What is the appropriate assessment and plan for a 79‑year‑old woman with a history of coronary artery disease status post triple coronary artery bypass graft (left internal mammary artery to left anterior descending artery and saphenous vein grafts to obtuse marginal branches), hypertension, hyperlipidemia, chronic obstructive pulmonary disease, obstructive sleep apnea, and heart failure with reduced ejection fraction (35‑40 %), who presented with severe hypertension and chest pain, was diagnosed with a non‑ST‑elevation myocardial infarction, underwent percutaneous coronary intervention with a drug‑eluting stent to the obtuse marginal branch, and now has bradycardia, hypotension, mildly elevated creatinine, and is taking aspirin, ticagrelor, bempedoic‑acid/ezetimibe, losartan/hydrochlorothiazide, isosorbide mononitrate, and sertraline?

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Assessment and Plan: 79-Year-Old Female Post-NSTEMI with PCI to OM1

CARDIOVASCULAR

Acute Coronary Syndrome

Continue dual antiplatelet therapy (DAPT) with aspirin 81 mg daily plus ticagrelor 90 mg twice daily for a full 12 months without interruption 1, 2. This patient requires uninterrupted DAPT given her recent drug-eluting stent placement to OM1—any premature discontinuation significantly increases the risk of acute stent thrombosis and death. The 2014 AHA/ACC NSTE-ACS guidelines explicitly state that P2Y12 inhibitor therapy (ticagrelor or clopidogrel) should be continued for at least 12 months in all patients with NSTE-ACS who receive a stent 1. The most recent 2025 ACC/AHA ACS guidelines reaffirm that ticagrelor is preferred over clopidogrel in patients undergoing PCI for ACS 2.

Critical medication reconciliation needed: Ensure ticagrelor is sent to her outpatient pharmacy immediately as documented in the cardiology note. Patient education must emphasize that missing even a few doses can be catastrophic.

Heart Failure with Reduced Ejection Fraction (HFrEF)

Continue SGLT2 inhibitor (Jardiance 10 mg daily) and ARB (losartan 50 mg daily) as guideline-directed medical therapy for her newly diagnosed HFrEF (EF 35-40%) 3. The 2006 AHA/ACC secondary prevention guidelines recommend ACE inhibitors or ARBs be started and continued indefinitely in all patients with LVEF ≤40% 3.

Discontinue isosorbide mononitrate (Imdur) as planned—this patient is now hypotensive (BP in low 100s/60s) post-PCI, and nitrates will worsen hypotension without providing mortality benefit in this context. The bradycardia (HR 50s-60s) appropriately precludes beta-blocker initiation at this time, though beta-blockers should be started once heart rate normalizes, as they provide mortality benefit in post-MI patients with reduced EF 3.

Hold hydrochlorothiazide temporarily given current hypotension. Reassess blood pressure trends over the next 24-48 hours before restarting diuretic therapy. The single dose of IV Lasix 20 mg was appropriate for elevated LVEDP of 18 mmHg, but ongoing diuresis should be guided by volume status and blood pressure tolerance.

Hyperlipidemia

Continue bempedoic acid-ezetimibe (Nexlizet 180-10 mg daily)—this combination is FDA-approved and has demonstrated cardiovascular benefit in patients with established CVD who cannot tolerate statins 4. The CLEAR Outcomes trial showed bempedoic acid reduced MACE-4 (HR 0.87) and MACE-3 (HR 0.85) in patients with statin intolerance 4. Current LDL-C of 113 mg/dL is above the goal of <55 mg/dL for very high-risk patients 1.

Plan outpatient trial of Leqvio (inclisiran) as documented—this PCSK9 inhibitor may be better tolerated than Repatha (evolocumab) which she previously reacted to. Recheck fasting lipid panel 4-8 weeks after any lipid therapy adjustment.

Post-Reperfusion T-Wave Changes

The deep T-wave inversions in leads I, II, aVL, V2-V6 on today's EKG are consistent with Wellens' syndrome pattern (post-reperfusion changes) following successful PCI to OM1. These are expected findings and do not indicate acute re-occlusion. However, any recurrence of chest pain should prompt immediate repeat EKG and troponin to rule out stent thrombosis.

Hemodynamic Monitoring

Observe overnight with continuous telemetry and frequent blood pressure monitoring given current hypotension (systolic BP low 100s). Tentative discharge tomorrow is appropriate if:

  • Blood pressure stabilizes >100/60 mmHg
  • No recurrent chest pain or dyspnea
  • Heart rate remains >50 bpm
  • No arrhythmias on telemetry

NEUROLOGICAL

Hypertensive Emergency (Resolved)

Initial presentation with SBP 200s and headache has resolved. Continue current antihypertensive regimen (losartan 50 mg, holding HCTZ temporarily) with close outpatient follow-up. The hypertensive emergency was likely precipitated by acute coronary syndrome and associated catecholamine surge.

RESPIRATORY

COPD and OSA

Continue Trelegy once daily and montelukast 10 mg daily. The episode of shortness of breath on [DATE] was appropriately managed with nebulization and consideration of COPD exacerbation versus volume overload (hence the Lasix dose). Repeat EKG ruled out acute ischemia. Patient's inability to tolerate CPAP for OSA is noted—consider discussing alternative therapies (positional therapy, oral appliances) at outpatient follow-up.

RENAL

Acute Kidney Injury (Mild)

Creatinine elevated to 1.1 mg/dL from baseline 0.9 mg/dL, likely multifactorial from contrast-induced nephropathy post-catheterization, hemodynamic changes, and diuretic use. Monitor daily creatinine and ensure adequate hydration while avoiding volume overload. Hold nephrotoxic agents. Renal function should improve with stabilization of hemodynamics.

GASTROINTESTINAL

GI Prophylaxis

Start proton pump inhibitor (e.g., pantoprazole 40 mg daily) for GI prophylaxis given DAPT use 1. The 2014 NSTE-ACS guidelines state that PPIs are reasonable in patients without known GI bleeding history who require triple antithrombotic therapy or DAPT 1. This reduces risk of upper GI bleeding, which is elevated with aspirin plus ticagrelor.

Continue cardiac diet with sodium restriction (<2 grams daily) given HFrEF.

ENDOCRINE

Diabetes and Thyroid

No active issues. A1c 5.3% and TSH 2.1 are both within normal limits. Continue current management.

PSYCHIATRY

Depression

Continue sertraline 50 mg daily. Depression screening and treatment are Class I recommendations in post-ACS patients 3.

DISCHARGE PLANNING

Mandatory Pre-Discharge Actions:

  1. Confirm ticagrelor prescription sent to outpatient pharmacy
  2. Provide written DAPT education: Emphasize 12-month duration, consequences of non-adherence (stent thrombosis, death)
  3. Activity restrictions: No driving for 1 week post-PCI, no heavy lifting >10 lbs for 2 weeks, gradual return to activity
  4. Angina action plan: If chest pain lasts >2-3 minutes despite rest, take sublingual nitroglycerin; if pain persists 5 minutes after first dose, call 911 immediately 5, 6
  5. Cardiac rehabilitation referral (Class I recommendation) 3
  6. Outpatient cardiology follow-up within 1 week to reassess beta-blocker candidacy once heart rate normalizes
  7. Lipid panel recheck in 4-8 weeks after Leqvio trial initiated

Discharge Medications:

  • Aspirin 81 mg daily (lifelong)
  • Ticagrelor 90 mg twice daily (12 months minimum)
  • Bempedoic acid-ezetimibe 180-10 mg daily
  • Losartan 50 mg daily
  • Jardiance 10 mg daily
  • Trelegy inhaler once daily
  • Montelukast 10 mg daily
  • Sertraline 50 mg daily
  • Pantoprazole 40 mg daily (new)
  • HOLD: Isosorbide mononitrate, hydrochlorothiazide (reassess outpatient)

Critical Safety Points:

  • No elective surgery or dental procedures for 12 months without cardiology clearance due to DAPT requirement
  • Bleeding precautions: Avoid NSAIDs, monitor for signs of GI or other bleeding
  • Stent thrombosis warning signs: Sudden severe chest pain, shortness of breath—call 911 immediately

References

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