Chapter 16: Acute Coronary Syndrome: St-Elevation Myocardial Infarction: I Can’t Handle the Pressure Level III

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LEARNING OBJECTIVES

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

• 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

HTN

Type 2 DM

Dyslipidemia

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

FH

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

SH

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

Meds

Aspirin 81 mg PO daily

Metoprolol tartrate 25 mg PO BID

Atorvastatin 40 mg PO QHS

Metformin 500 mg PO BID

SL NTG PRN CP

All

NKDA

ROS

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

Physical Examination

Gen

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

VS

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

HEENT

PERRLA, EOMI, fundi benign; TMs intact

Neck

No bruits; mild ...