From the Guidelines
This patient requires immediate medical attention for cardiogenic shock with anterior ischemia, and the priority should be to improve oxygenation and perfusion. The patient's blood pressure is 89/45 mmHg, pulse is 60 beats per minute, and she is experiencing difficult breathing, which indicates a life-threatening condition that requires urgent action 1. The ECG shows anterior ischemia, which suggests a possible acute coronary syndrome, and the patient's presentation is consistent with cardiogenic shock. The treatment should focus on improving oxygenation, perfusion, and cardiac function, and the following steps should be taken:
- Administer supplemental oxygen to improve oxygenation
- Start fluid resuscitation with normal saline 250-500 mL bolus while monitoring for pulmonary edema
- Obtain urgent 12-lead ECG, cardiac biomarkers, chest X-ray, and arterial blood gases
- Administer aspirin 325 mg chewed immediately and consider clopidogrel 300-600 mg loading dose
- Activate the cardiac catheterization lab for primary percutaneous coronary intervention (PCI), as this is likely an acute myocardial infarction causing hemodynamic compromise
- For hypotension, start low-dose inotropic support with dobutamine 2-20 mcg/kg/min or norepinephrine 0.1-0.5 mcg/kg/min titrated to maintain systolic BP >90 mmHg, as recommended by the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1. The patient's presentation suggests anterior wall myocardial infarction with resultant pump failure, and rapid revascularization is essential to salvage myocardium and improve survival. Key considerations in the management of this patient include:
- Monitoring cardiac rhythm continuously for arrhythmias
- Avoiding nitrates and beta-blockers initially due to hypotension
- Considering mechanical circulatory support if necessary, as recommended by the ESC guidelines 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Norepinephrine Bitartrate Injection is a concentrated, potent drug which must be diluted in dextrose containing solutions prior to infusion. Restoration of Blood Pressure in Acute Hypotensive States Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs
The patient's blood pressure is 89/45 mmHg, which is considered hypotensive. The patient also has anterior ischemia on ECG and is experiencing difficult breathing.
- The initial dose of norepinephrine can be started at 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute.
- The goal is to maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) to ensure adequate circulation to vital organs.
- It is also important to correct blood volume depletion as fully as possible before or concurrently with norepinephrine administration 2.
From the Research
Patient Presentation
The patient is a 70-year-old lady with the following symptoms:
- Blood pressure: 89/45
- Pulse: 60
- Difficulty breathing
- ECG showing anterior ischemia
Treatment Options
Based on the patient's symptoms, the following treatment options are considered:
- Aspirin is recommended for all patients with suspected acute coronary syndrome (ACS) unless contraindicated 3
- Addition of a second antiplatelet (e.g., clopidogrel, ticagrelor, or prasugrel) is also recommended for most patients 3
- Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 3
- Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 3
- Statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain) are also recommended 3
- Oxygen therapy is recommended for patients with difficulty breathing 3
Revascularization Options
The following revascularization options are considered:
- Percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible for patients with ST-segment elevation myocardial infarction (STEMI) 3
- Fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 4, 3
- For non-ST-segment elevation ACS, PCI is recommended; fibrinolytic therapy is typically not recommended 3
- Coronary artery bypass grafting (CABG) surgery may be considered for patients who require revascularization but are not candidates for PCI 3
Antiplatelet Therapy
The following antiplatelet therapy options are considered:
- Dual antiplatelet therapy with aspirin and clopidogrel is the standard of care for patients with ACS and those undergoing PCI 5
- Newer, more potent antiplatelet agents such as prasugrel and ticagrelor may be considered as alternative strategies 5
- The benefits of starting clopidogrel on admission appear to outweigh the risks, even among those who proceed to CABG during the initial hospitalization 6
Key Considerations
The following key considerations are noted:
- The patient's age (70 years) and symptoms (difficulty breathing, anterior ischemia on ECG) suggest a high-risk presentation 4, 3
- The patient's blood pressure (89/45) and pulse (60) suggest potential hemodynamic instability 4, 3
- The use of antiplatelet and anticoagulation therapy should be carefully considered in light of the patient's risk of bleeding 3, 6