04-29-2009, 07:54 AM
A 26-year-old man is brought to the emergency department complaining of chest pressure radiating to his left arm and jaw. The pain is constant in nature and started while he was at an œafter-hours dance club. He has no previous history of heart trouble, has never been hospitalized, and has no family history of myocardial infarction. Examination reveals a diaphoretic, anxious young man in mild discomfort. His pupils are widely dilated and he is tachycardic, but otherwise he has a normal exam. Cardiac enzymes reveal changes consistent with a myocardial infarction. An electrocardiogram shows ST segment depression in the lateral leads. The intern on call gives morphine, oxygen, a nitroglycerin drip, aspirin, intravenous metoprolol, and lovastatin. Shortly thereafter the patient complains of worsening substernal pressure. He is watched in the emergency room, where repeated blood pressure checks show elevated systolic blood pressures of 180 to 220 mm Hg. The patient acutely decompensates and is intubated and transferred to the intensive care unit. Which of the following may have prevented this patient™s decompensation?
A. Administration of immediate thrombolytic therapy after EKG and enzyme results
B. Immediate administration of phentolamine after worsening pain and hypertension
C. Increased dose of intravenous beta-blocker to reduce blood pressure
D. Not giving lovastatin in the acute setting of myocardial infarction
E. Stopping nitroglycerin and giving a bolus of normal saline