Location: Emergency room
Vitals: Pulse: 80/min; B.P: 145/90 mm Hg; Temp: 98.8 F; R.R: 16/min; Height: 72 inches (180 cm); Weight: 72 Kg (158.4 lbs) .
CC: Severe chest pain
HPI: A 60-year old white male comes to E.R with a two- hour history of severe central chest pain that began while relaxing on the couch at home. The patient denies any exertional activity prior to the onset of symptoms. The pain is constant, 9/10 in severity, crushing in quality, and radiates to the left side of the jaw and left shoulder. There is associated nausea without vomiting. Over the past two months he has experienced several episodes of exertional chest pain while at work. The pain is usually relieved with rest. He did not seek any medical attention thinking that the pain was work related muscle spasms. Medical problems include hypertension for which he has been taking hydrochlorothiazide the past 10 years. He has no known allergies. FH: His father died of MI when he was 55. Mother is 85 yrs old and healthy. SH: He has been married for 34 years and has two sons. He is not sexually active. He has a 30-pack per year smoking history. He drinks moderate amounts of alcohol on weekends, but denies the use of recreational drugs. He is a truck driver. ROS: Denies headaches, vision changes, tinnitus, or vertigo. Denies muscle tenderness, joint pain, stiffness, or weakness. Rest of ROS is unremarkable.
How to approach this case?
This patient has come to the ED with chest pain of recent onset which has many causes and some of them may cause sudden death. Therefore, all such patients should be transported to ED immediately. Oxygen, IV access, cardiac monitoring, and EKG need to be done as soon as possible. Aspirin is given if MI is likely.
Therefore, we should order the following:
Pulse oximetry, stat
Oxygen inhalation, continuous
Aspirin, oral, continuous
Nitroglycerin, sub lingual, one time, stat (*Repeat every 5 minutes x 3 as needed for chest pain)
IV access, stat
Cardiac monitoring, continuous
Cuff, BP monitoring, continuous
EKG, 12 lead, stat
The history and physical examination complemented by selected tests such as chest X-ray, EKG, cardiac enzymes allow the physician to accurately diagnose most causes of chest pain, especially CAD. Therefore, we will also do the following
Rectal exam (As this patient may require Heparin for CAD)
Musculoskeletal (for possible DVT)
98% saturation on room air and 99% on 2-lit oxygen.
Physical exam is completely normal. Rectal exam shows hem negative stools.
EKG shows normal sinus rhythm with 3 mm ST depression and T wave inversion in lead II, III and AVF.
Heparin, IV, continuous
Metoprolol IV, bolus x 3 (5 minutes apart)
Chest X-ray, PA, portable, stat
CK-MB, stat and every 8 hours x 2
Troponin-I, stat and every 8 hours x 2
CBC with diff, stat and daily
BMP, stat and daily
*Order brief history
Patient is still complaining of pain. His history, CAD risk factors such as smoking, HTN, family history, and the EKG findings of T wave inversion suggest the diagnosis of either unstable angina or non-Q wave infarction. In cases of unstable angina, troponins or CK-MB are not elevated but they are elevated in cases of non-Q wave infarcts. However, even in cases of non-Q wave infarcts, troponins levels may not be detectable at initial presentation. We will start heparin and anti-ischemic therapy in this patient.
Shift to ICU
Nitroglycerin, IV, continuous (blood pressure should be monitored as hypotension may develop) or nitro paste, topical, continuous
EKG, 12 lead, stat (repeat this to see the EKG changes)
Bed rest, complete
NPO, as this patient may require emergency catheterization
Metoprolol, oral, continuous
Simvastatin, oral, continuous
Cardiac enzymes are within normal limits.
*Order brief history
Now the patient is pain free; his second set of cardiac enzymes are negative.
D/C intravenous nitroglycerine or nitro paste (once pain free)
Shift to ward after 24 hours and continue the above treatment.
Lipid panel, routine
LFTs (for baseline before you start statins), routine
Consult cardiology (for cardiac catheterization)
*Obtain TSH if the patient has abnormal lipids especially elevated triglycerides.
*Usually the case will end if you do this much. If it continue then follow...
Diet, low sodium
Diet, low cholesterol (fat)
Follow up visit at two to six weeks
His discharge medications should be (aspirin, metoprolol, statin, Sub lingual nitroglycerine, and +/- clopidogrel)
The guidelines for the management of USA/NSTEMI are:
Bed rest with continuous ECG monitoring in patients with ongoing rest pain.
NTG, sublingual, followed by intravenous administration, for the immediate relief of ischemia.
Aspirin should be given as early as possible. Clopidogrel is used in patients who are unable to take ASA because of allergic reactions or major gastrointestinal intolerance.
Pulse oximetry and/or ABG
Supplemental oxygen for patients with cyanosis or respiratory distress
IV Morphine when the chest pain is not immediately relieved with NTG or when acute pulmonary congestion and/or severe agitation is present.
IV beta-blocker followed by a oral dose provided there are no contraindications. The goal of the treatment is to bring the heart rate down to 60-70/min. If there are any contraindications for beta blockers and the patient is having continuous or frequently recurring, a nondihydropyridine calcium antagonist (e.g., verapamil or diltiazem) can be used as initial therapy in the absence of severe LV dysfunction or other contraindications.
Routine use of ACEI to all patients with USA/NSTEMI is a class II recommendation. However, an ACEI is used when hypertension persists despite treatment with NTG and a beta-blocker, in patients with LV systolic dysfunction and in diabetic patients.
Anticoagulation with LMWH or intravenous unfractionated heparin should be added to antiplatelet therapy with ASA and/or clopidogrel. Enoxaparin is the best studied of all. Heparin should be given for at least 2 days.
A platelet GP IIb/IIIa antagonist (Tirofiban or eptifibatide) should be administered, in addition to ASA and heparin, to patients in whom catheterization and PCI are planned.
Early invasive therapy is indicated for high-risk patients with UA. Patients with refractory ischemia, recurrent symptoms, ST segment depression, and hemodynamic instability are at high risks. These patients should be referred for angiography and revascularization. In the absence of these findings, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization.
Role of statin therapy is conflicting. However, in the acute setting the mechanism of benefit from statin therapy probably involves anti-inflammatory effects rather than the lipid lowering. The other added benefit is, studies have shown that the long term compliance is better if the statins are started before the discharge.
Thrombolytic therapy is not indicated in the treatment of USA/NSTEMI and should not be used.