Question

A 59-year-old man presents to the emergency department (ED) complaining of new onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management?

Answer 1

Answer:

Initiate dual antiplatelet therapy (aspirin + clopidogrel/ticagrelor/etc).

Explanation:

This man has multiple coronary risk factors (male sex, age, HTN, cholesterol, smoking). T wave inversions are characteristic of myocardial ischemia. The ECG changes in combination with clinical symptoms such as chest pain, particularly in the face of all these risk factors, are highly suggestive of NSTEMI.

The goals of therapy for NSTEMI (and other acute coronary symptoms) are to reverse the ischemia, prevent progression of the obstruction, and provide pain relief with the underlying goal of mitigating further heart damage.

The fastest way to accomplish the reversal of ischemia/progression of obstruction are to intiate dual antiplatelet therapy. Following this, adjunct therapies include supplementary O2 (to maximize O2 delivery to tissues), nitroglycerin and morphine (to reduce pain and consequently sympathetic strain on the heart), and beta blockers (to reduce strain on the heart). Serum troponins should be measured and followed, and further workup such as coronary angiogram may be indicated to inform subsequent treatments.