Riddler Q9 Answer

465 views

Published on

Published in: Health & Medicine, Sports
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
465
On SlideShare
0
From Embeds
0
Number of Embeds
10
Actions
Shares
0
Downloads
4
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Riddler Q9 Answer

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

×