Ischemic Chest Pain and Hypertension: Use of Adjunctive Anti-ischemic Therapy

A middle aged male with several CAD risks has had several months of exertional angina relieved by rest and nitro.  He had the onset of chest discomfort at rest and presented by ambulance about 3 hours later with "severe crushing chest pain," with a blood pressure of 200/100 and pulse of 100.  The prehospital ECG cannot be found.  Here is his initial ED ECG:Sinus rhythm, nearly tachycardia.  Left axis deviation with QRS of 90 ms, R-wave peak time in aVL perhaps reaches 45 ms, so possible left anterior fascicular block.  There is minimal ST depression (but also a wandering baseline) in V3-V6.Exam was otherwise normal, including clear lungs and the absence of any murmur. The pain continued and a second ECG was recorded 20 min later, after 2 sublingual NTG.  This second ECG was unchanged. At t=102 min, after 2 more sublingual NTGs, another ECG was recorded.  It is unclear to me whether the patient was still having chest pain.Now there is definite ST depression in V2 and V3, diagnostic of ischemia.  There is very slight ST depression in I, II, and V4-V6, and minimal reciprocal ST elevation in aVR.  So there appears to be subtle widespread subendocardial ischemia.The ST depression was not commented on, and the initial troponin was less than the 99% reference value.  A 3 hour troponin I returned elevated (and it eventually peaked at 0.15 ng/mL).  The patient was given an aspirin, 600 mg of clopidogrel, and heparin bolus and...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs