What prophylaxis or PRN (as needed) medications would be reasonable for a 50-year-old male with mildly elevated calcium score, hypertension (HTN), and premature ventricular contractions (PVCs) presenting with a near syncopal episode and minor troponin elevation?

Prophylaxis and PRN Orders for Admitted Patient with Near-Syncope, PVCs, and Minor Troponin Elevation

Immediate Prophylaxis Orders

Beta-blocker therapy should be initiated immediately as the cornerstone of prophylaxis in this patient with suspected acute coronary syndrome, hypertension, and ventricular arrhythmias. 1, 2

Beta-Blocker Initiation

• Start oral metoprolol 25-50 mg every 6 hours (or equivalent cardioselective beta-blocker) 1, 3
• The AHA/ACC guidelines for unstable angina/NSTEMI recommend early beta-blocker administration in the absence of contraindications, particularly for high-risk patients with ongoing symptoms 1
• Beta-blockers are specifically Class I recommended for symptomatic ventricular arrhythmias including PVCs, and are first-line for reducing arrhythmia burden in patients with hypertension and coronary disease 1, 2, 4
• Use cardioselective agents (metoprolol, atenolol) rather than non-selective agents to minimize bronchospasm risk 5
• Monitor heart rate (target >50 bpm), blood pressure, and continuous telemetry during initiation 1, 3

Antiplatelet and Anticoagulation Therapy

• Aspirin 162-325 mg loading dose, then 81 mg daily indefinitely 1
• Clopidogrel 300 mg loading dose, then 75 mg daily 1
• Subcutaneous enoxaparin (LMWH) or intravenous unfractionated heparin should be added to antiplatelet therapy given the minor troponin elevation suggesting acute coronary syndrome 1
• These are Class I recommendations for patients presenting with unstable angina/NSTEMI 1

Anti-Ischemic Therapy

• Sublingual nitroglycerin 0.4 mg PRN for chest pain (up to 3 doses, 5 minutes apart) 1
• Consider intravenous nitroglycerin if recurrent ischemic symptoms develop, starting at low doses with careful blood pressure monitoring 1
• ACE inhibitor therapy should be initiated given hypertension and concern for acute coronary syndrome, particularly if any LV dysfunction is found on echo 1, 2

PRN Medication Orders

For Breakthrough Arrhythmias or Symptoms

• Metoprolol 5 mg IV PRN for sustained symptomatic tachyarrhythmias (may repeat every 5 minutes up to 15 mg total if hemodynamically stable) 1, 3
• Morphine sulfate 1-5 mg IV PRN for chest pain not relieved by nitroglycerin, repeatable every 5-30 minutes as needed 1
• Morphine should be administered with careful blood pressure monitoring and can be given alongside IV nitroglycerin 1

For Severe Arrhythmias (If They Develop)

• Procainamide IV can be useful for hemodynamically stable sustained VT if it develops 1
• Amiodarone 150 mg IV may be considered for refractory sustained VT, though prophylactic use is contraindicated 1
• Immediate cardioversion should be available for hemodynamically unstable arrhythmias 1

Critical Contraindications and Monitoring

Beta-Blocker Contraindications to Assess

• Active bronchospasm or severe asthma 1
• Heart rate <50 bpm or significant bradycardia 1
• Systolic blood pressure <90 mmHg 1
• Signs of acute heart failure (rales on auscultation) 1
• High-grade AV block without pacemaker 1

Aspirin Contraindications

• Active bleeding, hemophilia, or severe untreated hypertension 1
• True aspirin allergy (manifested as asthma) - use clopidogrel alone if present 1
• Active peptic ulcer disease 1

Common Pitfalls to Avoid

Do not use calcium channel blockers (verapamil, diltiazem) as first-line therapy for wide-complex tachycardia of unknown origin - these are potentially harmful and contraindicated 1. Beta-blockers are superior and safer for this indication 1, 2.

Avoid prophylactic lidocaine or high-dose amiodarone - these are potentially harmful when given prophylactically in suspected MI 1.

Do not use rapid-release, short-acting dihydropyridines (nifedipine) without concurrent beta-blockade - controlled trials show increased adverse outcomes in acute coronary syndromes 1.

The minor troponin elevation combined with near-syncope and PVCs suggests this patient has acute coronary syndrome until proven otherwise, warranting aggressive anti-ischemic and antiplatelet therapy alongside arrhythmia management 1. The beta-blocker serves dual purposes: reducing ischemia and suppressing ventricular ectopy 1, 2, 6.