CCS Interactive Case 17

Question 1

60 y/o M presents to ED w/sudden onset of severe substernal chest pain that began at rest, radiates to the jaw and left shoulder, and is accompanied by shortness of breath and nausea. HDS. 2-month history of stable angina. Smoker, HTN, +family history of heart disease

First steps?

Answer 1

Order oxygen, IV access, cardiac monitoring, and EKG (all stat).

Give aspirin and nitroglycerin ASAP too (so long as BP can tolerate nitro)

Then, focused exam.

Question 2

EKG reveals ST depressions and T wave inversions, but no ST elevations. DDx + next steps?

Answer 2

Unstable angina and NSTEMI - heparin should be initiated AFTER a negative fecal occult blood test is obtained. Also order a beta-blocker to bring HR to 60-70/min

Cardiac enzymes (CK-MB and troponin) to distinguish NSTEMI from unstable angina - serial (2 sets 8 hours apart) are necessary

Also order transfer to ICU, CBC, CMP, CXR, Echocardiography

Question 3

Cardiac enzymes are negative

Next?

Answer 3

ST depressions in unstable angina are an indication for early invasive therapy -> cardiology consultation and catheterization

GP IIB/IIIA inhibitors should also be added if scheduled for cath

Question 4

After acute management and cath?

Answer 4

Risk reduction

Lipid profile; if dyslipidemia, obtain TSH (WHY)
Smoking cessation, cardiac diet (low sodium and cholesterol), exercise program, discharge medications (ASA, beta-blocker, statin, sublingual nitro), follow-up

Question 5

Stat orders for chest pain?

Answer 5

Interventions: IV access, cardiac and blood pressure monitor, pulse ox
Meds: O2, nitroglycerine, aspirin, beta-blocker, IV morphine (if chest pain not immediately relieved with nitro or when acute pulmonary congestion and/or severe agitation is present)
abs: EKG, cardiac enzymes, CXR, CBC, BMP, PT/INR, PTT/LFTs

Question 6

When hx, EKG, and enzymes suggest unstable angina?

Answer 6

Add heparin
Transfer to ICU
Early invasive therapy is indicated for high-risk patients with UA (refractory ischemia, recurrent symptoms, ST depression, HD instability) -> refer to angio and revascularization

If absent -> proceed with either an early conservative or an early invasive strategy

GP IIB/IIIA inhibitor before sending to cath

Question 7

After cath, address risk factor reduction:

Answer 7

Lipid profile and TSH if abnormal
Counseling
Smoking cessation
Limit alcohol
Exercise program
Medication compliance
Relaxation techniques
Diet, low sodium
Diet, low cholesterol (fat)
F/u at 2 to 6 weeks
DC meds should be aspirin, metoprolol, statin, sublingual nitroglycerine, clopidogrel

Question 8

Sequence

Answer 8

Order: pulse ox, O2, cardiac monitor, continuous BP monitor, ASA, EKG (12 lead), IV access, nitroglycerine (sublingual, one time) - all STAT
Exam: Focused
Clock: advance to obtain EKG results - note ST depression and inverted T waevs
Order: FOBT stat, metoprolol IV one time
Clock: reevaluate case with next available result - FOBT negative
Order: heparin IV continuous, PTT Q 6hrs (not needed for LMWH), portable CXR-PA, CBC w/diff, cardiac enzymes Q8hrs, BMP
Advance to get enzyme results, partial relief from chest pain
Change to ICU
Order: NPO, bedrest, 12 lead, urine output, metoprolol (PO), simvastatin (PO), echo stat, cardiology consult stat for cath, eptifibatide IV continuous, lipid panel, LFTs
Clock: reevaluate in 1 hour to obtain recs, pain is resolved
Order: cardiac catherization routine, coronary angioplasty routine
Advance to obtain procedure results
Case ends
Final orders - counseling
Dx: unstable angina