What is the plan of care for a 61-year-old male with an Electrocardiogram (EKG) showing possible inferior myocardial infarction and ST-segment elevation in leads V1, V2, V3, and V4, with right axis deviation?

From the Guidelines

The plan of care for a 61-year-old male with an EKG showing possible inferior myocardial infarction and ST-segment elevation in leads V1, V2, V3, and V4, with right axis deviation, requires immediate intervention with a primary PCI strategy, unless the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion is > 120 min, when fibrinolysis should be initiated immediately. This patient should be treated as having an acute ST-elevation myocardial infarction (STEMI) until proven otherwise. Initial management includes administering aspirin 325 mg chewed, and either prasugrel or ticagrelor as the preferred P2Y12 inhibitor, with a loading dose of 60 mg for prasugrel or 180 mg for ticagrelor, and heparin (either unfractionated at 60 units/kg bolus followed by 12 units/kg/hr infusion, or enoxaparin 1 mg/kg subcutaneously) 1. Pain control with IV morphine 2-4 mg and supplemental oxygen if saturation is below 94% should be provided. The patient needs immediate cardiac catheterization for potential percutaneous coronary intervention (PCI), ideally within 90 minutes of first medical contact, with routine radial access and routine drug-eluting stent (DES) implantation as the standard of care during primary PCI 1. If PCI is unavailable within this timeframe, fibrinolytic therapy with alteplase, reteplase, or tenecteplase should be considered if no contraindications exist. Additional medications include beta-blockers (metoprolol 5 mg IV every 5 minutes for 3 doses, followed by oral therapy) and high-intensity statin (atorvastatin 80 mg daily). The right axis deviation may indicate right ventricular involvement or other cardiac pathology requiring additional assessment. Continuous cardiac monitoring, serial troponin measurements, and echocardiography are essential to evaluate cardiac function and complications.

Key Considerations

• The patient's EKG changes and clinical presentation are consistent with an acute STEMI, requiring prompt reperfusion therapy 1.
• Primary PCI is the preferred reperfusion strategy, with a goal of PCI-mediated reperfusion within 120 minutes of STEMI diagnosis 1.
• The use of antithrombotic therapy, including aspirin, prasugrel or ticagrelor, and heparin, is crucial in the management of STEMI patients 1.
• Routine radial access and routine DES implantation are the standard of care during primary PCI, with contraindications to routine thrombus aspiration or deferred stenting 1.
• The patient's management should be coordinated with a 24/7 high-volume PCI center, with immediate transfer to the PCI center, bypassing the emergency department 1.

Additional Assessment

• The patient should undergo non-invasive imaging, such as echocardiography, to evaluate cardiac function and identify potential complications 1.
• The patient's right axis deviation may require additional assessment to rule out right ventricular involvement or other cardiac pathology 1.
• The patient's management should be individualized, taking into account their specific clinical presentation, medical history, and potential contraindications to certain therapies 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Plan of Care

The plan of care for a 61-year-old male with an Electrocardiogram (EKG) showing possible inferior myocardial infarction and ST-segment elevation in leads V1, V2, V3, and V4, with right axis deviation, involves the following:

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 2
• Addition of a second antiplatelet (ie, dual antiplatelet therapy) (eg, clopidogrel, ticagrelor, or prasugrel) also is recommended for most patients 2
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 2
• Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 2
• Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin and morphine (to relieve chest pain), and oxygen 2

Intervention

For patients with an ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 2

• However, fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 2
• The combination of antiplatelet and anticoagulant agents should be chosen according to the patients' characteristics and the management strategy of the acute coronary syndrome 3

Antiplatelet Therapy

Clopidogrel has demonstrated improved outcomes for patients with acute coronary syndromes in several large randomized controlled trials 4

• Clinical trial results have demonstrated a reduction in the composite endpoint of death, myocardial infarction, or stroke for patients with acute coronary syndromes who received clopidogrel plus aspirin compared with aspirin alone 4
• The benefits of initiating patients on a 600-mg loading dose of clopidogrel before PCI have been demonstrated in several clinical trials 4
• Newer antiplatelet agents such as prasugrel or ticagrelor have superior anti-ischemic efficacy, compared with clopidogrel 3