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Chapter 4. Acute Coronary Syndromes

LC is a 76-year-old woman who presents to ED via 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.” LC’s weight is 65 kg.

Past medical history: CAD and arthritis

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

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

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

Laboratory data: Serum creatinine (SCr) = 1.9 mg/dL, total cholesterol 250 mg/dL, triglycerides 150 mg/dL, high-density lipoprotein (HDL) 40 mg/dL, LDL 130 mg/dL, troponin I = 5.7 ng/mL

Electrocardiogram: ST-segment elevation

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

a. Chew ASA 81 mg, clopidogrel 75 mg, UFH for 48 hours

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

c. Chew ASA 325 mg, administer ticagrelor 180 mg orally once, abciximab 16.25 mcg IV bolus and percutaneous intervention with coronary stent placement

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

Answer c is correct. LC 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.

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

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

Answer d is incorrect. This is a possibility for treatment since this patient is a STEMI and will need reperfusion either with fibrinolytic or 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. Also, if the facility has PCI capabilities, the patient should receive PCI as it is more effective than ...

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