Can you provide a cardiology practice case for a nurse practitioner student featuring a 67‑year‑old male carpenter presenting with acute anterior ST‑segment elevation myocardial infarction (STEMI)—including his presenting symptoms, vital signs, past medical history (hypertension, hyperlipidemia, type 2 diabetes, former smoker), physical exam findings, ECG changes, troponin level, and the recommended immediate management (antiplatelet therapy, nitroglycerin, beta‑blocker, high‑intensity statin, anticoagulation, and transfer for primary PCI)?

Cardiology Practice Case: Acute Anterior STEMI

Patient Presentation

Chief Complaint: 67-year-old male carpenter presents with severe, crushing substernal chest pain radiating to the left arm and jaw, onset 90 minutes ago while working.

Vital Signs:

• BP: 148/92 mmHg
• HR: 102 bpm, regular
• RR: 22 breaths/min
• SpO₂: 94% on room air
• Temperature: 37.1°C (98.8°F)

Past Medical History:

• Hypertension (on lisinopril 20 mg daily)
• Hyperlipidemia (on atorvastatin 40 mg daily, though admits poor adherence)
• Type 2 diabetes mellitus (HbA1c 7.8%, on metformin)
• Former smoker (quit 2 years ago, 30 pack-year history)

Physical Examination:

• General: Diaphoretic, anxious, clutching chest
• Cardiovascular: S1, S2 regular, no murmurs/rubs/gallops appreciated, JVP not elevated
• Respiratory: Clear bilaterally, mild tachypnea
• Extremities: No edema, pulses 2+ bilaterally

Diagnostic Findings

12-Lead ECG (obtained within 5 minutes of arrival):

• ST-segment elevation of 3-4 mm in leads V1-V4 (anterior wall)
• ST-segment elevation of 2 mm in leads I and aVL (lateral extension)
• Reciprocal ST-segment depression in leads II, III, aVF

Initial Laboratory Results:

• Troponin I: 2.8 ng/mL (elevated; normal <0.04 ng/mL)
• CK-MB: 45 ng/mL (elevated)
• Complete blood count: Within normal limits
• Basic metabolic panel: Creatinine 1.1 mg/dL, glucose 178 mg/dL
• INR: 1.0

Your Task

Based on the 2017 ESC and 2013 ACCF/AHA STEMI guidelines, answer the following:

1. What is your immediate diagnosis and risk stratification?

2. What is the optimal reperfusion strategy for this patient, and what is your target time frame? 1, 2, 3

3. What antiplatelet regimen should be initiated immediately? 1

4. What additional acute pharmacotherapy should be administered in the first 30 minutes? 4

5. What anticoagulation strategy should be used during primary PCI? 1

6. What medications should this patient be discharged on for secondary prevention, and for how long? 1

7. Identify two critical time metrics you must document for quality improvement purposes. 2, 5

8. What is one absolute contraindication to fibrinolytic therapy that you must screen for? 4

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Expected Management Algorithm

Immediate Actions (First 10 minutes):

• Primary PCI is the definitive reperfusion strategy with a first medical contact-to-device time goal of ≤90 minutes 1, 2, 3
• Activate cardiac catheterization laboratory immediately; patient should bypass emergency department and go directly to cath lab 1
• Administer aspirin 162-325 mg chewed immediately (oral or IV if unable to swallow) 1
• Administer potent P2Y₁₂ inhibitor: prasugrel 60 mg loading dose (preferred over clopidogrel due to faster onset and superior efficacy in reducing nonfatal MI and stent thrombosis) OR ticagrelor 180 mg if prasugrel contraindicated 1
• Sublingual nitroglycerin 0.4 mg every 5 minutes × 3 doses for symptom relief (monitor BP; avoid if systolic BP <90 mmHg or if right ventricular involvement suspected) 4
• Morphine sulfate 2-4 mg IV if pain persists despite nitroglycerin 4
• High-intensity statin: atorvastatin 80 mg or rosuvastatin 40 mg 6

Anticoagulation During PCI:

• Unfractionated heparin (UFH) weight-adjusted bolus followed by infusion, OR
• Bivalirudin (preferred if high bleeding risk) 1
• Do NOT use fondaparinux for primary PCI 1

Post-PCI Discharge Medications (Minimum 12 months):

• Dual antiplatelet therapy (DAPT): aspirin 75-100 mg daily PLUS prasugrel 10 mg daily (or 5 mg if ≥75 years or <60 kg) OR ticagrelor 90 mg twice daily 1
• Beta-blocker (especially if LVEF <40% or heart failure) 1
• ACE inhibitor or ARB 7, 8
• High-intensity statin continued 1
• Proton pump inhibitor if high GI bleeding risk 1

Critical Quality Metrics:

• Door-to-balloon (device) time: goal <90 minutes 2, 5
• First medical contact-to-device time: goal ≤90 minutes 2, 3

Key Contraindications to Screen:

• Prior intracranial hemorrhage (absolute contraindication to fibrinolysis)
• Active bleeding or bleeding diathesis
• Ischemic stroke within 3 months
• Suspected aortic dissection 4

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Clinical Pearls:

• This patient has a large anterior STEMI (high-risk territory) with lateral extension—primary PCI is strongly preferred over fibrinolysis 4
• The 90-minute symptom onset makes him an ideal candidate for immediate mechanical reperfusion
• His diabetes and anterior location place him at higher risk for adverse outcomes, reinforcing the need for optimal GDMT 8
• Routine echocardiography should be performed during hospitalization to assess LV function and exclude complications 1