Case Study: Acute Myocardial Infarction

Mr. Mark Green is a 52-year-old man who lives in rural Nebraska with his family. He is an automotive repair man. However, he recently lost his job. He is the primary source of income for his family of six. Recently, he was playing basketball with his eldest son and developed substernal chest pressure. It was a little worrisome, but he thought it was just "heartburn" so he continued playing. After another 15 minutes, the chest pressure became worse. He also noticed that his left arm was numb. At that time his son mentioned that his color was pale and also noticed that he was sweating a lot. He called the paramedics at 11:50 am. However, because they live in a rural area, the emergency medical responders stated that an estimated time of arrival was 30 minutes to the home and 30 minutes to the closest hospital. The closest hospital was not equipped for invasive cardiac procedures. The hospital that could provide cardiovascular procedures was 2 hours away. Past medical history: None. "I am fine so I just don't go see a doctor. I haven't had a reason to." Cardiac risk factors: Family history; father died at age of 48 from cardiovascular disease Smoker; quit a few years ago Size 42 waist pants Medications: None Allergies: None Fibrinolytic Checklist: Denies central nervous system disease Denies closed head or facial trauma No recent surgery The time was 12:30 pm when the paramedics arrived at Mr. Green's home. They found him resting on the couch, diaphoretic, respiratory rate of 26, heart rate 98 bpm, blood pressure 102/60 mm Hg, saturated oxygen 96% on room air, complaining of chest pressure "elephant on my chest" of 8 on a scale of 1 to 10, left arm numb and tingling. A cardiac monitor was placed, and the rhythm was sinus rhythm with ST elevation of greater than 0.1 mm with a presumably new bundle branch block. Mr. Green was transported to the closest hospital. The paramedics provided notification to the ED of the closest hospital. In route, a nasal cannula was placed with oxygen at 4 L. Mr. Green's vital signs remained unchanged. The chest pressure remained the same at 8 out of 10. Nonenteric-coated aspirin 325 mg was given to Mr. Green to chew along with sublingual nitroglycerin 0.4 mg and morphine 2 mg IV. The cardiac monitor remained in place during transport. Sinus rhythm with ST elevation and LBBB was identified. Mr. Green arrived at the closest hospital at 1:00 pm. The ED nurse and physician were expecting Mr. Green's arrival and began care immediately. Together they completed the Fibrinolytic Checklist for STEMI and determined him to be eligible for fibrinolytic therapy. At 1:30 pm Mr. Green received alteplase, recombinant (tPA) bolus 15 mg and then 0.75 mg/kg for 30 minutes and 0.5 mg/kg over the next 1 hour. During the fibrinolytic administration, his chest pressure and arm numbness subsided to 3 out of 10. On the cardiac monitor, his heart rhythm remained in sinus rhythm. However, the ST deviation decreased to less than 0.5 mm, and the LBBB remained the same but without Q-wave formation. Lab results showed elevated troponin I and CK-MB. He stayed in the ED for another 6 hours for monitoring prior to admission to the cardiac unit. After the administration of tPA, IV heparin infusion was initiated. While in the ED he also received metoprolol 12.5 mg PO. During day 1 of his hospitalization, 24 hours after the cardiac event, lisinopril 5 mg PO daily was started. Labs from Day 1 showed LDL-C of 220 mg/dL, triglycerides of 450 mg/dL, high-density lipoprotein cholesterol (HDL-C) of 30 mg/dL, and fasting glucose of 120 mg/dL. His rhythm on the cardiac monitor was stable overnight. He did not experience recurrent chest pain, and his vital signs were stable. During day 2 of his hospitalization, Mr. Green was thankful to have survived an AMI. His family was at his bedside, and Mr. Green was planning on going home that day. Arrangements were being made for Mr. Green to be enrolled in cardiac rehabilitation at the larger urban hospital. His discharge paperwork noted initiation of new medications, including: Metoprolol 25 mg PO daily Lisinopril 5 mg PO daily Aspirin 81 mg PO daily Participate in cardiac rehabilitation for 6 weeks