Case 1 - Table Of Contents

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

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.
1	The most likely cause of this patient's symptoms is an acute myocardial infarction.
2	This patient should have a targeted clinical examination and a 12-lead EKG within 10 minutes of presenting to the ED.
3	This EKG shows that this patient has an inferior wall myocardial infarction.
4	This patient should be monitored electrocardiographically while in ED.
5	All patients with myocardial infarction should be admitted to the CCU.
6	In this patient an elevated rise in cardiac markers is required to confirm the diagnosis of myocardial infarction.
7	As this patient presented within the first two or three hours of symptom onset, the most appropriate serum cardiac markers for the early diagnosis of MI are myoglobin and CK-MB subforms.
8	In this patient cardiac specific troponins may not be detectable for up to 6 hours after onset of chest pain.
9	It is universal practice to administer oxygen because it has been well documented this therapy limits myocardial damage, reduce morbidity and mortality.
10	Although this patient has an uncomplicated myocardial infarction and his oxygen saturation is >95%, oxygen should be administered for at least 24-48 hours.
11	Long-acting oral nitrates should be administered early in the management of this patient's acute MI to relieve pain.
12	As nitroglycerin is quite effective in relieving ischemic-type chest discomfort due to acute coronary syndromes, it is preferred to narcotic analgesics to manage the chest pain in this patient.
13	Aspirin used alone, in the treatment of evolving MI, has been shown conclusively to reduce 35-day mortality by at least one-fifth.
14	This patient's EKG suggests that he has high likelihood of occluding the infarct-related coronary artery.
15	This patient's history, examination and EKG suggest that thrombolysis will be ineffective in this patient.
16	Since this patient is below 60 years old primary PTCA is preferred to thrombolysis.
17	Following reperfusion therapy the patient is transferred to the CCU where he undergoes electrocardiographic monitoring. It has been proved that computer algorithms are superior to medical personnel for detection of arrhythmias.
18	Invasive arterial monitoring is preferred in this patients.
19	In the CCU this patient should be encouraged prolonged bed rest (>24 hours) including avoiding activities such as toileting, assisted bathing and light ambulation.
20	Since this patient is less than 45 years of age he should be encouraged to perform isometric exercise and Valsalva maneuvers to hasten recovery.
21	As this patient used to be a regular coffee drinker (~4 cups of coffee per day) he should avoid coffee while in the CCU.
22	This patient is asymptomatic and has no complications in the CCU. He can, therefore, safely be transferred out of the CCU within 24 to 36 hours.
23	Family members of this patient should be taught CPR.
24	It is recommended that patients should be administered pharmacological anxiolytics such as diazepam during their hospital stay.
25	While the patient is in CCU, visiting should be restricted to one or two family members.
26	This patient should receive lidocaine in the first 24 hours to prevent life-threatening ventricular arrhythmias.
27	Beta-blocker therapy is not indicated in this patient because he has successfully undergone reperfusion with thrombolytics.
28	Beta-blockers are contra-indicated in this patient because he has a 12-pack year history of smoking.
29	This patient should be administered an ACE inhibitor within the first 24 hours of symptoms even if he has a normal ejection fraction.
30	This patient should be started on short acting nifedipine because it reduces mortality after MI.
31	As this patient had a uncomplicated myocardial infarction, he should have symptom limited stress testing within two to three days of his acute myocardial infarction.
32	Before this patient is discharged a routine ambulatory (Holter) monitor recording is necessary to identify whether this patient will benefit from prophylactic anti-arrhythmic therapy.
33	The American Heart Association Step II diet, which is low in saturated fat and cholesterol (<7% of total calories as saturated fat and <200 mg/d cholesterol), should be instituted in all patients after recovery from acute myocardial infarction.
34	Smoking cessation reduces rates of reinfarction and death within a year of quitting.
35	Since this patient had an uncomplicated myocardial infarction he does not need to participate in a cardiac rehabilitation program.
36	This patient can safely return to prior activities.
37	This patient has to wait for 12 weeks before resuming sexual activity.
38	This patient should be advised to refrain from driving for 16 weeks.
39	This patient should avoid air-travel for 6 months.

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