The Correct Answer is B!

 

A 66-year-old woman presents to the emergency department at a non-PCI-capable hospital with a 5-hour history of central chest pain radiating to her neck. She is also dyspneic and diaphoretic. Her past medical history is remarkable for hyperlipidemia and diabetes mellitus. Physical examination reveals a pulse of 98 beats per minute, blood pressure of 150/76 mmHg, normal heart sounds, no murmurs, and normal jugular venous pressure. Lungs are clear to auscultation. Her medications include aspirin 325 mg daily, simvastatin 20 mg daily, and glyburide 5 mg daily. The patient’s electrocardiogram demonstrates an acute inferior ST-elevation myocardial infarction.

In addition to the administration of oxygen, analgesic, aspirin, metoprolol, and fibrinolytic therapy, what would be the most appropriate drug(s) that should also be administered at presentation?

A. Intravenous heparin only
B. Clopidogrel and intravenous heparin
C. Abciximab and clopidogrel
D. Intravenous heparin and abciximab

Rationale:

ST elevation myocardial infarction (STEMI) is characterized by symptoms of myocardial ischemia resulting in persistent ST elevation on ECG and release of biomarkers due to myocardial necrosis. ST elevation of ≥ 1 mm must be present in at least two contiguous leads. New left bundle branch block is also considered a STEMI equivalent.

Primary percutaneous cardiac intervention (PCI) is the preferred method of reperfusion in STEMI. However in cases of patients with STEMI presenting at non-PCI-capable hospitals when the anticipated first medical contact (FMC)-to-device time at a PCI-capable hospital will exceed 120 minutes, fibrinolytic therapy should be administered. Adjunctive antiplatelet therapy with aspirin (162 to 325 mg loading dose) and clopidogrel (300 mg loading dose for patient ≤75 years of age, 75 mg dose for patients >75 years of age) should be administered with fibrinolytic therapy. This is a Class IA recommendation according to the 2013 ACCF/AHA Guideline for Management of STEMI. In addition, patients with STEMI reperfused with fibrinolysis should receive anticoagulation to improve vessel patency and prevent reocclusion. Acceptable anticoagulants include unfractionated heparin (UFH), enoxaparin, or fondaparinux administered for at least 48 hours. GP IIb/IIIa receptor antagonists such as abciximab are not indicated as adjunctive therapy to fibrinolysis. They can be utilized as adjunctive anti-platelet therapy in selected cases (large thrombus burden, inadequate P2Y12 receptor antagonist loading) of patients with STEMI undergoing primary PCI.

 

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