CASE LEARNING OBJECTIVES
List key electrocardiographic and clinical features identifying a patient with non–ST-segment elevation (NSTE) acute coronary syndrome (ACS) who is at high risk of myocardial infarction (MI) or death
Devise a pharmacotherapy treatment plan for a patient with ST-segment elevation myocardial infarction (STEMI) given patient-specific data
Devise a pharmacotherapy treatment and monitoring plan for a patient with NSTE ACS given patient-specific data
Formulate a monitoring plan for a patient with NSTE ACS receiving aspirin, clopidogrel, β-blocker, anticoagulant, and glycoprotein IIb/IIIa receptor inhibitor
Devise a pharmacotherapy and risk-factor modification treatment plan for secondary prevention of coronary heart disease (CHD) events in a patient following MI
List the quality performance measures of care for MI
"My chest discomfort is gone now that they put a stent in my coronary artery."
History of Present Illness
Jonathan Wright is a 66-year-old male who presented to the emergency department (ED) by ambulance at 14:00 complaining of 4 hours of continuous chest pressure that started while raking leaves. JW developed substernal chest pressure at 10:00 about 30 minutes after starting to rake leaves at his home. He stopped and rested but the chest pressure did not resolve. Local paramedics were summoned, and he was given three 0.4 mg SL NTG tablets by mouth, 325 mg aspirin by mouth, and morphine 2 mg IV push at 13:30 without relief of chest discomfort. He was brought to the ED by ambulance. A 12-lead ECG was performed, and NTG 10 mcg/min IV infusion was initiated at 14:15. The cardiology attending consulted with the interventional cardiologist and the decision was made to bring JW to the cardiac catheterization laboratory for coronary angiography (see Figure 6-1). Bivalirudin was initiated at the time of percutaneous coronary intervention (PCI) and was discontinued in the cardiac catheterization laboratory following successful PCI. The patient is now in the CCU s/p PCI with placement of a bare metal stent in the LAD coronary artery.
Coronary angiogram of the left coronary artery (LCA) with a tight stenosis in the proximal left anterior descending (LAD) artery (black arrow). The circumflex artery (CX) has two moderately severe stenoses (white arrows). (Reproduced, with permission from Usatine RP, Smith MA, Mayeaux Jr EJ, Chumley H, Tysinger J The Color Atlas of Family Medicine. New York, McGraw-Hill, 2009, Fig 45-1.)
Father with MI at age 75; mother and sister alive with type 2 DM
Retired former newspaper reporter
Nonsmoker. Denies use of alcohol or illicit drugs