Posted: September 4th, 2023

RM a 45-year-old male, presents with acute chest pain

Patient Information:
RM, a 45-year-old male, presents with acute chest pain.

S.
CC (chief complaint): Acute chest pain.
HPI: RM reports sudden onset of chest pain while at rest. The pain is located in the center of his chest and feels like pressure or tightness. He describes it as an 8 out of 10 in intensity and says it radiates to his left arm. He has never experienced chest pain like this before. He has no history of cardiovascular disease, and his last physical examination was six months ago, which revealed normal vital signs and blood work. He denies shortness of breath, nausea, vomiting, sweating, or dizziness. He took two aspirins before coming to the clinic.
Current Medications: None
Allergies: No known drug allergies or reactions to environmental factors such as food, pollen, or dust.
PMHx: RM has no known medical conditions or history of hospitalization.
Soc & Substance Hx: He works as an accountant, is married, and has two children. He has never smoked or used illicit drugs. He drinks one glass of red wine with dinner occasionally.
Fam Hx: His mother had hypertension, and his father died of a heart attack at the age of 58.
Surgical Hx: None
Mental Hx: None
Violence Hx: None
Reproductive Hx: Not applicable
ROS:
GENERAL: No weight loss, fever, fatigue, or chills.
HEENT: Eyes: No visual complications or yellow sclerae. Ears, Nose, Throat: No hearing difficulties, sneezing, nasal congestion, or sore throat.
SKIN: No skin rashes, lesions, or itching.
CARDIOVASCULAR: Acute chest pain
RESPIRATORY: No cough, sputum, or shortness of breath.
GASTROINTESTINAL: No vomiting, diarrhea, nausea, or abdominal pain.
GENITOURINARY: No pain or burning sensation during urination.
NEUROLOGICAL: No headache, numbness, dizziness, or inappropriate control of the bladder.
MUSCULOSKELETAL: No joint pain or stiffness.
HEMATOLOGIC: No bleeding, anemia, or bruising.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: None
ENDOCRINOLOGIC: No history of cold and heat intolerance or polyuria.
REPRODUCTIVE: Not applicable

O.
Vital Signs: Blood pressure 150/90 mmHg, heart rate 100 bpm, respiratory rate 20 breaths per minute, oxygen saturation 99% on room air, temperature 98.6°F (37°C).
Physical Examination: Heart: regular rhythm without murmur or gallop. Lungs: clear to auscultation bilaterally. Abdomen: soft, non-tender, non-distended with no organomegaly or masses. No peripheral edema or cyanosis noted. Chest X-ray ordered.
Diagnostic tests: ECG shows ST-segment elevation in leads II, III, and aVF.
A.
RM presents with symptoms suggestive of acute coronary syndrome. The ECG results confirm the diagnosis of an ST-elevation myocardial infarction (STEMI). Given his risk factors and presentation, the patient requires immediate reperfusion therapy.
P.
The patient was transferred immediately to the nearest emergency department for further evaluation and treatment. Intravenous nitroglycerin and heparin were initiated during transport. Antiplatelet therapy with aspirin and a P2Y12 inhibitor should be started as soon as possible. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy and should be performed within 90 minutes of arrival to the hospital, if feasible. If PCI is not available within this timeframe, fibrinolytic therapy may be considered. The patient’s vital signs should be closely monitored, and he should be placed on continuous cardiac monitoring. Pain management should be provided with intravenous opioids as needed. The patient should also receive oxygen therapy to maintain oxygen saturation above 94%. Consultation with a cardiologist and prompt transfer to a tertiary care center may be necessary. Education on lifestyle modifications, such as smoking cessation, regular exercise, and a heart-healthy diet, should also be provided to the patient and his family.

References:

Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-228.

Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119-77.

Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2016;67(10):1235-50.

O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 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 Practice Guidelines. Circulation. 2013;127(4):e362-425.

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