Nitroglycerin and mortality?!?!?!?!?

[adagio]

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MTB step 2 says that Nitroglycerin lowers mortality!!!!! I think this is a mistake, is it true?!?!?!


If it does, then is the best next step in a chest pain Nitro and NOT aspirin!?!?!? i am confused!!@$#!@#!

 

[Fuzuli]

MTB step 2 says that Nitroglycerin lowers mortality!!!!! I think this is a mistake, is it true?!?!?!


If it does, then is the best next step in a chest pain Nitro and NOT aspirin!?!?!? i am confused!!@$#!@#!

As far as I know, nitroglycerin doesn't lower mortality, but even if we were to accept that it somewhat lowers mortality, it wouldn't change the overall approach. Aspirin, nitrates, oxygen, morphine, beta blockers, heparin, etc. are all adjunctive therapies for MI. Aspirin is still the king and should be given first. If the question stem doesn't mention it, it's the correct answer. If not, then the field is open: Choosing nitrates, morphine, oxygen, beta-blocker are all correct.

A 50 year old man presents to ED with acute substernal chest pain that radiates to his left arm. He had this pain for 30 minutes, his pain isn't relieved by resting or sublingual nitrates. His EKG shows 0.1 mm ST depressions in leads V3-4. What is the next best step?

a) Give 300 mg non-enteric coated aspirin
b) Obtain CK-MB and cTn-I
c) Give sublingual nitroglycerin
d) Titrate O2 for SaO2 >=%90
e) Give 5 mg IV metoprolol
f) Give 75 mg PO clopidogrel
h) Give 60 units/kg IV UFH

Isn't it A? After all, there are ST depressions, so I better be quick and give him his due aspirin. However, this is not the correct approach. Since his EKG shows no ST segment elevation, I would have to evaluate him as NSTEMI. After EKG, the next step would be to calculate this patient's likelihood of significant CAD, so that I can decide whether to catheterize the patient or not. A low risk patient would need to have all of the following conditions: negative cardiac enzyme markers, no significant (>0.5 mm) ST depressions and no high-risk history, symptoms or signs (new murmur, S3, hypotension, brady/tachycardia etc.). So, I need to know his cardiac enzyme markers as well. Therefore, the answer is B.

In the patient above, his cardiac enzyme markers are elevated. EM resident decides to give him four non-enteric coated chewable baby aspirin tablets. What is the next best step for this patient?

a) Give sublingual nitroglycerin
b) Titrate O2 for SaO2 >=%90
c) Give 5 mg IV metoprolol
d) Give 75 mg PO clopidogrel
e) Give 60 units/kg IV UFH

I don't think there will ever be a question like this, but even if there's, there's no single correct answer. You need to administer all of the above (barring any contraindications for the individual medications, of course).

Hope this helps.

 

[adagio]

Therefore, the answer is B.

I disagree in this instance, as it has been emphasized explicitly that the best next step should be aspirin BEFORE obtaining any cardiac enzymes ... This is angina not relieved by rest, so making it unstable by definition (which is a clinical diagnosis as far as i think) ...

What would we lose if we let him chew on the aspirin and then take the enzymes? i think that aspirin should always be whats first in any case of suspected ACS (suspected, and not necessarily proven) ... am i making any sense?

 

[Fuzuli]

I disagree in this instance, as it has been emphasized explicitly that the best next step should be aspirin BEFORE obtaining any cardiac enzymes ...

I've taken the algorithm from the AHA/ACC guideline. So let's apply for the patient: He has symptoms suggestive of ACS, and based on his age and character of symptoms, he's likely to have a definite ACS. His EKG is taken and he has no ST-elevation. Therefore, obtaining cardiac enzyme levels is correct for this patient.

But you're not incorrect. The difference is the setting of the care. For instance, if the patient was at his home, the first thing to do after a chest pain would be taking a sublingual nitroglycerin, even before having an aspirin. In fact, it's recommended that aspirin should be given in a pre-hospital setting, by EMS. Since it's written in the question that EKG is already performed as the hospital, should I accept that it's already given? Maybe 🙂

Let's suppose a question is like this: "A 50 year old man presents to ED with acute substernal pain that radiates to his left arm. What is the next best step? a) Obtain EKG b) Give 300 mg ASA c)...." A or B? I have to say I'm still inclined to choose A, but choice B has a strong argument as well. I'm going to read the section in Harrison's to see if I'm missing something.

Ultimately, it is a very nit-picky question intended to show a point. By design, I might add 🙂 So don't worry, you will never encounter a question like this.

This is angina not relieved by rest, so making it unstable by definition (which is a clinical diagnosis as far as i think)

If angina is not relieved by rest, it may either be STEMI or UA/NSTEMI.
If the word "unstable" is there, then it would imply UA/NSTEMI.

STEMI and UA/NSTEMI have different approaches, so angina not relieved by rest is not necessarily UA/NSTEMI.

 

[adagio]

" A or B? I have to say I'm still inclined to choose A, but choice B has a strong argument as well. I'm going to read the section in Harrison's to see if I'm missing something.

the way i understood it, is that in this question, you should pick Aspirin, cause an EKG would not change the diagnosis of even a stable angina if it was totally normal (and assuming the pain receded) ... For safety sake, I would choose aspirin.