascular death.
Because this is his first infarction and there is no evidence of congestive heart failure as well as a relatively small peak creatine kinase, it is unlikely that he has any significant degree of left ventricular dysfunction. If the patient had symptoms of congestive heart failure or had documentation of an ejection fraction of less than 40%, he would benefit from long-term treatment with angiotensin-converting enzyme (ACE) inhibitors. In the absence of the aforementioned findings, ACE inhibitors are not indicated.
Beta-blockers have been shown to be beneficial in the long-term treatment of patients following myocardial infarction if they have evidence of recurrent ischemia or have sustained a Q-wave myocardial infarction. Interestingly, subgroup analysis of the beta-blocker trials demonstrated no benefit in patients with small or non–Q-wave myocardial infarctions.
Diltiazem and verapamil (which do not increase heart rate) have been shown to benefit patients with non–Q-wave myocardial infarctions. Unfortunately, the trials that evaluated diltiazem did not include aspirin treatment. The benefit of these agents appeared to be due to a reduction in recurrent myocardial infarction, an event that can also be reduced with aspirin therapy. Likewise, warfarin may have some beneficial role in prevention of subsequent myocardial infarction; however, there appears to be no benefit over aspirin, which is inexpensive and less complicated to regulate.
Although nitrates may play a role in reducing the level of angina, there are no data to suggest that prophylactic use of nitrates in the setting of an acute myocardial infarction or in the subsequent care of a myocardial infarction patient reduces mortality
___________________
Maverick
|
|
| |
| | | | |
Similar forum topics