Chest Pain

CP is a 64-year-old male who presents to the emergency department (ED) via ambulance for chest pain. He was out shoveling snow from his driveway when he developed left anterior chest pain, pressure-type, radiating to his jaw and shoulder. Despite the cold weather, he was sweating. He also noted palpitations and shortness of breath, although he thought it was just because he was “a little out of shape.” He was afraid that something was wrong, so he asked his wife to call 911.

Past Medical History

• Hypertension

• Hyperlipidemia

• Diabetes mellitus

• Gout Medications

• Hydrochlorothiazide, 25 mg once daily

• Allopurinol, 300 mg once daily

Social History

• Retired factory worker

• Smokes one pack of cigarettes per day

• Drinks about six beers per day (sometimes more)

Physical Examination

• Well-developed obese man in moderate distress

• Height: 69 inches; weight: 252 lbs.; blood pressure: 172/110; pulse: 92; respiration rate: 16; temperature: 98.7 °F

• Lungs: Scattered bilateral wheezes

• Heart: Regular with grade II/VI systolic murmur

• Extremities: No edema

Labs and Imaging

• Complete blood count with mild leukocytosis (WBC 12.9k)

• Potassium: Low at 2.9 mEq/L

• Glucose: 252 mg/dL

• Troponin I: 1.7 ng/L

• Uric acid: 11.1 mg/dL

• EKG: ST segment depression with T-wave inversion over lateral leads; no pathologic Q waves Next Steps

• CP’s admitting diagnoses are non-ST segment elevation acute coronary syndrome, hypertension, diabetes mellitus, obesity, alcohol abuse, hyperuricemia, and smoker

Discussion Questions

1. What medications should be instituted for CP?

2. What medications should be continued after discharge?

3. What lifestyle modifications can be recommended for CP?

PLEASE ANSWER THE 3 QUESTIONS ABOVE, AFTER DEVELOP THE ANSWER CREATE A RATIONALE FOR EACH QUESTION

NO PLAGIO MORE THAN 10 %

2 REFERENCES NO OLDER THAN 5 YEARS

What medications should be instituted for CP?
Answer: The medications that should be instituted for CP include aspirin, a P2Y12 inhibitor, such as clopidogrel or ticagrelor, a beta-blocker, such as metoprolol or atenolol, and a nitrate, such as nitroglycerin.
Rationale: CP is presenting with symptoms of non-ST segment elevation acute coronary syndrome (NSTEMI), and the recommended treatment for NSTEMI is aspirin, a P2Y12 inhibitor, a beta-blocker, and a nitrate. Aspirin is used to prevent further thrombus formation and reduce the risk of a cardiac event. The P2Y12 inhibitors and beta-blockers are used to reduce the risk of future myocardial infarction and death. Nitrates are used to relieve chest pain and reduce the workload on the heart.

What medications should be continued after discharge?
Answer: The medications that should be continued after discharge include aspirin, a P2Y12 inhibitor, a beta-blocker, and a nitrate.
Rationale: The patient’s symptoms and EKG findings are consistent with NSTEMI, and these medications have been shown to be effective in reducing the risk of future cardiac events and death. In addition, the patient’s hypertension, hyperlipidemia, and diabetes mellitus should be managed with appropriate medications, such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, and metformin.

What lifestyle modifications can be recommended for CP?
Answer: The lifestyle modifications that can be recommended for CP include quitting smoking, limiting alcohol intake, maintaining a healthy diet, and increasing physical activity.
Rationale: CP is a smoker, drinks heavily, and is overweight, all of which are risk factors for cardiovascular disease. Quitting smoking will significantly reduce the risk of future cardiac events and death. Limiting alcohol intake and maintaining a healthy diet, rich in fruits and vegetables and low in saturated and trans fats, will help manage the patient’s diabetes, hyperlipidemia, and hypertension. Increasing physical activity, such as walking or other forms of exercise, can also improve the patient’s overall cardiovascular health and reduce the risk of future cardiac events.

References:

Gibson CM, et al. 2018 AHA/ACC/HRS Guideline for the Evaluation and Management of Patients With Syncope. J Am Coll Cardiol. 2018;71(2):e29-e122.
American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 127(4), e362-e425.