Pharmacotherapy Case Study 8: ST-Elevation Myocardial Infarction (STEMI) by Dr. Nehad Jaser

 

Patient Profile: 58-year-old male

Subjective Data

  • Chief Complaint: “Crushing chest pain for the past hour, radiating to my left arm and jaw. I feel nauseous and can’t catch my breath.”
  • History of Present Illness:
    • Sudden-onset substernal chest pain at rest, unrelieved by rest or nitroglycerin (borrowed from a neighbor).
    • Associated diaphoresis, dyspnea, and nausea.
    • Prior episodes of exertional chest discomfort over the past month (self-treated with rest).
  • Medical History:
    • Hypertension (10 years), hyperlipidemia, type 2 diabetes (5 years).
    • Smokes 1 pack/day × 25 years.
  • Medications:
    • Metformin 500 mg BID.
    • No antiplatelet, statin, or antihypertensive adherence (“stopped meds 6 months ago”).
  • Social History:
    • Sedentary lifestyle; diet high in fast food.
    • Family history of CAD (father died of MI at age 60).

Objective Data

  • Vitals:
    • BP: 160/100 mmHg (initial), dropping to 90/60 mmHg after 30 minutes.
    • HR: 110 bpm (sinus tachycardia), RR: 28/min, SpO₂: 90% on room air.
    • Temp: 98.6°F, BMI: 31 kg/m².
  • Physical Exam:
    • Cardiovascular: Elevated JVP (9 cm), S3 gallop, muffled heart sounds.
    • Lungs: Bibasilar crackles (pulmonary edema).
    • Extremities: Cool, clammy skin; delayed capillary refill.
  • Diagnostic Studies:
    • ECG: ST-segment elevation (>2 mm) in leads V1–V4 (anteroseptal STEMI).
    • Troponin-I: 15 ng/mL (elevated).
    • Echocardiogram: LVEF 40%, anterior wall hypokinesis.
    • Coronary Angiography: 100% occlusion of the proximal left anterior descending (LAD) artery.

Assessment

  1. Primary Diagnosis:
    • ST-Elevation Myocardial Infarction (STEMI) due to LAD occlusion.
    • Killip Class II (pulmonary edema without shock).
  2. Comorbidities:
    • Hypertension, diabetes, hyperlipidemia, obesity.
  3. Immediate Complications:
    • Acute pulmonary edema, risk of ventricular arrhythmias.

Pharmacotherapy Plan

Immediate Reperfusion & Acute Management

  1. Reperfusion Therapy:
    • Primary PCI performed within 90 minutes of presentation with drug-eluting stent placement.
    • Anticoagulation during PCI:
      • Unfractionated heparin (bolus 70 U/kg).
  2. Dual Antiplatelet Therapy (DAPT):
    • Aspirin 325 mg chewed immediately.
    • Ticagrelor 180 mg loading dose, then 90 mg BID (preferred over clopidogrel in diabetes).
  3. Symptom & Complication Management:
    • Nitroglycerin IV infusion (start at 10 mcg/min; titrate for pain/BP).
    • Morphine 2–4 mg IV PRN (caution: monitor respiratory status).
    • Furosemide 40 mg IV for pulmonary edema.
    • Metoprolol 5 mg IV (if HR >60 bpm and SBP >100 mmHg).

Long-Term Secondary Prevention

  1. Cardioprotective Medications:
    • High-intensity statin: Atorvastatin 80 mg daily (LDL goal <70 mg/dL).
    • Beta-blocker: Carvedilol 3.125 mg BID (titrate to 25 mg BID; improves survival post-MI).
    • ACE Inhibitor: Lisinopril 5 mg daily (titrate to 20 mg; reduces LV remodeling).
    • SGLT2 Inhibitor: Empagliflozin 10 mg daily (reduces HF risk in diabetes).
  2. Diabetes Management:
    • Continue metformin; avoid hypoglycemic agents with CV risk.

Monitoring

  • Continuous: ECG for arrhythmias (e.g., VT/VF), BP, urine output.
  • Labs: Troponin trend, K⁺/Mg²⁺ (replenish if low), renal function.
  • Echocardiogram: Repeat at 6 weeks to reassess LVEF.

Patient Education

  • Medication Adherence: Stress DAPT for 1 year (aspirin lifelong), statin necessity.
  • Lifestyle: Cardiac rehab, smoking cessation, Mediterranean diet.
  • Symptom Recognition: Seek immediate care for recurrent chest pain or dyspnea.

Rationale

  • Primary PCI is gold-standard for STEMI to restore coronary flow and limit infarct size.
  • Ticagrelor offers faster, more potent platelet inhibition vs. clopidogrel, critical in diabetes.
  • Carvedilol and lisinopril reduce mortality and prevent LV remodeling.
  • Empagliflozin addresses both diabetes and HF risk, aligning with recent CVOT data.
  • Aggressive LDL lowering with atorvastatin stabilizes plaques and reduces recurrent events.

Key Considerations:

  • Avoid NSAIDs and non-DHP CCBs (worsen outcomes).
  • Monitor for bleeding with DAPT; consider GI protection (PPI if high risk).
  • Address modifiable risks (smoking, diet) to prevent recurrence.

 

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