darkhorse
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A 57-year-old woman with diabetes and nephrolithiasis is admitted to the medical services for evaluation of her chest pain that began when playing with her grandchild. She had a previous myocardial infarction and is status-post a three-vessel bypass two years prior. Her medications include atenolol, lisinopril, allopurinol, and atorvastatin daily. You are called to the patient's room because the patient is currently complaining of chest pain. She reports that while talking on the telephone, she became very angry with her daughter and developed chest pain. On arrival she is lying in bed and appears uncomfortable. She is diaphoretic and appropriately anxious. Her blood pressure is 190/110 mm Hg and pulse is 110/min. She has an S4 gallop and scant bi-basilar rales. An electrocardiogram shows sinus tachycardia with a left axis deviation. Voltage criteria are met for LVH and there are ST segment depressions of 2.5mm in leads V1-V5. The most appropriate next step in management is to
A. administer verapamil, intravenously
B. give furosemide, intravenously
C. give morphine, intravenously
D. give nitroglycerine, intravenously
E. obtain a chest radiograph
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| Kamsi
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D Pt has non ST elevation MI
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| tamerbashir
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| Kamsi
Forum Guru
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In Non ST elevation MI,give anti anginal drugs....beta blocker or nitrates ,but give Ca channel blker if
a contraindication to Beta n mitates
b those who remain symptomatic or hypertensive on appropriate anti-htn dose
I'm thinking of IV verapamil to take care of pts htn, moreover Nitroglycerin is usually given sublingual unless severe Darkhorse pls clear me on that
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| arlete
Intern in 2009!!!!!
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Do not give calcium channel blockers during MI, they increase the mortality.
Patients with NSTEMI who remain symptomatic on appropriate medication should go to the cath lab right away.
Answer is D.
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| neurom
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Non-Q-wave MI: supplemental oxygen, nitrates, if the chest pain persists - iv morphine.
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| darkhorse
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The correct answer is D. This patient is having cardiac ischemia in the setting of increased myocardial oxygen demand. She has known coronary disease and her vital signs at the time of her angina episode show hypertension and tachycardia. The patient must have her blood pressure lowered acutely to the goal of terminating the angina with nitroglycerin.
Verapamil (choice A) is a calcium channel blocker that is used most often to slow the ventricular rate in patients with atrial fibrillation. These drugs are generally contraindicated in an acute myocardial ischemia as they tend to be associated with worse outcome.
Furosemide (choice B) may work to relieve some pulmonary congestion that this patient has as a result of her ischemia and increased left-sided filling pressures. It however fails to address the primary problem of her increased demand.
Morphine (choice C) is usually given to relieve pain, but nitroglycerin is more important at this time because it can relieve pain and also reduce the underlying ischemia.
A chest radiograph (choice E) would not be without benefit in this emergent situation, it has no role in altering any decision making or therapeutic intervention. This patient must have her blood pressure and heart rate lowered
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