A 48-year-old male with a history of diabetes, obesity and tobacco use presents with severe substernal chest pressure and shortness of breath. His temperature is 99.0, blood pressure 90/60 mm Hg, heart rate 90 beats per minute, respirations 20 per minute and oxygen 90% on room air. His chest X-ray shows significant pulmonary edema. Laboratory studies reveal a troponin of 10.5, creatinine of 1.4 and hemoglobin of 11.0. His ECG is below:
Which of the following medical therapies is NOT appropriate at this time?
E. Low molecular weight heparin
Guidelines from the American Heart Association recommend early intravenous beta-blockers when no contraindications exist and there is angina, hypertension or tachycardia not related to heart failure. Otherwise, oral beta-blocker therapy is given in the acute setting. It is important not to give beta-blockers if there are signs of cardiogenic shock, such as hypotension or pulmonary edema on chest X-ray. Long-term therapy (lifetime) has been shown to reduce myocardial infarction incidence and improve mortality. Also, if left ventricular systolic dysfunction remains after a STEMI, beta-blockers are important for chronic systolic HF. With lower heart rates, low dose oral beta-blockers should be used ― as long as the patient is stable, and there is no heart block present.