Case Scenarios

Decision Point 1
What is your differential diagnosis at this

time?
a) Pneumonia
b) Pulmonary Embolism
c) Acute MI
d) GERD
e) Unstable angina

 a) Pneumonia
No

The patient has no cough or fever; his

history is inconsistent with this diagnosis.
A chest x-ray would be helpful to
completely rule this diagnosis out.

 b) Pulmonary Embolism
No
Although it may be in the differential

diagnosis, this patient's symptoms of

chest pain on exertion, relieved with rest
and these ECG changes are not
consistent with PE.

 c) Acute MI
Possibly

The pain that the patient describes

lasted only 20 minutes and was relieved
with rest. The ECG shows ST
depression in V2-V3. It is possible that
the patient is having a non-Q-wave MI or
posterior wall MI. Further work-up will be
needed. This is not the best answer

 d) GERD
Unlikely

This is not our first concern. The pain of

esophageal disease is often difficult or
impossible to distinguish from cardiac
pain. Many of those patients admitted to
cardiac units and not found to have
cardiac pathology will have esophageal
disease

 e) Unstable angina
Yes

Unstable angina is ischemic chest pain

that lasts longer than the patient's
normal angina, starts while at rest, or is
new in onset. This patient has never had
chest pain until today, so it is new-onset
angina. This is the best diagnosis at this
time.

Decision Point 2
Which of the following are high-risk

indicators in patients with Acute

Coronary Syndromes?
a) Diabetes Mellitus
b) Hypercontractile left ventricle
c) Lateral wall involvement
d) Pulmonary Edema
e) ST depression

 a) Diabetes Mellitus
Yes

In multiple papers it has been observed

that diabetes is a predictor of increased
in-hospital complications

 b) Hypercontractile left ventricle

No

Hypercontractile ventricles are not

predictive of complications. In fact,
decreased ventricular function is more
predictive of poor outcome

 c) Lateral wall involvement

No
Anterior wall involvement rather then

lateral wall involvement has been

associated with higher complication
rates

 d) Pulmonary Edema
Yes

The presence of congestive heart failure

on chest x-ray or rales beyond the bases
on auscultation increase the risk of
complications in patients with unstable
angina

 e) ST depression
Yes

In a study of 1899 patients admitted with

unstable angina, ST depression > 1mm had a
significantly higher mortality (4). ST segment
depression is only seen in about 20% of people
having angina (5). Its absence does not exclude
cardiac ischemia. The majority of patients with
acute ischemia, unfortunately, lack this finding.

Decision Point 3
Which of the following cardiac markers

levels are indicated at this time?

a) Creatine Kinase
b) Myoglobin
c) Troponin
d) LDH

 a) Creatine Kinase- MB
Yes

CK-MB becomes elevated 6-10 hrs after an

infarct. The most sensitive CK parameter is the
index form (CK-MB/total CK). Remember that
serial levels must be obtained (based on the
time of presentation with respect to the time of
pain onset) and that a single negative initial CK
cannot rule out a myocardial infarction. A
negative CK series does not exclude angina.

 b) Myoglobin
Possibly

Myoglobin is released within 4 hrs of

ischemia but has not been found to be
specific enough to be of much benefit.
Some observation unit will use this in low
risk patients to help exclude active
ischemia prior to stress testing.

 c) Troponin
Yes

Troponin T and I are found on the

contractile apparatus of the myocardium.
They are used frequently to evaluate for
ischemia and they remain elevated up to
1 week after an event. Elevated Troponin
has been associated with an increased
rate of adverse outcomes (6).

 d) LDH
No

The use of troponin has eliminated the

need for checking LDH in acute coronary
syndromes. Troponin remains elevated
as long and is much more sensitive.

Decision Point 4
Which of the following tests should be

performed initially on this patient?

a) D-dimer
b) Liver function tests
c) Electrolytes
d) Renal profile
e) CXR

 a) d-dimer
No

This is a non-specific test for fibrin

formation and degradation; however, no
literature currently supports its use in the
evaluation of acute myocardial infarction

 b) Liver function tests

No

There is no added value to obtaining

liver function tests unless other
etiologies of the pain are suspected.

 c) Electrolytes
Yes

Imbalance of electrolytes such as

potassium or magnesium can
predispose the patient to arrhythmias

 d) Renal profile
Yes

Patients with renal disease are more likely to

have underlying cardiac pathology. This will be
of importance also if the patient goes to the
catheterization lab because of the contrast
utilized. Thus a blood urea nitrogen (BUN) and
a creatinine are of value among this population.

 e) CXR
Yes

A chest X-ray is important to rule out

other serious causes of chest pain such
as pneumonia, thoracic aneurysm,
pneumothorax or possibly pulmonary
embolism. If the patient has CHF, this is
also a poor prognostic indicator. (2

Decision Point 5
Which pharmacotherapies are indicated

at this time?
a) Oxygen
b) Nitroglycerin
c) ACE inhibitors
d) -blockers
e) Calcium channel blocker
f) Aspirin

 a) Oxygen
Yes

Though no studies have shown a

benefit, it is regarded as the standard of
care

 b) Nitroglycerin
Yes

Nitroglycerin works mostly by causing venous

dilation, which decreases preload, decreasing
the amount of work of the heart. Nitroglycerin
also causes a small amount of coronary vessel
dilation. Nitroglycerin has a proven role in AMI.
It is less well documented on its effects in
angina, but at this point it is considered the
standard of care.

 c) ACE inhibitors
No

The use of angiotension-converting

enzyme inhibitors has no documented
use in angina. It has been shown to be
effective in patients with large
myocardial infarctions with low ejection
fractions.

 d) -blockers
Yes

-blockers work by lowering heart rate

and contractility hence reducing oxygen
demand. They can also suppress
arrhythmias.

 e) Calcium channel blocker

Probably not
Studies have shown that short acting calcium
channel blockers can actually increase
mortality. At this time long acting calcium
channel blockers can only be recommended in
people that continue to have pain after receiving
nitrates and -blockers.

 f) Aspirin
Yes

This is the most widely used platelet inhibitor

and no other anti-platelet agent has a more
impressive risk-benefit and cost-benefit ratio.
Aspirin works by blocking cyclooxygenase,
which converts arachidonic acid to
prostaglandins, which will later be converted to
thromboxane A2. In patients admitted for
unstable angina there can be as much as a 51%
reduction in fatal and nonfatal MI (7).

Decision Point 6
Which of the following are used in

patients with acute unstable angina?

a) Heparin (unfractionated)
b) Low molecular weight heparin
(LMWH)
c) Coumadin
d) Thrombolytics such as
TPA/Retivase/streptokinase

 a) Heparin (unfractionated)
Probably

The ACC/AHA recommends that a

continuous infusion of heparin be started
at a rate of 80units/kg followed by a drip
of 18units/kg/hr. The goal is to maintain
an INR of 2-2.5. Unfractionated heparin
should not be used with LMWH.

 b) Low molecular weight heparin (LMWH)

Yes

LMWH such as enoxaparin are more predictable than

unfractionated heparin in anticoagulation and
pharmacokinetics. Further, being given SQ, LMWH does
not require a constant infusion. It also does not require
monitoring of blood levels or clotting. Drug cost with
enoxaparin is higher than that of UFH (unfractionated
heparin) for those people not on IV therapy, but economic
substudy of the ESSENCE data indicates that, overall,
the former is more cost-effective. (8)

 The ESSENCE trial studied enoxaparin (1 mg/kg) twice

daily versus standard unfractionated heparin and found a

decrease in composite end points of death, MI or
recurrent angina at 14 and 30 days. A recent metaanalysis (12 studies with 17,157 total patients) compared
LMWH to unfractionated heparin and found no difference
in terms of efficacy (death or MI) or safety (bleeding)
during short term therapy (9). This study, however,
included multiple formulations of LMWH, only one of
which-enoxaparin-has been shown to be superior to UFH
in individual trials. LMWH should not be used in
conjugation with unfractionated heparin

 c) Coumadin
No

There is no role for coumadin in unstable

angina. Coumadin is useful after ED
care in patients with large anterior infarct
to help prevent thrombus formation.
These patients should be started on
heparin prior to instituting coumadin.

 d) Thrombolytics such as

TPA/Retivase/streptokinase
No
Thrombolytics have no role in unstable angina.
They are reserved for patients who are having
myocardial infarctions associated with
persistent pain and ST elevation or new bundle
branch block (usually LBBB). (10)

Decision Point 7
Which of the following is the mechanism

of action of LMWH?
a) Prevents platelet aggregation
b) Blocks thrombin
c) Depletes factor VII
d) Activates tissue plasminogen

 a) Prevents platelet aggregation

No
b) Blocks thrombin
Yes
c) Depletes factor VII
No
d) Activates tissue plasminogen
No

Decision Point 8
What is/are the possible disposition/s of

this patient?
a) Home
b) CCU
c) Catheterization lab
d) Stress test
e) Observation unit

 a) Home
No
This patient has the classical symptoms

and history of angina, which seems to be

escalating and he needs further work-up
and treatment. Inadvertent discharge of
patients with myocardial infarctions
accounts for the greatest percent of
damage awards in malpractice claims of
ED physicians.

 b) CCU
Yes
This is the best option in this case. If

medical treatment is effective in abating

his symptoms he can be treated
medically in a closely observed unit
while he is being ruled out for a MI.

 c) Catheterization lab
Yes
The patient has classic symptoms of

cardiac ischemia. The pain is recurring

and if the hospital has a therapeutic cath
lab (only about 20% in the US), this is
the most appropriate disposition.

 d) Stress test
No
It is not appropriate to stress someone

who continues to have chest pain with

an abnormal ECG and a moderate risk
for cardiac disease. The patient will need
a stress test at sometime but it's best to
rule the patient out for MI first.

 e) Observation unit
Probably not
These units are used for low risk patient

and usually will get stressed prior to

leaving. Because this patient is
intermediate to high risk this is not the
best choice