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Chapter 8: Acute Coronary Syndromes

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TS is a 75-year-old woman who presents to emergency department (ED) via emergency medical system (EMS) to a large academic medical center (with a coronary catheterization laboratory) complaining of sudden onset of diaphoresis and nausea. She states, “About 5 hours ago my chest started hurting and I just don’t feel well.” TS’s weight is 65 kg.

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  Past medical history: Coronary artery disease and arthritis

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  Family history: Father died of acute myocardial infarction at 76 years of age and mother passed away at age 70 from pneumonia

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  Social history: Does not drink; smokes 1 pack of cigarettes per week.

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  Medications: Aspirin 81 mg orally once daily, atorvastatin 40 mg orally at bedtime, conjugated estrogens 0.625 mg, and celecoxib 200 mg orally daily.

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  Laboratory data: SCr = 1.9 mg/dL, total cholesterol 250 mg/dL, triglycerides 150 mg/dL, HDL 40 mg/dL, LDL 130 mg/dL, troponin I = 5.7 ng/mL.

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  Electrocardiogram: ST-segment elevation.

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Which one of the following is the preferred approach to reperfuse this patient?

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a. Chew aspirin 81mg, clopidogrel 75 mg, unfractionated heparin (UFH) for 48 hours

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b. Reteplase 10 units IV for two doses 30 minutes apart and UFH for 48 hours

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c. Chew aspirin 324 mg, administer clopidogrel 600 mg orally once, abciximab 16.25 μg IV bolus, and percutaneous intervention with coronary stent placement

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d. Streptokinase 1,500,000 units IV over 30 minutes, aspirin 81 mg, and clopidogrel 300 mg

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Answer c is correct. TS is experiencing a STEMI that requires emergent reperfusion and has presented to a hospital with cardiac catheterization capabilities. The patient should be loaded (higher doses) with antiplatelets, and started on abciximab since he will be going to catheterization emergently.

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Answer a is incorrect. TS is experiencing a STEMI and the goal for these patients is always primarily reperfusion. Aspirin, clopidogrel, and UFH will prevent further platelet aggregation and thrombus formation but they do not dissolve current clots.

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Answer b is incorrect. A regimen including reteplase is a possibility for TS's treatment since reperfusion can occur either with fibrinolytic or percutaneous coronary intervention (PCI). However, if the facility has PCI capabilities, the patient should receive PCI as it is more effective than thrombolysis.

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Answer d is incorrect. This is a possibility for treatment since this patient is a STEMI and will need reperfusion either with fibrinolytic or percutaneous transluminal coronary angioplasty (PTCA). However, streptokinase is not a common or highly recommended fibrinolytic due to its lack of specificity and capability of allergic reactions. Newer second generation fibrinolytics are preferred.

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