Question

A 59-year-old man comes to the emergency department due to chest pain beginning 2 hours ago and profuse sweating 1 hour ago. He feels weak. Past medical history includes type 2 diabetes mellitus and hypercholesterolemia. The patient's medications include metformin, glipizide, and simvastatin. Blood pressure is 165/98 mm Hg in the right arm and 160/90 mm Hg in the left, pulse is 78/min, and oxygen saturation is 98% on room air. He appears mildly uncomfortable. Lungs are clear to auscultation. His ECG is shown. Which of the following is the best next step in managing this patient?

Options:

A. Aspirin, cardiac enzyme levels, and observation in the intensive care unit
B. Aspirin, heparin infusion, and admission to the telemetry floor
C. Aspirin and immediate cardiac catheterization
D. CT scan of the chest
E. Nonsteroidal anti-inflammatory drugs as needed for pain

Correct Answer: C (Aspirin + Immediate Cardiac Catheterization)

Reason: In STEMI, the goal is rapid reperfusion through PCI or thrombolysis to minimize myocardial damage.

59-year-old Male with Chest Pain 🧠

Chest pain onset: 2 hours ago

Profuse sweating: 1 hour ago (autonomic response to myocardial infarction)

Weakness (due to myocardial ischemia and ↓ cardiac output)

Past medical history: Type 2 diabetes, hypercholesterolemia

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Risk Factors for Coronary Artery Disease

Diabetes and hypercholesterolemia ↑ (atherosclerosis formation)

Plaque rupture in coronary artery → Thrombosis formation 🧠

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Myocardial Ischemia → Progresses to Myocardial Infarction (STEMI)

↓ Blood flow to heart muscle → Ischemia → Necrosis 🧠

ST-segment elevation on ECG (key indicator of STEMI)

Blood pressure mildly elevated; pulse slightly reduced due to vagal response

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ECG Findings: ST-segment Elevation 🧠

Diagnostic for STEMI

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Immediate Management - Aspirin 🧠

Mechanism: Inhibits platelet aggregation, preventing further clot growth

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Urgent Step: Immediate Cardiac Catheterization 🧠 (Option C - Correct Answer)

Indication: Cardiac catheterization with possible percutaneous coronary intervention (PCI) to restore blood flow (reperfusion)

Why Other Options Are Incorrect:

A. Aspirin, cardiac enzyme levels, ICU observation 🧠

• Incorrect: While aspirin is correct, ICU observation alone delays necessary reperfusion (which is critical in STEMI)

B. Aspirin, heparin infusion, admission to telemetry floor 🧠

• Incorrect: Telemetry admission without urgent PCI delays critical treatment for STEMI (appropriate for NSTEMI or unstable angina)

D. CT Scan of the Chest 🧠

• Incorrect: CT scan is not useful in diagnosing STEMI, it's used for non-cardiac causes (e.g., pulmonary embolism)

E. NSAIDs for Pain 🧠

• Incorrect: NSAIDs are contraindicated in MI because they ↑ risk of adverse cardiac events and inhibit healing

Flashcards

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