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Mona is a 29 y/o female who is a nursing student and works full time as a tele-tech. She drinks 5-7x a week and smokes 1-2 packs a day to cope with the stressors of her life. She regularly eats fast food but has been increasing even more recently due to upcoming finals. Her medical history is as follows: uncontrolled hypertension, hyperlipidemia, peripheral vascular disease, smoking, alcohol use and obesity (5’4″, 205 pounds, BMI 35.2).
While studying for finals with her classmate, she became ill and her friend rushed her to the ER. Mona described her chest pain as 8/10 “pressure, flu like symptoms (fatigue, N/V, back pain), anxiety, diaphoresis, bilateral edema, capillary refill > 4 seconds, cool and clammy skin. Her presenting vitals were: HR 110, RR 24, BP 142/94, O2 92%, T99.4.
An MI is suspected. An IV is inserted. Labs and a 12-lead ECG are ordered. Immediate interventions are taken (Oxygen at 2 L, Aspirin 325 mg PO, Nitroglycerin 5 mg SL x3, Morphine 1 mg IV push). The ECG shows ST elevation.
Labs
Troponin T* – 0.78ng/mL (reference <0.035 ng/mL)
Creatine Kinase* – 183 units/L (reference 5-25 units/L)
Myoglobin* – 124 mcg/mL (reference 25-72 mcg/mL)
BNP* – 425 pg/mL (reference <100 pg/mL)
Total cholesterol* – 243 mg/dL (reference <200 mg/dL)
LDL* – 166 mg/dL (reference < 199 mg/dL)
HDL* – 52 mg/dL (reference < 100 mg/dL)
Triglycerides* – 287 mg/dL (reference <150 mg/dL)
Hemoglobin – 14.2 g/dL (reference 12-16 g/dL)
Hematocrit – 39% (reference 36-47%)
Platelets – 224,000 (reference 150,000-450,000/mcL)
PT – 13 sec. (reference 11-14 seconds)
PTT – 32 sec. (reference 25-35 seconds)
Treatment Plan: percutaneous coronary intervention was unsuccessful because there was 95& blockage in the LAD and 70% blockage of the left main coronary artery and a stent was unable to be placed. The backup treatment plan is tenecteplase 50 mg IV (weight based). Tenecteplase was successful. Mona was given extensive education upon discharge.
- What risk factors does Mona have/not have? Which of these are modifiable? (Has: obesity, diet, smoking, drinking, lack of exercise, constant/chronic stress, *all are modifiable except stress can be coped with*. Does not have: male, over 45 year old, family hx *all non-modifiable*)
- If Mona was not a candidate for tenecteplase, what would the next treatment plan be? (CABG)
- What interdisciplinary teams would you involve? (dietary and case management for cardiac rehabilitation referral)
