ACUTE MYOCARDIAL INFARCTION: THROMBOLYTIC THERAPY IN THE EMERGENCY DEPARTMENT

Jason R. is a 38-year-old white male who called the ED about 30 min prior so arrival to ask if he should
come to the hospital. Jason said over the phone. "\fy wife's bugging me to come over there. I've got a
heavy pressure in my chest, sort of like indigestion. I've had it before, but it always went away. This time
I can't gel rid of it. "Jason was advised by the ED nurse to come to the hospital, preferably by ambulance.

Jason arrived by car and is noted to look pale and uncomfortable. He complains of pain in the center of
his chest that feels like a heavy pressure that is now going down both arms. The pain has increased in
severity since he left home. Jason rates his pain as 8 on a scale of 1 to 10. Jason is assisted to a stretcher
and while lying in semi-Fowler's position has no dyspnea. His vital signs are temperature 99° F. pulse 60
and regular, respiratory rate 22, and BP 108/60. Lung sounds are clear and heart sounds are regular with
normal s1 and S2. He has an extra heart sound. S4

When questioned about recent health, Jason tells the nurse that he has had chest pain off and on for
about 1 week. Jason describes the pain as a tightness or heaviness in the center of his chest under the
breastbone. Jason also mentions that the pain occurs with physical exertion and goes away with rest.

Jason is married and has two children. He is a sales executive and received a promotion 1 month ago.
Jason smokes about one pack of cigarettes per day. He has no previous medical history and does not
take any drugs. Jason says that his father died of a heart attack and his mother has hypertension.

Triage Assessment, Acuity Level IV: Chest pain, unrelieved: pain continues at rest.

Jason is taken immediately to the treatment area to rule out myocardial ischemia or injury. A 12-lead
ECG is immediately done and reveals ST segment elevation in leads I, II, III, A VF, V4, V5, and V6. T waves
are inverted in VI, V2. and 1 '3. and an abnormal R wave is present in VI. The initial creatinine
phosphokinase (CPK) is reported as 153 (0 to 225 is normal). The ED physician makes a diagnosis of
acute inferior lateral myocardial infarction (MI). True posterior MI is also considered.

Jason is given oxygen via nasal cannula at 5 liters/min and sublingual nitroglycerin with significant
reduction in his pain. After consultation with a cardiologist. Jason is deemed a candidate for
thrombolytic therapy. A lidocaine bolus is administered per protocol and a continuous infusion of
lidocaine is started at 2 mg/min. Tissue plasminogen activator (t-PA) is selected as the thrombolytic
agent for Jason. An intravenous bolus dose of 10 mg of t-PA is given by the physician, and an infusion of
t-PA is initiated at a rate of 50 mg/hr. Jason is then transferred to the coronary care unit (CCU) for
further definitive therapy and monitoring

QUESTIONS

1. What is the significance of the risk factors for coronary heart disease that can be identified for
Jason?

Although the mortality rate for cardiovascular disease has decreased from 39% in 1964 to 19% in 1984,
60% of the deaths related to myocardial infarction occur outside the hospital (1). Prevention of sudden
death due to acute myocardial infarction (AMI) can be enhanced through efforts directed at early
recognition of symptoms and risk factors. Risk factors identified for Jason include sex (incidence of AMI
occurs more often in men than in premenopausal women), cigarette smoking (associated with an AMI
risk 2.5 times greater than nonsmokers), and family history positive for coronary heart disease.
In addition, Jason seems to have experienced a recent increase in stress, related to his job promotion.
Stress, hypertension, diabetes mellitus, and elevated cholesterol are all risk factors for CHD and
occurrence of AMI.

Chest pain should also be recognized as a risk factor. The importance of the patient acknowledging chest
pain as a potential precursor of sudden death is essential in order to reduce prehospital mortality from
CHD. Educational efforts by the American Heart Association (AHA) emphasize the importance of not only
recognizing risk factors. but also the importance of seeking medical intervention at the onset of
symptoms. In particular, the role of the spouse or significant other is stressed; this person might
encourage their loved one to seek medical attention when he or she has chest pain. Jason had chest
pain for about a week before his AMI. He was reluctant to come to the hospital and called for advice
only at the urging of his wife. Educational efforts need to continue to alert people like Jason to request
medical help as soon as they experience chest pain.