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Riddler Q9 Answer
 

Riddler Q9 Answer

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    Riddler Q9 Answer Riddler Q9 Answer Presentation Transcript

    • Riddler #9
      • A 76 y/o woman is admitted with 3 hours of crushing substernal chest pain. PMH of PVD (Left carotid occlusion with hemiparesis 3 months ago), HTN, HLD, and DM complicated by neuropathy and retinopathy. BP 120/70, hr 120, sat 92% on RA, S3 and JVD on exam. Meds include warfarin 5mg; atenolol 25mg; pravastatin 20. EKG with 3mm ST- Segment elevation in V2-6. INR 1.8
    • Riddler #9
      • What medications can you give her in the ED to lower her mortality risk? 3pt
      • Would you give thrombolytics if the cath lab will not be available for at least 2 hours? why or why not? 3pts
      • Assuming that this patient was reperfused within 4 hours what is her 30 day mortality risk? (be as specific as possible) 5pts
    • Riddler #9
      • 1) Accepted answers:
        • ASA (23%-49% decrease in death)
        • IF PCI GP IIB/IIIA inhibitors (60%)
        • LWMH (25%)
        • BB (15%)
        • ACEI (10%) be careful in the acute setting (prior to reperfusion). Benefit is in the long term
        • Nitrates did show a 35% benefit pre lytic era (1988)
        • Plavix prior to PCI (20%) – not studied with IIB/IIIA
        • Thrombolytics
        • Statins
    • Answer con’t
      • Morphine and 02 improve pt symptoms but no proven mortality benefit
    • Answer Con’t
      • 2) Lytics in this patient would be contraindicated. Absolute Contraindications:
        • Any hemorrhagic stroke
        • Non-hemorrhagic stroke or CVA events within the past 6 months (some even suggest a year)
        • Known Intracranial neoplasm
        • Active internal bleeding or active PUD
        • Suspected aortic dissection
        • BP >180/110 despite antihypertensive therapy
    • Answer Con’t
      • Notes:
        • INR of >2.0 is a relative contraindication
    • Answer Con’t
      • Using the TIMI Risk score for patients with ST-segment elevation. Total risk score 0-14 (Lancet 2001. 358:1571-5)
        • Age >75 3pts
        • Age 65-74 2pts
        • Diabetes, hypertension, angina 1pt
        • SBP <100 3pts
        • HR >100/min 2pts
        • Killip class II-IV (1-no hf, 2- moderate , 3-overt, 4 cardiogenic shock) – 2pts
        • Weight <150lb 1pt
        • Anterior ST segment elevation MI or LBBB – 1pt
        • Time to reperfusion >4hrs – 1pt
    • Answer Con’t
      • Risk Score 30 Day Mortality Rate (%)
      • 0 0.8
      • 1 1.6
      • 2 2.2
      • 3 4.4
      • 4 7.3
      • 5 12
      • 6 16
      • 7 23
      • 8 27
      • >8 36
      • Hulten 24
      • Paolino 23.5
      • Goyal 22.5
      • Williams 22.5
      • Tsai 16
      • Bellin 11