A 65-year-old female with a history of hypertension and DM type 2 was admitted to the general medical floor with fever and cough for 3 days. The patient was diagnosed with community-acquired pneumonia and was started on levofloxacin. She improved and her fever resolved. On hospital day 3, the patient complained of severe pressure-like substernal chest pain with radiation to the left shoulder of 20 minutes duration. The pain was associated with sweating and nausea. The on-call internal medicine resident was paged. The patient was sitting on the edge of the bed and looked very distressed. Her vital signs showed temperature of 36.5°C, heart rate of 88 bpm, blood pressure of 160/95, respiratory rate of 24/min, and blood oxygen saturation of 98% on room air.
The patient has a history of poorly controlled diabetes mellitus type 2, hypertension, and hypercholesterolemia. She is a heavy ex-smoker. Physical examination is significant only for crackles over the right lower lung base.
The nurse had already done an ECG before the resident arrived (Figure 7-1).
1. What do you think is wrong with this patient?
2. What should you do next?
This is a 65-year-old female patient with several risk factors for coronary artery disease who is presenting with cardiac chest pain. Her ECG showed deep T-wave inversion in the anterior leads, which is consistent with ischemia.
The patient is having an acute coronary syndrome (ACS), and needs emergent diagnostic and therapeutic plans. Sublingual nitroglycerine (NTG) should be given for pain. The patient should chew 2 tablets of 81 mg aspirin (ASA). A high dose of clopidogrel and an intravenous beta-blocker should be given as soon as possible.
You should check cardiac enzymes, complete blood count, coagulation profile, basic metabolic panel, and magnesium levels stat. The patient should be moved to a telemetry floor with frequent vital sign checks and closer nursing observation. A cardiologist should be contacted immediately. Discussion with the cardiologist should focus on the decision of medical versus early invasive therapy, and the best anticoagulation to be given.
You will frequently face patients presenting with ACS during training. Fast and accurate management is crucial in improving patient outcomes. This review will summarize the most important elements of ACS management.
ACS can be divided into unstable angina, NSTEMI, and ST elevation MI (STEMI) (Table 7-1). The algorithm for unstable angina and NSTEMI management is the same. The initial management of all ACSs is the same; however, it differs significantly subsequently. The review will be arranged in the same way (initial acute management, unstable angina/NSTEMI management, ...