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Office of Education
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Charlotte Scarlotti: DiscussionA 66 year old woman is examined about 30 minutes after the onset of severe sub- sternal pain. Physical examination shows diaphoresis and the EKG shows inferior ST elevations compatible with acute inferior wall myocardial infarction or, much less likely, transmural ischemia causing variant or Printzmetal's angina. When acute myocaridal infarction (AMI) is suspected in the out-patient setting, the principal role of the physician is to stabilize the patient, relieve pain, ensure rapid transport to the hospital, and notify a cardiologist. Emergency out-patient treatment of acute MI includes sublingual nitroglycerine grains 1/150 Q 5 minutes to relieve pain and coronary spasm followed by morphine sulfate 2-5 mg subcutaneously Q 30 minutes if needed for residual pain. Aspirin should be administered at once, since a number of trials have shown significant benefit in terms of immediate mortality, reinfarction, and stroke. Aspirin should be chewed and swallowed. Effective doses are 162mg (2 baby aspirin), or 325 mg (one adult aspirin. Continuation of aspirin long-term confers further benefit. Oral beta blockers have been shown to improve mortality and prevent reinfarction in patients with acute MI. Doses studied in RCTs include metopropolol 50 mg po and atenolol 100 mg po Other acute interventions include nasal oxygen and insertion of an IV catheter for access. As soon as AMI is suspected a paramedic unit should be summoned to transport the patient safely to the hospital. The emergency department and a cardiologist should be notified of the patient's imminent arrival so that preparations can be made for catheterization and PTCA or thrombolysis depending on the hospital's capabilities. Tobacco smoking increases the risk for MI up to 6 fold in women and 3 fold in men. Smoking cessation reduces but does eliminate the increase in risk. Next: References for this case  |
