CardioMan - Case 1

Case 1:

JF is a 42-year old previously healthy farmer who presented with sudden onset central chest pain of one hour duration to the ED. The pain is associated with sweating and radiates to the left arm and jaw. The area of discomfort is about the size of the fist.

Ragavendra R. Baliga, M.D
Assistant Professor
Division of Cardiology
University Of Michigan

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Question 30 of 39:

This patient should be started on short acting nifedipine because it reduces mortality after MI.

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Nifedipine (short acting) is generally contraindicated in routine treatment of acute myocardial infarction because of its negative inotropic effects and the reflex sympathetic activation, tachycardia and hypotension associated with its use.

Calcium channel blockers have not been show to reduce mortality after acute myocardial infarction, and in certain patients with cardiovascular disease there are data suggesting that these drugs are harmful.

Verapamil or diltiazem may given to patients in whom beta-blockers are ineffective or contraindicated (e.g. bronchospastic conditions) for relief of ongoing ischemia or rapid control of a rapid ventricular response with atrial fibrillation after acute myocardial infarction in the absence of congestive heart failure, left ventricular dysfunction or AV block. In non-ST elevation infarction, diltiazem may be given to patients without left ventricular dysfunction, pulmonary congestion or congestive heart failure. It may be added to standard therapy after the first 24 hours and continued for 1 year. Diltiazem and verapamil are contraindicated in patients with acute MI and associated left ventricular dysfunction or congestive heart failure.

Calcium channel blockers have not proven beneficial in early treatment or secondary prevention of acute myocardial infarction, and the possibility of harm has been raised. In patients with first non-Q wave or first inferior wall infarction without LV dysfunction or pulmonary congestion, verapamil and diltiazem may reduce the incidence of reinfarction, but their benefit beyond that of beta-adrenoreceptor blockers and aspirin is unclear. Similarly, there are no data to support the use of second-generation dihydropyridines (eg, amlodipine, felodipine) for improving survival in acute myocardial infarction.