40 yo male with CP

[pbruss]

40 year old male with no know medical problems come in with CP. for past month has had substern pressure that radiates to jaw with sob and diaphoresis. normally caused by exertion and relieved by stress. his mom is a nurse and got him in to see a cardiologist who put him on aspirin, nitro patch, and SL nitro for breakthrough pain. he has apt with his cardiologist tomorrow for echo and stress.

tonight at 7pm he had CP while at rest which is not normal for him. he took 2 SL nitro wich took the pain away. he came in at 8pm for evaluation and the pain has not returned.

its a busy night at Toledo and you are the east zone doc. the triage nurse ordered pre-emptive CP pathway and he had EKG done in triage. the ekg was seen and signed off by the attending and he went back out to triage for 60 minutes.

when you see him he is pain free and has a normal exam and vitals.

attached is his EKG. CBC, BMP, CKMB, Troponin are all back by the time you see him and they are all normal.

based on the EKG which of the following would be the next best step in treatment?

A. CTA chest
B. sed rate, CRP, bedside echo
C. asprin, plavix, lovenox, admit to cardiac ICU
D. IV thrombolyitcs
E. CTA head and neck with detailed neuro exam

Attachments:

ekg.pdf (495.74 KB)

[Bjs04f]

C- guy has wellens

[pbruss]

you are right this is a wellens wave, but would you let someone with signs and symptoms of infarction sit in the cardiac ICU without some type of reprofusion therapy? the multiple choice question is a good example of how some of the board questions are structured. hopefully the answer you wanted was activated the cath lab but that is not listed. the closest answer to waht you would do in real life is D - IV thrombolytics. I found these types of questions very frustrating because they dont give you what you know is right, they give you a crappy equalivlant.

when i saw this guy i repeated an EKG right away and activated the cath lab. turn out his cardiologist canceled the emergent cath. he gat serial enzymes and a 2D echo the next day both of which were abnormal. he gat an elective cath 48 hours later showing 90% occlusion in LAD and RCA and went for emergent CABG. I attached his second EKG for you review.

Attachments:

ekg 2.pdf (444.19 KB)

[Bjs04f]

Cath lab would be great, but outside of a STEMI it appears out cards colleagues can pick and choose when to follow literature or not based on desire to cath. Had two cases now with AVR elev that werent cathed until a week later each showing significant occlusion, requiring stenting.