Non-ST-Segment Elevation Myocardial Infarction: The Daily PANCE Blueprint
A 62-year-old male with a history of T2DM presents to the ER with central chest pressure radiating to his left arm x 1 hour. On arrival, he is diaphoretic and mildly dyspneic. His vitals are stable. The ECG shows T-wave inversions in leads V4-V6 without ST elevation. Initial troponin I is elevated. Which of the following is the most appropriate initial medication to administer immediately upon diagnosis?
A. Clopidogrel
B. High-intensity statin
C. Oxygen via nasal cannula
D. Intravenous beta-blocker
E. Chewable aspirin
Answer and topic summary
The answer is E. Chewable aspirin
A non-ST elevation myocardial infarction (NSTEMI) is defined by the absence of persistent ST-elevation with elevated cardiac biomarkers (e.g., troponin I or T, CK-MB, etc). It happens due to a partially occluded epicardial coronary artery (leading to subendocardial ischemia). NSTEMI typically presents as pressure-type chest pain; it may radiate to the arms, neck, or jaw.
Patients with a suspected acute coronary syndrome should receive a 12-lead EKG within 10 minutes of arrival. ST depression, transient ST-elevation, and/or T-wave inversions may be seen on EKG, but they are NOT required for the diagnosis of NSTEMI.
The most important medication to give them is non-enteric-coated chewable aspirin 325 mg. Other indicated medications include sublingual nitroglycerin, oxygen as needed, beta blockers (assuming no contraindications), high-intensity statin, ACE inhibitors (if CKD, DM, or EF < 40%), P2Y12 inhibitor (clopidogrel, ticagrelor, etc), anticoagulation, and possibly PCI with stenting or CABG (not all are candidates for revascularization).
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Cardiology ⇒ ⇒ ⇒
Also covered as part of the Family Medicine EOR, Internal Medicine EOR, Emergency Medicine EOR topic list
