1. HPI
CC: Chest Pain

2. HPI
A 55 year old male with a PMHx of Hyperlipidemia presented to the Emergency Department with a CC of Chest Pain. The patient described the onset of his Chest Pain beginning 8 hours prior while he was sitting in his car. He described the pain as a deep burning over the middle of his chest with radiation down his left arm. He endorsed that the pain was an 8/10 in severity, and he has experienced diaphoresis with associated SOB since its onset. He recalled experiencing a similar event 4 days prior when exerting himself at work. The pain had not relieved with rest and he could not recollect if anything specifically made the pain better or worse.
He denied N/V, abdominal pain, HA, dizziness, confusion, fever, chills, cough, weight loss, fatigue or weakness.

3. Past Medical History:
- Hyperlipidemia
KNA
Medications:
Past Surgical History:
- Atorvastatin - 20 mg PO (Take one half tablet at bed time)
- Appendectomy - Could not recall date
Family History:
- Father (No significant medical history)
- Mother (No significant medical history)
- Sister (No significant medical history)
Social History:
Residence - Lives in Home alone
Tobacco - Denied tobacco use
ETOH - Denied alcohol use
IVDU/Illicit Drug use - No history of Cocaine
Marital Status - Single
Employment - Delivery Man
Allergies:

4. Objective:
Vitals: BP: 140/82, Pulse: 78, Resp: 16 Temp: 98.4 F (oral), SPO2: 95% on RA
General: NAD, non toxic appearance, respirations non labored, no conversational dyspnea
HEENT: NCAT, No JVD, Trachea Midline, No carotid bruits, Thyroid mobile and non enlarged
Cardiovascular: Regular rate, rhythm, no murmurs
Respiratory: Mild rales left lung base
Abdominal: Soft, NTTP, +BS, no rebound tenderness, guarding or rigidity
Extremities: Pulses +2/4 UE and LE B/L, no edema, no cyanosis
Skin: No diaphoresis, pink, warm, without rash
Neuro: Lifts all ext. against gravity, speech spontaneous, face symmetric, follows commands

5. Differential Diagnosis?

6. EKG: New T wave depression in Lateral Leads.

7. Portable CXR: No acute findings.

8. Hepatic Function Panel: CMP:
LABS:
Hepatic Function Panel:
CMP:
Total Protein ( )
Na ( )
Albumin (3.4-5)
K ( )
Bili Total (0-1.0)
Cl (98-107)
Bili Direct (0-.30)
Carbon Dioxide - 29 (21-32)
Bili Indirect
Anion Gap - 8 (6-11)
Alk Phos - 68 (50-136)
Glucose - 88 (74-106)
AST - 18 (15-37)
Blood Urea Nitrogen - 14 (7-18)
ALT - 16 (12-78)
Creatinine ( )
Other Labs:
Calcium (8.5-10)
Anion Gap: 9
Troponin: 4.61 (<0.5)
CBC:
Magnesium: 1.95
WBC: 8.6 ( )
Hemoglobin: 14.7 ( )
Hematocrit: 43.2 ( )
Platelet: 229 ( )

9. NSTEMI! You're admitting an NSTEMI what do you do?
- MONABASH (Morphine, Oxygen, Nitroglycerin, Aspirin, Beta Blockers, Ace Inhibitors, Statin therapy, Heparin)
- Morphine, don’t use this (Stay Tuned)
- Oxygen (Guidelines: give if <90% O2)
- Nitroglycerin (Use for pain with considerations, check for hemodynamic stability)
- Aspirin + Plavix: Administer both Consider Plavix Load
- Beta Blockers: Metoprolol or Atenolol (IV or Oral) Unless Cocaine Caused it… then give a Benzo
- Ace Inhibitor
- Statin Therapy: High Intensity, give Atorvastatin 80mg or Rosuvastatin 20-40mg daily

10. Treatment Plan: - Repeat EKG’s - Labs: Troponin: Q4H until down trend
- Monitor BMP: Potassium, Magnesium
- Cardiology Consult
- Begin Heparin Infusion
- Order Echocardiogram
- Place Patient On Telemetry
- Plavix Load followed by 75mg daily
- ASA 81 mg daily
- Metoprolol tartrate 12.5 mg BID
- Lipitor 80 mg
- PRN Nitroglycerin 0.4 mg (with parameters)
- Obtain Code Status
- Main goal get these patient’s to the cath lab

11. Management Considerations:
to consider:
Management Considerations:
Why DAPT vs. one alone? The CURE randomized trial established that Dual anti platelet therapy significantly reduced the risk of non fatal MI, stroke and cardiovascular death. (9.3 vs 11.4%)
Is Fibrinolysis Recommended for NSTEMI? Short answer, No.
NSAIDS should ALWAYS be stopped on presentation.
Magnesium and Potassium ranges during NSTEMI have been studied with patient outcome data. Goal Magnesium is 2.o, where patients with Potassium’s between 3.5 and <4.5 had the best outcome resulting in a goal of 4.0
If PCI is performed and no intervention occurs how long do I continue Heparin? Recommendations suggest continuing anticoagulation for a MINIMUM of 48 hours.
Ace Inhibitor’s in a meta analysis of 4 trials were revealed to decrease 30 day mortality if started within 36 hours from MI. (7.1% vs 7.6%)

12. Discussion: Things to consider:
Should I use Morphine? In the CRUSADE initiative a nonrandomized, retrospective observational study, it revealed a higher adjusted risk of death in NSTEMI patients treated with morphine. Why? The Impression Trial (study that compared a P2Y12 receptor blocker/Morphine showed decreased anti platelet effectiveness)
Oxygen therapy is delivered if below 90% saturation, however if what if the patient is above 90% saturation? In the DETO2X -AMI registry based, open label trial of Showed no difference in mortality or re-hospitalization at one year.
When can I not use Nitroglycerin? In the setting of RV heart strain, known severe aortic stenosis, hypotension and use of phosphodiesterase inhibitors.
The Patient is Borderline in Hemodynamic Stability should I give a BB? COMMIT/CCS2 trial (largest placebo-controlled trial for BB in Acute MI) suggests it is reasonable to defer IV BB therapy until stable, at which point oral is reasonable.
Which Risk Stratification Calculator should I use: GRACE, TIMI or PURSUIT? GRACE has best predictability, however TIMI was superior with the following end points death, MI, urged revascularization at 30 days and AUC analysis. Summary, do you.
When do you Plavix load when don’t you? If you think LHC then load them if they need a CABG then do not. In summary we can’t really predict this but it takes roughly 5 days for Plavix to wash out.

13. Have a Good Ward Day?

14. Resources:
"UpToDate." UpToDate. N.p., n.d. Web. 4 July