What is the appropriate acute and secondary management for a 71-year-old man presenting with chest pain, suspected myocardial infarction, normotensive, and severe hypercholesterolemia?

Acute Management of 71-Year-Old with Suspected MI, Severe Hypercholesterolemia, and Hypertension

This patient requires immediate activation of the cardiac catheterization laboratory for emergency coronary angiography with intent to perform primary PCI within 120 minutes of first medical contact, while simultaneously initiating dual antiplatelet therapy, anticoagulation, and pain control. 1

Immediate Actions (Within 10 Minutes)

• Obtain a 12-lead ECG within 10 minutes of presentation to identify ST-segment elevation ≥1 mm in contiguous leads, new left bundle branch block, or other ischemic changes. 1, 2
• Administer aspirin 162-325 mg chewed (non-enteric coated) immediately unless contraindicated. 2, 3
• Initiate continuous ECG monitoring with defibrillation capability to detect life-threatening arrhythmias. 1, 2
• Establish IV access and draw cardiac troponin, but do not wait for results before initiating reperfusion therapy if diagnostic ST-elevation is present. 1, 2
• Administer IV morphine 4-8 mg initially, then 2 mg every 5 minutes until chest pain is relieved, as uncontrolled pain increases sympathetic drive and myocardial oxygen demand. 1, 2

Reperfusion Strategy (Time-Critical)

• Activate the cardiac catheterization laboratory immediately for primary PCI, which must be performed within 120 minutes of first medical contact; the target door-to-balloon time is <90 minutes. 1, 2
• Add a P2Y12 inhibitor (ticagrelor 180 mg or prasugrel 60 mg loading dose) for dual antiplatelet therapy unless contraindicated. 1
• Start unfractionated heparin or low-molecular-weight heparin during transfer to the catheterization laboratory. 1
• If primary PCI cannot be achieved within 120 minutes, administer fibrinolytic therapy within 30 minutes of hospital arrival. 2

Hemodynamic Management

• Provide supplemental oxygen (2-4 L/min) only if oxygen saturation is <90%, the patient is breathless, or shows signs of heart failure; routine oxygen may be harmful. 1, 2
• Consider IV beta-blocker (metoprolol 5 mg IV every 2 minutes for 3 doses) if hemodynamically stable (BP >100 mmHg systolic, HR >60 bpm, no signs of heart failure or heart block) to reduce myocardial oxygen demand. 2, 4
• Administer IV nitroglycerin for ongoing chest pain only if systolic BP >90 mmHg; avoid if hypotension is present. 3

Critical Pitfalls to Avoid

• Do not delay reperfusion therapy waiting for cardiac troponin results when diagnostic ECG changes are present; the European Society of Cardiology explicitly prohibits this practice. 1
• Do not order stress testing in the acute setting—this patient already has suspected MI and further testing is dangerous and contraindicated. 1
• Do not assume a normal initial troponin excludes MI; troponins may not rise until 3-6 hours after symptom onset. 5
• Do not attribute chest pain to non-cardiac causes without excluding ACS first, especially given the high-risk features (age 71, severe hypercholesterolemia). 6, 7

Secondary Prevention (Initiated Within 24 Hours)

Lipid Management

• Start high-intensity statin therapy immediately (atorvastatin 80 mg or rosuvastatin 40 mg daily) regardless of the LDL of 304 mg/dL, as early statin initiation in ACS reduces mortality and recurrent events. 2
• The severely elevated LDL (304 mg/dL) confirms the need for aggressive lipid-lowering therapy, but acute MI causes a rapid decline in cholesterol levels after 24 hours, so this baseline value is critical for risk assessment. 8

Blood Pressure Management

• Start an ACE inhibitor (lisinopril 5 mg daily initially, titrate to 10 mg daily) within the first 24 hours if evidence of heart failure, LV systolic dysfunction, anterior infarction, or diabetes is present. 2, 9
• The BP of 140/80 mmHg is acceptable acutely; aggressive BP lowering during acute MI can compromise coronary perfusion and worsen outcomes. 9
• Continue oral beta-blocker (metoprolol 25-50 mg twice daily) for at least 6 weeks, ideally indefinitely, after the acute phase. 2, 4

Long-Term Medical Therapy

• Maintain indefinite dual antiplatelet therapy: aspirin 75-100 mg daily plus P2Y12 inhibitor (clopidogrel 75 mg, ticagrelor 90 mg twice daily, or prasugrel 10 mg daily) for at least 12 months post-PCI. 2
• Continue ACE inhibitor indefinitely, as it reduces mortality and prevents adverse remodeling post-MI. 2, 9
• Continue high-intensity statin indefinitely regardless of achieved LDL levels. 2

Risk Stratification Considerations

• Age 71 years is a significant risk factor for increased in-hospital mortality (6-14%) and 6-month mortality (approximately 12%) in unselected STEMI patients. 1
• The combination of chest pain, suspected MI on ECG, and severe hypercholesterolemia (LDL 304 mg/dL) places this patient at very high risk for adverse outcomes without immediate intervention. 6, 7
• Prior abnormal stress test (if present), peripheral arterial disease, or pain radiating to both arms would further increase the likelihood of ACS (LR 2.6-3.1). 7

Post-Revascularization Monitoring

• Monitor for complications including persistent hypotension (9% incidence with lisinopril in acute MI), renal dysfunction (2.4% incidence), heart failure, and arrhythmias. 9
• Assess left ventricular function with echocardiography within 24-48 hours to guide further therapy and prognosis. 5
• Implement cardiac rehabilitation and lifestyle modifications including smoking cessation (if applicable), exercise program, and diet low in saturated fat and cholesterol. 2