Treatment Desired Outcomes

Short-term desired outcomes in a patient with ACS are: (a) early restoration of blood flow to the infarct-related artery to prevent infarct expansion (in the case of MI) or prevent complete occlusion and MI (in UA); (b) prevention of death and other com plications; (c) resolve ECG changes; (d) prevention of coronary artery reocclusion; and (e) relief of ischemic chest discomfort.

Patient Encounter 1, Part 1

SD is a 55-year-old, 85 kg (187 lb) male who developed chest tightness while skiing at 20:30 hours. He became short of breath and diaphoretic. Local paramedics were summoned and he was given three 0.4-mg sublingual nitroglycerin tablets by mouth, 325 mg ASA by mouth, and morphine 2-mg IV push without relief of chest discomfort. SD presented to the hospital at 21:15 hours. The hospital does not have a cardiac catheterization laboratory and transport time to the nearest hospital with intervention-al facilities is more than 1.5 hours away via air transport.

PMH: HTN for 10 years; dyslipidemia for 6 months; two-vessel CAD (60% right coronary artery [RCA] and 80% left anterior descending artery [LAD] occlusion) after intracoronary sirolimus-eluting stent placement to the mid-LAD artery lesion 10 months ago

FH: Father with myocardial infarction at age 65; mother alive and well; one sibling with HTN

SH: Smoked one pack per day for 30 years, quit 10 weeks ago Allergies: NKDA

Meds: Metoprolol 25 mg by mouth twice daily; ASA 325 mg by mouth once daily; lovastatin 20 mg by mouth once daily at bedtime; enalapril 5 mg by mouth once daily

ROS: 7/10 chest pain/squeezing, diaphoretic

HEENT: Normocephalic atraumatic

CR: Regular rate and rhythm S1 S2, +S3, +S4, no murmurs or rubs

Lungs: Rales bilaterally V4 way up

Abd: Nontender, nondistended

Gl: Normal bowel sounds

GU: Stool guaiac negative

Exts: No bruits, pulses 2+, femoral pulse present, good range of motion Neuro: Alert and oriented x 3, cranial nerves intact

Labs: Sodium 138 mEq/L (138 mmol/L), potassium 4.2 mEq/L (4.2 mmol/L), chloride 105 mEq/L (105 mmol/L), bicarbonate 24 mEq/L (24 mmol/L), SCr 1.0 mg/dL (88 pmol/L), glucose 95 mg/dL (5.27 mmol/L), WBC 9.9 x 103/mm3 (9.9 x 109L), hemoglobin 15.7 g/dL (157 g/L or 9.7 mmol/L), hematocrit 47%, platelets 220 x 103/mm3 (220 x 109L), brain natriuretic peptide 3,238 pg/mL (3,238 ng/L), troponin I 16 ng/ mL (16 mcg/L), oxygen saturation 99% on room air

ECG: Normal sinus rhythm, PR 0.16 seconds, QRS 0.08 seconds, QTc 0.38 seconds, occasional polymorphic premature ventricular contractions, 3 mm ST-segment elevation anterior leads

CXR: Congestive heart failure, borderline upper normal heart size

Echo: Hypocontractile left ventricle, akinesis of anterior apical wall, EF 20%

What information is suggestive of acute MI?

What complications of Ml are present?

Long-term desired outcomes are control of risk factors, prevention of additional cardiovascular events, including reinfarction, stroke and heart failure, and improvement in quality of life.

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