promoting venodilation
Morphine to treat the pain is the treatment of choice in acute STEMI situations. In addition to treating the pain, it improves hemodynamics by promoting venodilation and reducing cardiac preload. It can also reduce modest arterial dilation and in so reduce afterload as well. This reduction in preload and afterload help by lowering cardiac oxygen demand, helping to preserve the ischemic myocardium. Beta blockers are also important in treating acute STEMI. The reduce cardiac pain, infarct size, and short-term mortality. They also reduce recurrent ischemia and reinfarction. They reduce myocardial wall tension and may decrease the risk for myocardial rupture. Continued use of oral beta-blockers increases long term survival rates. They work by blocking preventing beta receptor activation. Ultimately this reduces heart rate and contractibility, reducing oxygen demands and blood pressure. They increase coronary blood flow and myocardial oxygen supply. This patient is already taking Metoprolol 50mg BID at home so this step has already been taken.
The patient’s cardiac enzymes are positive which verifies an acute cardiac event. The rest of her labs and vital signs are normal. My next drug of choice would be nitroglycerin, which according to Rosenthal et al. (2018), acts directly on vascular smooth muscle to promote vasodilation. This works by increasing the blood flow to the ischemic areas of the heart. Educating the patient that this medication cause headache, orthostatic hypotension, and reflex tachycardia are important, along with the benefits of this medication for her current condition. Nitroglycerin should be avoided in patients with hypotension, bradycardia, and suspected right ventricular infection.
I work in a small critical access hospital so at this point I would be contacting a tertiary care center for cardiology recommendations and transfer of cares for this patient. Sometimes the cardiologist will recommend reperfusion therapy with fibrinolytics prior to transfer for PCI therapy. Fibrinolytic drugs resolve clots by converting plasminogen into plasmin, a proteolytic enzyme that digests the fibrin meshwork that holds a clot together. The common drugs used for this is alteplase, reteplase, and tenecteplase. These drugs are most effective when presentation is early. When given in a timely manner they can open the occluded artery in 80% of patients. The major complications of this therapy are bleeding, which occurs in 1-5% of patients. Intercranial hemorrhage is the greatest concern. Patients undergo an intense screening process to make sure they are appropriate candidates for therapy and reduce the risk of these complications. Patients who receive this therapy are also treated with anticoagulants such as heparin and antiplatelets such as aspirin or Plavix. These are proven to decrease mortality in acute cardiac events.
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