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POST index.php

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   * What Is the PANCE/PANRE?


EASE INTO PREP WITH A PANCE® QUESTION A DAY

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PANCE PRACTICE QUESTION FOR SEPTEMBER 9TH

A 57-year-old man with hypertension and hyperlipidemia comes to the emergency
department complaining of crushing substernal chest pain, diaphoresis, and
nausea for 3 hours. He denies palpitations or shortness of breath. He has no
previous history of angina or myocardial infarction. His temperature is 37.0° C
(98.6° F), blood pressure is 82/60 mm Hg, pulse is 103/min, and respirations are
20/min. Physical examination shows jugular venous distention, a tachycardic
heart that is without murmurs, and clear lungs. An electrocardiogram is shown.



A right-sided electrocardiogram is also performed that shows ST elevation in V3
and V4.





Which of the following is the most appropriate medical intervention at this
time?



Dopamine
Furosemide (Lasix)
Intravenous fluids
Metoprolol (Lopressor, Toprol XL)
Nitroglycerin

CORRECT
INCORRECT

The correct answer is C. This patient is having a right ventricular infarct. The
triad of jugular venous distention, hypotension, and clear lungs should make you
suspect the diagnosis. In addition, the electrocardiogram shows inferior
ST-segment elevation (II, III, and aVF), which is consistent with RV infarct.
Right-sided electrocardiogram can be used to support this diagnosis. The finding
of elevations in lead V4 on a right-sided electrocardiogram is 100% specific for
a right-sided infarct. The management of right ventricular infarct requires
aggressive fluid resuscitation, as this type of myocardial infarction is
fluid-dependent. The patients sustaining this type of infarction are now
preload-dependent. They require aggressive intervention to keep the preload
high. Aggressive intravenous fluids therefore should be started until the
patient stabilizes or goes for cardiac catheterization. Intravenous fluids
should be first-line in maintaining adequate blood pressure.

Dopamine (choice A) also might be a useful adjunct if blood pressure cannot be
maintained with intravenous fluids alone. Remember that cardiac pressors,
although good at maintaining blood pressure, can increase cardiac ischemia,
because they increase peripheral vascular resistance. Pressors are helpful at
maintaining blood pressure in this setting at the expense of increasing
myocardial oxygen demand.

Furosemide (choice B) is potentially harmful to patients who have right
ventricular infarction because of this type of infarct's dependence on preload.
This patient has borderline blood pressure and clear lungs. Furosemide would
decrease preload and therefore decrease cardiac output.

Metoprolol (choice D) is used in most patients who have acute coronary syndrome,
but it should not be used in patients who have bradycardia or hypotension. The
patient's systolic blood pressure is only 82 mm Hg. Beta-blockers should not be
used in a patient who has borderline blood pressure, because they will further
lower the patient's blood pressure.

Nitroglycerin (choice E) must be avoided in patients who have right ventricular
infarcts. Nitroglycerin is a potent preload reducer. It will decrease right
ventricular filling and therefore decrease cardiac output.





PEARL: Right ventricular infarct should be considered in all patients who
present with ST-segment elevation in the inferior leads, hypotension, and clear
lungs. These patients should not receive any medications that will decrease
preload (e.g., nitrates, diuretics). The treatment of choice is fluids to
increase the preload.




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