zaki
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An active 80-year-old woman presents to a small community hospital with severe crushing chest pain of approximately 5 hours’ duration. She has no history of a previous stroke, transient ischemic attack, or bleeding propensity. Her initial pulse rate is 80/min and blood pressure is 165/95 mm Hg. She has no signs of peripheral hypoperfusion, and the lungs fields are clear. Initial electrocardiogram reveals 4 mm of ST-segment elevation in the anterior precordial leads. The hospital is nearly 2 hours from the nearest cardiac catheterization laboratory.
What is the most appropriate initial therapy?
A) Aspirin, streptokinase, and intravenous heparin
B) Aspirin and streptokinase
C) Aspirin and accelerated dosing of tissue plasminogen activator (tPA) with intravenous heparin
D) Aspirin and tPA with subcutaneous heparin
E) Aspirin and nitrates
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Maverick
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| guest
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Choice A
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| no more a loser
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hey i dont know bout what accelerated tpA is? otherwise i would say
Aspirin, tPA, IV heparin
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| peace
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C) Aspirin and accelerated dosing of tissue plasminogen activator (tPA) with intravenous heparin
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| veri
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Thrombolysis is contraindicated in people older than 75.
So i think is aspirin and nitrates.
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| alice8
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is she suffering from aort dissection?my answer is going to be E) Aspirin and nitrates
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| Raja
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age is not an absolute contra indication. but risk of bleeding intracranially is present. so give asprin and strep INITIALLY. heparin iv should be the next step after finishing thrombolysis. not simultaneously.
Raja
Residencyandfellowship.com
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| gballarino
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ICP is superior than Thrombolysis when it can be performed in 90 +/- 30 minutes. So if you decide fast, she´s still elegible for PCI. Fortunately, this is not a given option. :wink: (glad we are).
She has no absolute contraindications for thrombolytic treatment. Age is NOT a contraindication. Knowing that she is older than 70, however, can influence the choice of the thrombolytic agent.
TPA, is associated with a higher relative risk of bleeding in elderly patients (above 70), and with lower potential benefit in patients with prolonged period of time from onset of symptoms (optimum: 1-3 hours). Both elements are relative contraindications for TPA and indications to use streptokinase.
Heparin is indicated when specific thrombolytics are infused (alteplase, reteplase, tecneplase). Heparin is not an indication when streptokinase is infused.
There´s no reason in the history to think of disection, is there?
I´d say she should be placed on Aspirin and Streptokinase. Option (B).
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Guillermo Ballarino
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| zaki
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can we transfer the pt for ptca even if the referal hospital is 2hrs from the hospital???
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Maverick
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| gballarino
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2000 guidelines from American Heart Asociation:
Percutaneous Coronary Interventions (PCIs) and fibrinolytic treatment might be equivalent interventions when all of the following is true:
:arrow: PCI (balloon dilation) can be performed within 90 +/- 30 minutes
:arrow: PCI operators have considerable expertise.
:arrow: PCI center do numerous procedures every year.
:arrow: PCI center reestablish a normal flow velocity in more than 90% of cases without emergent coronary reperfusion surgery (bypass), CVA, or death.
2 hours is the limit. If PCI would have been a choice, it would have been a tough one to discard. However, she´s been in pain for 5 hours, and delaying reperfusion another 2 when thrombolysis can be perfomed... mmmm.... I don´t know. I know I wouldn´t refer.
PCI is superior to fibrinolytics for patients in cardiogenic shock younger than 75.
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Guillermo Ballarino
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| zaki
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yap agree with the ptca is superior to the thrombolysis if with in 2 hrs referall is posible, you got it gballarino
Answer is B
Educational Objective: Determine patient eligibility for thrombolytic therapy, which thrombolytic drug should be used in a given situation, and the need for adjunctive heparin.
Although elderly patients are at high risk of having intracranial bleeding, they also have a higher mortality from their infarctions. It has been clearly demonstrated that elderly patients benefit from thrombolytic therapy; therefore, age alone should not be considered a contraindication. Furthermore, this patient is presenting with a relatively large myocardial infarction well within the acceptable time period for treatment with thrombolytic agents.
Three large randomized trials have demonstrated a higher risk of intracranial bleeding with tissue plasminogen activator (tPA) when compared with streptokinase therapy. This has been particularly true in patients who are over the age of 70 or who have hypertension at the time of presentation. Furthermore, accelerated tPA with intravenous heparin may produce lower mortality than streptokinase only in patients who are treated within the first 4 hours after onset of symptoms. Use of tPA with subcutaneous heparin offers no mortality advantage. Therefore, in this mildly hypertensive 80-year-old patient who is treated more than 4 hours after symptom onset and who is at risk of having an intracranial bleed, streptokinase is the clear choice.
There is no evidence to suggest that intravenous heparin is of any advantage when streptokinase is the thrombolytic drug. In fact, intravenous heparin appears to increase the bleeding complications with streptokinase, without any added reduction in mortality or reinfarction. For these reasons, when using streptokinase, no heparin should be used unless the patient has clear-cut indications, such as left ventricular thrombosis.
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Maverick
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