What is the appropriate management for a 52-year-old patient with a history of Non-ST-Elevation Myocardial Infarction (NSTEMI), atrial fibrillation with rapid ventricular response, impaired left ventricular function (Left Ventricular Ejection Fraction (LVEF) 45%), acute kidney injury, urinary tract infection, and suicidal ideation, currently on dual antiplatelet therapy with aspirin and Eliquis (apobarin) and metoprolol, with decreased vision and no recent follow-up with cardiology or ophthalmology?

From the Guidelines

The patient's complex presentation of NSTEMI, atrial fibrillation, impaired left ventricular function, acute kidney injury, urinary tract infection, and positive suicidal ideation necessitates immediate and comprehensive care coordination to address the high risk of morbidity, mortality, and poor quality of life. The patient is a 52-year-old who presents for hospital follow-up after being treated for a non-ST elevation myocardial infarction (NSTEMI), atrial fibrillation with rapid ventricular response, impaired left ventricular function with an ejection fraction of 45%, acute kidney injury, and urinary tract infection. During today's visit, depression screening revealed positive suicidal ideation without a specific plan, necessitating immediate intervention. The STAR Care crisis line was contacted, and the patient spoke with McCanda, resulting in the STAR Care team being dispatched to the clinic for further evaluation. The patient is currently taking dual therapy with aspirin and Eliquis for his cardiac conditions, along with metoprolol for rate control.

Key Considerations

• The patient's renal function should be closely monitored, and antithrombotic treatment should be adjusted according to the severity of renal dysfunction, as recommended by the European Society of Cardiology guidelines 1.
• The patient's impaired left ventricular function and heart failure are independent predictors of mortality and other major adverse cardiac events in NSTEMI, and therefore, require careful management and follow-up 1.
• The patient's gradual decline in vision over the past year should be evaluated with an eye examination to rule out any underlying conditions that may be contributing to the decline.
• The patient's mental health concerns, including positive suicidal ideation, should be addressed promptly and thoroughly, with a comprehensive treatment plan in place to ensure the patient's safety and well-being.

Management

• The patient should be referred to cardiology for follow-up and management of his cardiac conditions, including optimization of his antithrombotic therapy and rate control.
• The patient's renal function should be closely monitored, and adjustments should be made to his antithrombotic treatment as needed, based on the recommendations of the European Society of Cardiology guidelines 1.
• The patient should undergo an eye examination to evaluate his gradual decline in vision and rule out any underlying conditions that may be contributing to the decline.
• The patient's mental health concerns should be addressed promptly and thoroughly, with a comprehensive treatment plan in place to ensure the patient's safety and well-being.

From the FDA Drug Label

The mean elimination half-life of metoprolol is 3 to 4 hours; in poor CYP2D6 metabolizers the half-life may be 7 to 9 hours. The systemic availability and half-life of metoprolol in patients with renal failure do not differ to a clinically significant degree from those in normal subjects. Consequently, no reduction in dosage is usually needed in patients with chronic renal failure

• Chief Complaint: 52-year-old patient presents for post-hospital follow-up after experiencing NSTEMI, atrial fibrillation with rapid ventricular response, impaired left ventricular function (LVEF 45%), acute kidney injury, and urinary tract infection.
• History of Present Illness (HPI): The patient has a history of NSTEMI, atrial fibrillation with rapid ventricular response, and impaired left ventricular function. The patient is currently on dual antiplatelet therapy with aspirin and Eliquis, and metoprolol. The patient has follow-up appointments with nephrology but not cardiology. The patient reports decreased vision over the last 1 year without a recent eye exam. Additionally, the patient screened positive for suicidal ideation without a plan during a depression screening, prompting a crisis intervention. 2

From the Research

History of Present Illness (HPI)

The patient is a 52-year-old individual who presented for a post-hospital follow-up after experiencing a Non-ST-Elevation Myocardial Infarction (NSTEMI), atrial fibrillation with rapid ventricular response, impaired left ventricular function (LVEF 45%), acute kidney injury, and a urinary tract infection.

• The patient's current medication regimen includes dual antiplatelet therapy with aspirin and Eliquis, as well as metoprolol.
• During the visit, the patient underwent depression screening and was found to be positive for suicidal ideation without a plan, prompting a call to the Star Care crisis line and subsequent dispatch of the Star Care team to the clinic.
• The patient has a scheduled follow-up with nephrology but not with cardiology.
• Additionally, the patient reported a decrease in vision over the past year and has not undergone an eye exam.

Relevant Considerations

• The patient's suicidal ideation is a critical concern, and as noted in studies such as 3 and 4, assessing the intent, plan, and means, as well as the availability of social support, is essential in managing patients with suicidal thoughts.
• The management of suicidal behavior, as outlined in 5, involves medical stabilization, thorough risk assessment, and addressing modifiable psychosocial risk factors, which may be applicable to this patient's care.
• The importance of respecting patient dignity and autonomy, while prioritizing safety concerns, is highlighted in 6, which is relevant to the patient's current situation.
• The ethical considerations in responding to a suicide attempt, as discussed in 7, may also be pertinent in the patient's ongoing care, particularly in balancing the patient's wishes with the medical team's obligations.