From the Guidelines
The primary treatment for a 70-year-old male with third-degree heart block following MI with stent placement is permanent pacemaker implantation, as recommended by the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1. This is an urgent intervention given his symptomatic bradycardia and post-MI status, which significantly increases his risk of sudden cardiac death. While awaiting pacemaker placement, temporary transcutaneous or transvenous pacing may be necessary to maintain adequate heart rate. Medication management includes continuing dual antiplatelet therapy (typically aspirin 81mg daily plus clopidogrel 75mg daily or ticagrelor 90mg twice daily) to prevent stent thrombosis, as supported by the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction 1. However, the use of beta blockers, which are generally recommended for patients with MI, may need to be cautiously considered or avoided in this patient due to his bradycardia and heart block, as they can further reduce heart rate and worsen conduction abnormalities. For nutrition, a nasogastric or nasojejunal feeding tube should be placed to provide adequate nutrition since he cannot consume solid foods. Liquid medications can be administered through this tube. Physical therapy consultation is essential to prevent complications of immobility such as pressure ulcers, deep vein thrombosis, and muscle wasting. Prophylactic anticoagulation with enoxaparin 40mg subcutaneously daily (adjusted for renal function) should be considered. The prognosis depends on several factors including the extent of cardiac damage, comorbidities, and response to treatment, but with appropriate interventions including pacemaker placement, adequate nutrition, and rehabilitation, many patients can achieve significant improvement in symptoms and quality of life. Regular monitoring of electrolytes, particularly potassium and magnesium, is crucial as imbalances can worsen cardiac conduction abnormalities. Key considerations in the management of this patient include:
- Prompt pacemaker implantation to address the third-degree heart block
- Careful management of medications to avoid exacerbating bradycardia or heart block
- Adequate nutrition and hydration through a feeding tube
- Prevention of complications related to immobility
- Close monitoring of electrolytes and cardiac function.
From the FDA Drug Label
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From the Research
Treatment Options
- For a 70-year-old male with third-degree heart block, recent myocardial infarction (MI) and stent placement, bradycardia, who is bedridden and unable to consume solid foods, treatment options may include:
- The patient's complex medical condition, including third-degree heart block, recent MI, and bradycardia, requires careful management and monitoring in an intensive care setting 2
Prognosis
- The prognosis for a patient with third-degree heart block and recent MI is generally poor, with a high risk of complications and mortality 2
- The patient's bedridden status and inability to consume solid foods may further complicate their condition and worsen their prognosis 3, 4
- The patient's complexity, including medical and non-medical aspects, should be taken into account when assessing their prognosis and developing a care plan 3, 4
Nursing Care
- Nursing care for a patient with complex needs, such as this patient, requires a high level of intensity and frequency of activities, relational continuity of care, and home visits 5
- Nurses play a critical role in care coordination for patients with complex needs, and their contribution to care coordination efforts is essential 5
- The patient's unique situation and needs should be understood and addressed through a sensitive and attentive approach to nursing care 6