A 72-year-old man, ex-smoker, hypertensive and diabetic. History of stroke with residual paresis in the left arm 4 months ago. He comes to the emergency department of a regional hospital with intense precordial pain of 2 hours of evolution; in the physical examination he presents cold and sweaty skin, blood pressure of 80 mm Hg; electrocardiogram with marked ST segment elevation in leads V1-V6, I and aVL. Which of the following treatments of coronary repercussion is the most appropriate?
This question combines several important facts. To begin with, this is a patient with an extensive anterior and lateral AMI, with cardiogenic shock. On the other hand, in the history, we are told that the patient had a stroke 4 months ago. It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5. The basic question is whether to choose fibrinolysis (which can be done in a regional hospital) or PCI (for which the patient should be referred to a tertiary center). Option 2 does not make much sense, since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer. A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication), but the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI. Therefore, the correct answer is 3.
Immediate systemic fibrinolysis at the regional hospital.
Immediate transfer to a tertiary center for treatment with fibrinolysis.
Immediate transfer to a tertiary center for percutaneous coronary revascularization procedure.
Hemodynamic stabilization and deferred revascularization procedure.
Immediate treatment with fondaparinux and abciximab.
A history of stroke (presumably ischemic) 4 months ago is a relative contraindication for fibrinolysis (if the time is less than 3 months it is an absolute contraindication),
Option 2 does not make much sense, since in the event that fibrinolysis is indicated, it would only be a waste of time to make the transfer.
the definitive factor that tips the balance towards PCI is the extent of AMI and the presence of shock, which are indications for urgent PCI.
It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5.
It is evident from the patient's clinical picture that an urgent reperfusion strategy is indicated, which invalidates options 4 and 5.