Riddler #9Riddler #9

A 76 y/o woman is admitted with 3 A 76 y/o woman is admitted with 3 hours of crushing substernal chest pain. hours of crushing substernal chest pain. PMH of PVD (Left carotid occlusion with PMH of PVD (Left carotid occlusion with hemiparesis 3 months ago), HTN, HLD, hemiparesis 3 months ago), HTN, HLD, and DM complicated by neuropathy and and DM complicated by neuropathy and retinopathy. BP 120/70, hr 120, sat 92% retinopathy. BP 120/70, hr 120, sat 92% on RA, S3 and JVD on exam. Meds on RA, S3 and JVD on exam. Meds include warfarin 5mg; atenolol 25mg; include warfarin 5mg; atenolol 25mg; pravastatin 20. EKG with 3mm ST- pravastatin 20. EKG with 3mm ST- Segment elevation in V2-6. INR 1.8Segment elevation in V2-6. INR 1.8

Riddler #9Riddler #9

What medications can you give her in What medications can you give her in the ED to lower her mortality risk? 3ptthe ED to lower her mortality risk? 3pt

Would you give thrombolytics if the Would you give thrombolytics if the cath lab will not be available for at cath lab will not be available for at least 2 hours? why or why not? 3ptsleast 2 hours? why or why not? 3pts

Assuming that this patient was Assuming that this patient was reperfused within 4 hours what is her reperfused within 4 hours what is her 30 day mortality risk? (be as specific 30 day mortality risk? (be as specific as possible) 5ptsas possible) 5pts

Riddler #9Riddler #9

1) Accepted answers: 1) Accepted answers: – ASA (23%-49% decrease in death)ASA (23%-49% decrease in death)– IF PCI GP IIB/IIIA inhibitors (60%)IF PCI GP IIB/IIIA inhibitors (60%)– LWMH (25%)LWMH (25%)– BB (15%)BB (15%)– ACEI (10%) be careful in the acute setting (prior to ACEI (10%) be careful in the acute setting (prior to

reperfusion). Benefit is in the long termreperfusion). Benefit is in the long term– Nitrates did show a 35% benefit pre lytic era (1988)Nitrates did show a 35% benefit pre lytic era (1988)– Plavix prior to PCI (20%) – not studied with IIB/IIIAPlavix prior to PCI (20%) – not studied with IIB/IIIA– ThrombolyticsThrombolytics– StatinsStatins

Answer con’tAnswer con’t

Morphine and 02 improve pt Morphine and 02 improve pt symptoms but no proven symptoms but no proven mortality benefitmortality benefit

Answer Con’tAnswer Con’t

2) Lytics in this patient would be 2) Lytics in this patient would be contraindicated. Absolute contraindicated. Absolute Contraindications:Contraindications:– Any hemorrhagic strokeAny hemorrhagic stroke– Non-hemorrhagic stroke or CVA events within Non-hemorrhagic stroke or CVA events within

the past 6 months (some even suggest a year)the past 6 months (some even suggest a year)– Known Intracranial neoplasmKnown Intracranial neoplasm– Active internal bleeding or active PUDActive internal bleeding or active PUD– Suspected aortic dissectionSuspected aortic dissection– BP >180/110 despite antihypertensive therapyBP >180/110 despite antihypertensive therapy

Answer Con’tAnswer Con’t

Notes:Notes:– INR of >2.0 is a relative INR of >2.0 is a relative

contraindicationcontraindication

Answer Con’tAnswer Con’t

Using the TIMI Risk score for patients with ST-Using the TIMI Risk score for patients with ST-segment elevation. Total risk score 0-14 segment elevation. Total risk score 0-14 (Lancet 2001. 358:1571-5)(Lancet 2001. 358:1571-5)– Age >75 3ptsAge >75 3pts– Age 65-74 2ptsAge 65-74 2pts– Diabetes, hypertension, angina 1ptDiabetes, hypertension, angina 1pt– SBP <100 3ptsSBP <100 3pts– HR >100/min 2ptsHR >100/min 2pts– Killip class II-IV (1-no hf, 2- moderateKillip class II-IV (1-no hf, 2- moderate, 3-overt, 4 , 3-overt, 4

cardiogenic shock) – 2ptscardiogenic shock) – 2pts– Weight <150lb 1ptWeight <150lb 1pt– Anterior ST segment elevation MI or LBBB – 1ptAnterior ST segment elevation MI or LBBB – 1pt– Time to reperfusion >4hrs – 1ptTime to reperfusion >4hrs – 1pt

Answer Con’tAnswer Con’t

Risk ScoreRisk Score 30 Day Mortality Rate (%)30 Day Mortality Rate (%) 00 0.80.8 11 1.61.6 22 2.22.2 33 4.44.4 44 7.37.3 55 1212 66 1616 77 2323 88 2727 >8>8 3636

Hulten 24Hulten 24 Paolino 23.5Paolino 23.5 Goyal 22.5Goyal 22.5 Williams 22.5Williams 22.5 Tsai 16Tsai 16 Bellin 11Bellin 11