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The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 60-year-old man is evaluated in the emergency department for a 2-hour history of severe central chest pain radiating to the back and neck. Medical history is significant for hypertension and he is an active smoker. Medications are aspirin, hydrochlorothiazide, and pravastatin.

On physical examination, the patient is afebrile. Blood pressure is 160/90 mm Hg in both arms. Pulse rate is 100/min and respiration rate is 16/min. BMI is 30. The patient is diaphoretic and in moderate distress. The jugular vein is distended 1 to 2 cm above the clavicle at a 45-degree incline. The chest is clear except for a few bibasilar crackles. Cardiac examination reveals tachycardia with S3 and S4 present but no murmurs. There is no peripheral edema.

Laboratory studies are significant for an initial troponin I level of 10 ng/mL (10 μg/L) but are otherwise normal.

Rectal examination is negative for occult blood. Chest radiograph shows normal-sized aortic silhouette, mild pulmonary congestion, and normal heart size. Electrocardiogram is shown.

The patient is given a 325-mg loading dose of aspirin and started on clopidogrel, supplemental oxygen, metoprolol, nitroglycerin, heparin, and morphine, with improvement of his symptoms and electrocardiogram findings. The hospital has on-call cardiology services, but the nearest facility with percutaneous coronary intervention capability is 2 hours away.

Q.

Which of the following is the most appropriate management?

The most appropriate management for this patient with an acute ST-elevation myocardial infarction (STEMI) is thrombolysis. This patient's STEMI is demonstrated on electrocardiogram and supported by symptoms (chest pain), physical examination findings (diaphoresis, S3, S4), and abnormal laboratory studies (elevated troponin). In patients who present early (within 3 hours of symptom onset) but are unable to undergo primary percutaneous coronary intervention (PCI) in a timely manner (within 1 hour after first medical contact), early thrombolysis followed by subsequent coronary angiography provides reperfusion as effective as timely primary PCI, albeit with slightly greater risk for intracranial hemorrhage. In addition, this patient has mild (Killip class II) heart failure (mildly elevated central venous pressure, S3, crackles on lung examination, mild pulmonary congestion on chest radiograph), and thus is in a higher-risk category of STEMI. Priority is therefore even higher for reperfusion by whichever method is most readily available, rather than delaying perfusion by waiting for transfer for primary PCI. Patients with STEMI who present to a PCI-capable facility should undergo primary PCI.

Cardiac surgery evaluation would be appropriate for conditions that require urgent surgical intervention, none of which are suggested in this patient. In a patient with chest pain and evidence for acute STEMI, conditions generally requiring urgent surgical evaluation include acute mitral regurgitation, ventricular septal rupture, or left ventricular free wall rupture. This patient's presentation is not consistent with acute mitral regurgitation, which is characterized by a holosystolic murmur at the left sternal border and apex that may radiate to the axillae. Ventricular septal rupture is associated with new murmur and generally more severe heart failure. Ruptured left ventricular free wall may present with syncope.

Because of the known benefit of reperfusion therapy (either PCI or thrombolysis), continued medical management without further treatment in a patient with STEMI would not be appropriate.

This patient has presented with acute STEMI in a facility without timely access to PCI, and reperfusion should be pursued as quickly as possible, particularly because he has high-risk features. Thrombolysis should thus be pursued, rather than delaying to transfer to a PCI-capable facility, which in this case is too far away to offer timely reperfusion. Transfer to a PCI-capable facility would be appropriate after the administration of thrombolytic therapy if the patient remains stable.

Key Point

  • Acute ST-elevation myocardial infarction should be managed with thrombolysis and coronary angiography if timely reperfusion cannot be attained with percutaneous coronary intervention.
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