Sun28November0628PM 16

A 32-year-old city trader is brought to the Emergency department with central crushing chest pain. He was apparently dancing with friends at a club when he had to sit down because of feeling faint. By the time he arrives in the department he is pale and covered in sweat.

He smokes 20 cigarettes per day and is a heavy cocaine user.

Examination reveals a BP of 165/100 mmHg, pulse is 105 and regular. There are bilateral basal crackles on auscultation consistent with left ventricular failure.

Investigations reveal:

Hb 140 g/L (135-180)

WCC 5.1 x109/L (4.5-10)

PLT 381 x109/L (150-450)

Na 138 mmol/L (135-145)

K 3.6 mmol/L (3.5-5.5)

Cr 105 micromol/L (70-110)

ECG shows anterior ST elevation.

CXR shows LVF on admission film.

He is given bivalirudin, aspirin and clopidogrel and prepared for possible percutaneous intervention.

What other step would you take?

(Please select 1 option)

IV glycoprotein IIb IIIa inhibitor

IV beta blocker

Oral calcium channel antagonist

IV nitrate Correct

CPAP

Explanation

One possible explanation here is coronary artery vasospasm as a result of excessive cocaine use. The alternative is that the patient is suffering an acute STEMI related to accelerated coronary artery disease. In this situation nitrate is the best option because it will work as a treatment for vasospasm and also reduce pre-load and improve the symptoms of LVF.

Glycoprotein IIb IIIa antagonists are not recommended when rapid progression to the cardiac catheter suite is a possibility and should therefore be avoided here.

Beta blockade may worsen ischaemia in this situation and is therefore also not recommended.

In the absence of significant LVF, calcium antagonists can be used as a first line alternative to nitrates.

CPAP is not recommended in LVF related to acute ischaemia where other therapeutic options are available.

Answer Statistics

1

5%

2

11%

3

6%

4

76%

5

5%

Times answered: 269