64

PATIENT PRESENTATION
SECTION 2

■■ 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 complain-
ing of chest pressure/pain lasting 20–30 minutes occurring at rest.
He describes the pain as substernal, crushing, and pressure-like that
Cardiovascular Disorders

radiates to his jaw and is accompanied by nausea and diaphoresis.

The pain first started approximately 6 hours ago after he ate break-
fast 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

16 ■■ Meds
Aspirin 81 mg PO daily
Metoprolol tartrate 25 mg PO BID
Atorvastatin 40 mg PO QHS
ACUTE CORONARY Metformin 500 mg PO BID
SYNDROME: ST-ELEVATION SL NTG PRN CP

MYOCARDIAL INFARCTION ■■ All

NKDA
I Can’t Handle the Pressure . . . . . . . . . . . . . . . . . . . . . Level III
Kelly C. Rogers, PharmD, BCCP, FCCP, FACC ■■ ROS
Robert B. Parker, PharmD, FCCP Positive for some baseline CP on exertion for the past 3–4 weeks,
now with CP at rest

■■ Physical Examination
LEARNING OBJECTIVES Gen
After completing this case study, the reader should be able to: WDWN man, A&O × 3, still with ongoing chest pain, somewhat
anxious
•• Determine the goals of pharmacotherapy for patients with ST-
segment elevation myocardial infarction (STEMI).
VS
•• Discuss interventional strategies for patients with STEMI, BP 145/92, P 89, RR 18, T 37.1°C; Wt 95 kg, Ht 5′10″
and understand the pharmacotherapeutic agents used with
interventions. HEENT
•• Design an optimal therapeutic plan for the management of PERRLA, EOMI, fundi benign; TMs intact
STEMI, and describe how the selected drug therapy achieves the
therapeutic goals. Neck
•• Identify appropriate parameters to assess the recommended No bruits; mild JVD; no thyromegaly
drug therapy for both efficacy and adverse effects.
•• Provide appropriate education to a patient who has suffered Lungs
STEMI. Few dependent inspiratory crackles; bibasilar rales; no wheezes

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 65
CV
QUESTIONS

CHAPTER 16
Normal S1 and S2, no MRG
Collect Information
Abd 1. What subjective and objective findings in this patient are consis-
Soft, nontender; liver span 10–12 cm; no bruits tent with acute STEMI?

Genit/Rect Assess the Information

Deferred 2.a. What risk factors for the development of coronary artery dis-

Acute Coronary Syndrome: ST-Elevation Myocardial Infarction

ease are present in this patient?
MS/Ext 2.b. Create a list of this patient’s drug therapy problems and priori-
Normal ROM; muscle strength on right 5/5 UE/LE; on left 4/5 UE/ tize them. Include assessment of medication appropriateness,
LE; pulses 2+; no femoral bruits or peripheral edema effectiveness, safety, and patient adherence.

Neuro Develop a Care Plan

CNs II–XII intact; DTRs decreased on left; negative Babinski sign 3.a. What are the goals of pharmacotherapy in this case?
3.b. What pharmacotherapeutic alternatives are available for reper-
■■ Labs fusion in STEMI?
Na 134 mEq/L Ca 9.8 mg/dL Hgb 14.0 g/dL Fasting lipid profile 3.c. What nonpharmacologic alternatives are available for reperfu-
K 4.4 mEq/L Mg 2.0 mg/dL Hct 44% T. chol 159 mg/dL sion in STEMI?
Cl 102 mEq/L PO4 2.4 mg/dL WBC 5.0 × 103/mm3 Trig 92 mg/dL 3.d. What is the role of anticoagulant therapy during PCI, and how
CO2 23 mEq/L AST 22 units/L Plt 268 × 103/mm3 LDL 105 mg/dL
should these therapies be monitored?
BUN 15 mg/dL ALT 30 units/L PT 12.5 s HDL 36 mg/dL
SCr 1.0 mg/dL Alk Phos aPTT 32.4 s A1C 7.6% 3.e. What is the role of antiplatelet therapy before, during, and after
Glu 140 mg/dL 75 units/L INR 1.0 NT-pro-BNP PCI, and how should these therapies be monitored?
Troponin I 400 pg/mL 3.f. Create an individualized, patient-centered, team-based care
8.6 ng/mL
plan to optimize medication therapy for the initial (first
24–48 hours) management of this patient’s STEMI. Include
specific drugs, dosage forms, doses, schedules, and durations
■■ ECG of therapy.
ST-segment elevation of 2–3 mm in leads II, III, and aVF (Fig. 16-1)
■■ CLINICAL COURSE
■■ Assessment The patient received aspirin, morphine, oxygen, IV unfraction-
Acute inferior STEMI ated heparin (UFH), IV nitroglycerin, and oral metoprolol. An

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

II

VI

FIGURE 16-1. ECG taken on arrival in the emergency department showing ST-segment elevation (arrows) in leads II, III, and aVF, consistent with acute inferior
myocardial infarction. Right bundle branch block is also present in leads V1–V3.

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 66
interventional cardiologist was consulted and discussed with the and prasugrel resulting in decreased inhibition of platelet activity.
patient the need for primary PCI to restore blood flow to the heart. Although the impact of this drug interaction on clinical outcomes
SECTION 2

Within 1 hour of his arrival to the ED, the patient was transported remains to be determined, clinicians should be cautious about com-
to the cardiac catheterization lab. The catheterization revealed a bining these opioids with P2Y12 inhibitors.
60–70% proximal stenosis in the RCA with thrombus. Additionally,
there was a 40% mid-LAD obstruction and 20–30% distal circum-
flex disease, neither of which was amenable to PCI. In the cathe-
terization lab, the patient was loaded with oral ticagrelor 180 mg, REFERENCES
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