doyoudig
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A 70-year-old male is admitted to the hospital with chest pain for 8 h. Serum studies demonstrate elevation of troponin and CK-MB. ECG demonstrates anterior ST elevation, for which he is given tissue plasminogen activator, heparin, and intravenous nitroglycerin. His symptoms resolve after treatment. He is started on oral medications
and transferred out of the cardiac intensive care unit on day 3. The subsequent hospital course is uneventful until day 4, when he develops severe shortness of breath. Blood pressure is 110/70, and pulse is 120. Examination reveals a new systolic murmur. The
most appropriate therapeutic intervention would be
A. Emergent cardiac surgery consultation and transfer to the operating room
B. IV heparin
C. IV heparin and streptokinase
D. IV heparin and furosemide
E. IV sodium nitroprusside
Ur Dx n Rxment
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| Justice
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Papillary muscle rapture and mitral regurgitation...
Treatment could be D
the history is confusing... It does not say if previous treatments were discontinued but they say that something was given orally... Heparin???
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| NE
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The diagnosis is correct but the treatment of choice is urgent mitral valve replacement despite cardiogenic shock or recent MI.
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| doyoudig
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hey justice don't fall into the same trap, similar question but different source, that was posted before from Dr Fisher. He got PostMI Complication......ur rite w/ dx, not Rx
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| Justice
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doyoudig wrote:
hey justice don't fall into the same trap, similar question but different source, that was posted before from Dr Fisher. He got PostMI Complication......ur rite w/ dx, not Rx
I am trying not to, but it seemed reasonable to reduce preload and prevent potential thrombotic complications...
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| NE
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yes, I just read the explanation from another post....
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| Justice
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NE wrote:
yes, I just read the explanation from another post....
Are you about sodium nitroprussid? I think the mech-ms are different, as well as reasons...
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| doyoudig
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The answer is E.
This patient most likely is having a ventricular septal rupture and a subsequent defect, a
not uncommon complication of myocardial infarction (MI) that explains the need to
auscultate the heart on a daily basis during the early period after an MI. Myocardial
rupture after an MI can occur either in the free wall, with bleeding into the pericardium,
tamponade, and a high incidence of fatality, or in the ventricular septum, with a greater
potential for successful therapy despite the fact that this is a critical complication.
Therapy is geared toward decreasing afterload and systemic vascular resistance.
Interventions to be considered include IV nitroglycerin, IV sodium nitroprusside, and/or
intra-aortic balloon counterpulsation. Often cardiac surgery with septal repair is the only
viable long-term intervention; however, this is best undertaken when the patient has
stabilized and ideally once the infarction has healed. In many cases the patient does
not stabilize, at which point acute surgical intervention is indicated
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| ssrpk
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very good question
for mechanical complications including Mitral valve rupture and Ventricular septal rupture, surgery should be considered even if the condition is detected early and the patient is stable...however stabilization of the patient is the most important consideration. IV nitroprusside reduces afterload which significantly reduces the regurgitation or shunting fraction.
a useful link:
http://www.clevelandclinicmeded.com/diseasemanage...
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