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A 72-year-old man is evaluated for resting chest pain, occurring over the course of the day but also at night related to dreaming. He arrives at the emergency department at 10 AM, 2 hours after the onset of chest pain. He has hyperlipidemia and smokes cigarettes occasionally. His medications consist of an angiotensin-converting enzyme inhibitor, aspirin, and a statin. His brother underwent coronary artery bypass grafting last year.
On examination, the blood pressure is 185/95 mm Hg, heart rate 95/min, with no jugular vein distention, clear lungs, a faint S1, S2, and S4 and an early systolic murmur at the upper right sternal border. Examination of the abdomen and extremities is normal. The resting electrocardiogram is shown (;"" target=_blank name=tip tip="[img>'../figures/thumbs/mk14_a_cv_mcq_f049.jpg'/[/img>& #34;>Figure 49). Laboratory studies show normal hematology findings and a serum creatinine of 1.6 mg/dL (141.47 μmol/L), blood urea nitrogen of 29 mg/dL (10.36 mmol/L), and normal electrolytes.
Which of the following is the most appropriate next therapy?
A Fibrinolysis B Coronary angiography C Nitroprusside D Abciximab E Hydralazine This question has been answered. To clear answers, open the Answer Sheet. Answer and Critique (Correct Answer ) Key Points - Hypertension (blood pressure >180/110 mm Hg) is a relative contraindication to fibrinolysis in patients with STEMI.
- Revascularization should proceed expeditiously with concomitant medical therapy for hypertension complicating STEMI.
This patient has findings of acute myocardial infarction with ST-segment elevation (STEMI). Coronary angiography and subsequent revascularization with stenting or coronary artery bypass grafting is indicated. In patients with STEMI and poorly controlled hypertension, fibrinolytic therapy is relatively contraindicated. Percutaneous coronary intervention, which is the preferred approach when reperfusion can be achieved in a timely manner, is associated with >85% patency rate at late follow-up. It is especially suitable for STEMI patients who have an increased risk of bleeding.
The time to re-establishment of myocardial perfusion is critical to patient outcomes. The shorter the time from arrival in the emergency department to opening the artery (door-to-balloon time) as well as time to achieving full coronary flow, the better the outcome. Compared with fibrinolysis, percutaneous coronary intervention for STEMI is associated with lower overall mortality, reinfarction, and hemorrhage.
Bibliography - Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA. 2000;283:2941-7. [PMID: 10865271] []
- Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361:13-20. [PMID: 12517460] [PubMed]
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