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You are seeing in your office a patient with the chief complaint of relatively sudden onset of shortness of breath and weakness but no chest pain. ECG shows nonspecific ST-T changes. You would be particularly attuned to the possibility of painless, or silent, myocardial infarction in the
A) Advanced coronary artery disease patient with unstable angina on multiple medications
B) Elderly diabetic
C) Premenopausal female
D) Inferior MI patient
E) MI patient with PVCs
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elba 4
4 A 75-year-old African American female is admitted with acute myocardial infarction and congestive heart failure, then has an episode of ventricular tachycardia. She is prescribed multiple medications and soon develops confusion and slurred speech. The most likely cause of this confusion is
A) Captopril
B) Digoxin
C) Furosemide
D) Lidocaine
E) Nitroglycerin
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The answer is b. The classic presentation of acute myocardial infarction (MI) involves heavy or crushing substernal chest pain or pressure. However, 15 to 20% of infarctions may be painless, with the greatest incidence in diabetics and the elderly. Dyspnea or weakness may initially predominate in these patients. Other presentations include altered mental status, the appearance of an arrhythmia, or hypotension. Diabetics are likely to have abnormal or absent pain response to myocardial ischemia due to generalized autonomic nervous system dysfunction. The other choices have no specific link to greater likelihood of a silent MI.
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The answer is d. While the clinical picture itself could lead to these neurological symptoms, the only cardiovascular medication on this list likely to do so is lidocaine. Lidocaine is particularly likely to cause confusion in the elderly patient, for whom a lower dose of the drug should generally be given. Other potential adverse effects of lidocaine include tremor, convulsions, respiratory depression, bradycardia, and hypotension.
