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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Determine the goals of pharmacotherapy for patients with ST-segment elevation myocardial infarction (STEMI).

  • Discuss interventional strategies for patients with STEMI, and understand the pharmacotherapeutic agents used with interventions.

  • Design an optimal therapeutic plan for the management of STEMI, and describe how the selected drug therapy achieves the therapeutic goals.

  • Identify appropriate parameters to assess the recommended drug therapy for both efficacy and adverse effects.

  • Provide appropriate education to a patient who has suffered STEMI.

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PATIENT PRESENTATION

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Chief Complaint

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“This is the worst pain I have ever felt in my life.”

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HPI

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Gary Roberts is a 68-year-old man admitted to the ED complaining of chest pressure/pain lasting 20–30 minutes occurring at rest. He describes the pain as substernal, crushing, and pressure-like that radiates to his jaw and is accompanied by nausea and diaphoresis. The pain first started approximately 6 hours ago after he ate breakfast and was unrelieved by antacids or SL NTG × 3. He also states that he has been experiencing intermittent chest pain over the past 3–4 weeks with minimal exertion.

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PMH

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  • HTN

  • Type 2 DM

  • Dyslipidemia

  • CAD with PCI with a drug eluting stent (DES) 3 years ago

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FH

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Father died from heart failure at age 75 and mother is alive at age 88 with HTN and type 2 DM.

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SH

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(+) Tobacco × 20 years but quit when he received his DES 3 years ago; drinks beer usually on weekends; denies illicit drug use.

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Meds

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  • Aspirin 81 mg PO daily

  • Metoprolol tartrate 25 mg PO BID

  • Simvastatin 40 mg PO QHS

  • Metformin 500 mg PO BID

  • SL NTG PRN CP

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All

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NKDA

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ROS

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Positive for some baseline CP on exertion for the past 3–4 weeks, now with CP at rest

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Physical Examination

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Gen
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WDWN man, A & O × 3, still with ongoing chest pain, somewhat anxious

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VS
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BP 145/92, P 89, RR 18, T 37.1°C; Wt 95 kg, Ht 5′10″

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HEENT
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PERRLA, EOMI, fundi benign; TMs intact

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Neck
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No bruits; mild JVD; no thyromegaly

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Lungs
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Few dependent inspiratory crackles; bibasilar rales; no wheezes

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CV
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Normal S1 and S2, no MRG

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Abd
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Soft, nontender; liver span 10–12 cm; no bruits

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Genit/Rect
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