At the end of his working shift, a 47 year old bus driver
was admitted to the accident and emergency department complaining of worsening
severe chest pain and tightness, and shortness of breath. He had a strong
family history of ischaemic heart disease (both his father and uncle having
had heart attacks before the age of fifty), and he admitted to having smoked
since leaving school.
On examination his pulse was 96/minute and he had frequent premature
beats, while his blood pressure was 130/70 mm mercury. The electrocardiogram
showed ST elevation in the anterior leads. Chest X ray showed slight cardiomegaly
and a few 'fine horizontal linear shadows at the bases. Serum enzymes showed
elevated creatine kinase and aspartate aminotransferase.
A diagnosis of myocardial infarction was made, and he was discharged
after 12 days with medication to take home as well as instructions to take
things easily until review in the outpatient clinic.
Commentary:
-
What would you consider to be the likely management of the patient?
-
Antithrombotic therapy - thrombolysis in the acute stage, perhaps aspirin
thereafter
-
Advice on stopping smoking
-
Advice on weight control if overhweight, perhaps lipostatisc agents if
indicated
by his lipid profile
-
Other cardioprotective measures e.g. beta blockers
-
Advice on graded exercises
-
Further investigations e.g. angiography as a possible prelude to angioplasty
maybe...
But is this enough?
What else should be considered?
Think about this ...
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