The Challenge Thursday, November 17th

Which of the following is the most appropriate initial antihypertensive medication for use in patients with severely elevated blood pressure and acute cardiac ischemia?

65-year-old male presenting to the emergency department (ED) via emergency medical services (EMS) transport from home for shortness of breath and chest pain. The past medical history includes diabetes mellitus, and a recent NSTEMI and placement of a drug-eluting stent 3 days ago. Current medications include aspirin 81 mg PO daily, Clopidogrel 75 mg PO daily, atorvastatin 80 mg daily, Metoprolol tartrate 50 mg BID. The patient’s vital signs revealed a heart rate of 114 beats/min, blood pressure of 144/90 mm Hg (mean arterial pressure [MAP] 108 mm Hg), respiratory rate of 14 breaths/min, and oxygen saturation of 98%. His lab test results include Na 149 mEq/L, K+ 4.1 mEq/L, Cl 101 mEq/L, CO2 22 mEq/L, SCr 1.1 mg/dL (baseline 1.0 mg/dL), BUN 15 mg/dL, glucose 126 mg/dL, a VerifyNow P2Y12 platelet function result of 285 (Reference range 180-376 PRU). PM is 5’8” tall and weighs 150 lb. Which of the following is the most appropriate intervention for this patient?

What is the recommended dose for Selexipag?

A 45-year-old female presents to the Emergency Department with the complaint of sharp, substernal chest pain for the past 3 weeks which has slowly worsened in intensity. The pain increases with movement and is improved by sitting up. She is also complaining of fever and lethargy. On examination, a pericardial friction rub is auscultated and the diagnosis of pericarditis is confirmed with an ECG.

Which one of the following statements best describes the appropriate first-line treatment for this condition?

A 20-year-old man presents to the ED with several days of progressive chest pain, fatigue, myalgias, and exertional dyspnea. He states that he had the “flu” 1 week before. He denies any illicit drug use or family history of heart disease. Physical examination reveals temperature of 100.5°F, heart rate of 125, no murmurs on cardiac examination, and scattered bilateral crackles on lung examination. EKG demonstrates sinus tachycardia, chest x-ray reveals cardiomegaly and mild pulmonary edema, and laboratory reports are normal except for troponin I, which is elevated at 10 ng per mL. Which of the following is the most likely etiology?

What is the goal blood pressure after achieving adequate heart rate control for aortic dissection?

What intervention should be prioritized in patients presenting  aortic dissection with hypotension secondary to aortic rupture or pericardial tamponade?

An 82-year-old male with congestive cardiac failure experienced rapid decompensation of his clinical status, manifested by increasing shortness of breath, swelling, and increased fatiguability. Laboratory studies showed an elevation in his creatinine level. In order to manage this acute change, he was started on intravenous Dobutamine to improve his hemodynamic status. What effect does this drug have on the body?

A 63-year-old man arrives at the ER with a 20-minute history of crushing pain under the sternum. He was found to be uncomfortable and sweating during his presentation, with ST segment elevations in leads V3-V5. He is given a sublingual nitroglycerin tablet, which significantly reduces his pain level. Which of the following is the most important mechanism by which this drug works in this patient?

A 78-year-old woman presents to the emergency department because of increasing chest pain for last 3 hours. She had a history of intracranial hemorrhage 2 weeks ago. Her temperature is 98.3°F (36.8°C), blood pressure is 110/80 mmHg, pulse is 94/min, respirations are 26/min, and O2 saturation is 89% on room air. ECG shows inferior wall MI. Which of the following is contraindicated in this patient?