Assignment task:
P.H., a 68-year-old, 80-kg man, is being admitted to the ED after experiencing an episode of sustained chest pain while mowing his yard. After waiting 1 hour, he called 9999 and was transported to the ED. Heart rate and rhythm are regular, and no S3 or S4 sounds are present. Vital signs include BP 180/110 mm Hg, heart rate 105 beats/minute, and respiratory rate 32 breaths/minute. P.H.'s chest pain radiates to his left arm and jaw, and he describes the pain as "crushing" His pain has not responded to five sublingual (SL) nitroglycerin (NTG) tablets at home and three more in the ambulance. His ECG reveals a 3-mm ST segment elevation and Q waves in leads I and V2 to V4. Based on his history and physical examination, P.H. is diagnosed with an anterior infarction. Laboratory values include the following: Sodium (Na), 141 mEq/L Potassium (K), 3.9 mEq/L Chloride (Cl), 100 mEq/L CO2, 20 mEq/L Blood urea nitrogen (BUN), 19 mg/dL Serum creatinine (SCr), 1.2 mg/dL Glucose, 149 mg/dL Magnesium (Mg), 1.3 mEq/L CK, 1200 U/L, with a 12% CK-MB fraction (normal, 0%-5%) Troponin I, 60 ng/mL (normal <2) Cholesterol, 259 mg/dL Triglycerides, 300 mg/dL P.H. has a prior history of coronary artery disease (CAD). A previous cardiac catheterization 2 years ago revealed lesions in his middle left anterior descending coronary artery (75% stenosis) and proximal left circumflex artery (30% stenosis). His echocardiogram at the time showed an EF of 58%. These lesions were deemed suitable for medical management. He also has a history of recurrent bouts of bronchitis associated with bronchospasm for 10 years, diabetes mellitus treated with insulin for 18 years with a hemoglobin A1c of 6.8%, and stage 1 hypertension with blood pressures usually 140/85 mm Hg. His father died of an MI at age 70. His mother and siblings are all alive and well. P.H. has smoked one pack of cigarettes a day for 30 years On admission, P.H.'s medications include insulin glargine 40 units daily; albuterol inhaler, as needed (PRN); hydrochlorothiazide, 25 mg daily; NTG patch, 0.2 mg/hour; and NTG SL, 0.4 mg PRN for chest pain
1. What signs and symptoms does the patient exhibit that are consistent with the diagnosis of MI?
2. What are the immediate and long term therapeutic objectives in treating P.H?
3. Is P.H. a candidate for thrombolytic therapy? If yes, specify.
4. What role do the anticoagulant and antiplatelet agents have in P.H.'s management?
P.H. was stable initially after thrombolysis, but 48 hours later he experienced recurrent chest pain and ECG changes consistent with extension of his infarct. The attending cardiologist would like to readminister t-PA at this time.
5. Is this a reasonable course of therapy?
It is decided that P.H. will receive clopidogrel.
6. What loading dose should he receive and when should he receive it? What about his maintenance dose
7. In addition to his dual antiplatelet therapy of clopidogrel and aspirin, what specific anticoagulant should P.H. receive?