What should be administered to a patient with chest pain and hypotension?

Immediate Management: Crystalloid Bolus

This patient presenting with chest pain, hypotension (BP 91/68 mm Hg), and signs of acute coronary syndrome requires immediate crystalloid bolus administration to restore adequate perfusion pressure before considering other interventions. 1

Clinical Reasoning

This patient presents with classic acute myocardial infarction symptoms—severe pressure-like chest pain (8/10), diaphoresis, and lightheadedness—but the critical finding is hypotension with a systolic blood pressure of 91 mm Hg. 1

Why Crystalloid Bolus is the Priority

• Nitroglycerin is absolutely contraindicated in this patient because his systolic blood pressure is <90 mm Hg (or within 30 mm Hg of baseline), which represents a Class III contraindication according to AHA/ACC guidelines. 1

• The patient requires adequate preload to maintain cardiac output and coronary perfusion pressure. 1

• Before any vasodilator therapy can be considered, systolic blood pressure must be restored to >90 mm Hg. 1

• Hypotension in acute MI may indicate hypovolemia, which responds to fluid infusion and must be excluded before diagnosing cardiogenic shock. 1

Why Other Options Are Inappropriate

Nitroglycerin: Contraindicated with systolic BP <90 mm Hg as it will worsen hypotension, reduce coronary perfusion, and potentially precipitate cardiovascular collapse. 1, 2

Labetalol: Beta-blockers are contraindicated in the acute setting when there are signs of hypotension, low output state, or increased risk of cardiogenic shock. 1 This patient's BP of 91/68 mm Hg represents a clear contraindication to beta-blocker administration. 1

Atropine: Only indicated for bradycardia-associated hypotension (the "warm hypotension" with venodilatation seen in inferior MI). 1 This patient has a normal heart rate of 75 bpm, making atropine inappropriate. 1

Immediate Management Algorithm

1. Administer crystalloid bolus (typically 250-500 mL normal saline) to achieve systolic BP >90 mm Hg. 1

2. Reassess hemodynamics after fluid administration—measure blood pressure, heart rate, and assess for signs of pulmonary congestion. 1

3. Once BP is stabilized >90 mm Hg, then consider:

   • Aspirin 160-325 mg (chewed) if not already given 1
   • Morphine 2-4 mg IV for pain relief 1, 3
   • Nitroglycerin only after BP is adequate 1

4. Obtain 12-lead ECG immediately to determine if STEMI is present and guide reperfusion strategy. 1

Critical Pitfalls to Avoid

• Never administer nitroglycerin to hypotensive patients—this can cause paradoxical bradycardia, worsening angina, and cardiovascular collapse. 1, 2

• Distinguish between hypovolemia and cardiogenic shock before administering inotropes—hypovolemia presents with low jugular venous pressure and responds to fluids, while cardiogenic shock has elevated filling pressures. 1

• Monitor for right ventricular infarction, especially if inferior wall changes are present on ECG, as these patients are particularly preload-dependent and require adequate fluid resuscitation. 1

• After fluid resuscitation, if hypotension persists with evidence of elevated cardiac filling pressures, then inotropic support (dopamine 2.5-5 μg/kg/min or dobutamine) should be considered. 1