A 58-year-old asthmatic female with a history of hypertension, type 2 diabetes and a prior stroke presents to the ED with substernal chest pains radiating to her left arm. She is short of breath, diaphoretic and nauseated. She is afebrile with a blood pressure of 150/90 mm Hg, heart rate of 90 beats per minute, respirations 22 per minute and oxygen 92% on room air. Physical examination reveals an S4 heart sound and significant wheezing on lung examination. Her ECG is below:
Which of the following combinations of initial medical therapy is appropriate?
A. Aspirin, clopidogrel, unfractionated heparin, beta-blocker, oxygen, nitroglycerin
B. Aspirin, prasugrel, low molecular weight heparin, non-dihydropyridine calcium channel blocker, oxygen, nitroglycerin
C. Aspirin, clopidogrel, low molecular weight heparin, non-dihydropyridine calcium channel blocker, oxygen, nitroglycerin
D. Aspirin, prasugrel, unfractionated heparin, beta-blocker, oxygen, nitroglycerin
The non-dihydropyridine calcium channel blockers diltiazem and verapamil can be used when there is a contraindication to beta-blockers (such as asthma) and there is no heart failure or significant left ventricular systolic dysfunction present. They are especially helpful to lower heart rate and reduce oxygen demand in this situation. Sublingual nifedipine is contraindicated due to a reflexive increase in the sympathetic nervous system, which can be harmful.
Recall that prasugrel is contraindicated if a prior stroke or transient ischemic attack, or TIA, is present. Also, either low molecular weight heparin or unfractionated heparin are considered reasonable choices for anticoagulation.