A 62-year-old man with a history of hypertension is mowing his law n at 9:00 a.m. on a Saturday morning when he experiences a heavy sensation in his chest. He stops mowing the lawn and within 10 minutes his symptoms resolve, and he resumes cutting the grass. Approximately 10 minutes later, he experiences severe, crushing chest pain associated with shortness of breath and pain radiating down his left arm. As he walks to his house, he becomes diaphoretic and nauseated, and vomits twice. At this point, he calls an ambulance and is taken to the ER. When you arrive to examine him, he is still experiencing severe pain. A 12-lead ECG reveals 3-mm ST-segment elevation in leads V2, V3, V4, and V5 w ith inferior ST-segment depression. The pain has been present for a total of approximately 45 minutes.
\1. What initial actions should be taken in this patient?
2. Is this patient's hypertension a contraindication to thrombolytic therapy?
3. What are the risks associated w ith thrombolytic therapy and how long after the onset of acute MI is therapy beneficial?
4. Which is the better reperfusion therapy for acute MI—thrombolytic therapy or primary percutaneous transluminal coronary angioplasty (PTCA)?
5. What therapies should be administered acutely w ith thrombolysis or primary PTCA?
6. What measures should be carried out before this patient is discharged?
7. Under w hat circumstances should the patients undergo coronary angiography if they did not undergo acute angioplasty and/or stenting on admission?
Case Discussion
1. What initial actions should be taken in this patient?
The first actions that should be taken in this patient are to administer sublingual NTG, administer oxygen if oxygen saturation is below 90%, and establish venous access. IV β-blockers and aspirin should be given. Analgesics such as morphine should be given if the pain does not resolve with NTG. Immediate transfer to the cardiac catheterization laboratory for coronary angioplasty and reperfusion
