Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 66-year-old man with ST-elevation myocardial infarction

mksap
Conditions
February 2, 2019
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 66-year-old man is evaluated in the hospital following ST-elevation myocardial infarction treated with primary percutaneous coronary intervention of the left anterior descending artery 4 days ago. His initial presentation was complicated by the presence of heart failure and pulmonary edema. He is asymptomatic and ambulating, and he is nearly ready for discharge. Medical history is significant for hyperlipidemia, type 2 diabetes mellitus, and hypertension. Medications are aspirin, prasugrel, lisinopril, carvedilol, atorvastatin, and basal and prandial insulin.

On physical examination, vital signs are normal. Oxygen saturation is 99% breathing ambient air. The remainder of the examination is unremarkable.

Laboratory studies are significant for a serum creatinine level of 1.0 mg/dL (88.4 µmol/L) and a serum potassium level of 3.7 mEq/L (3.7 mmol/L).

An echocardiogram shows a left ventricular ejection fraction of 35%.

Which of the following is the most appropriate treatment?

A. Eplerenone
B. Isosorbide mononitrate
C. Valsartan
D. Warfarin

MKSAP Answer and Critique

The correct answer is A. Eplerenone.

The most appropriate treatment is eplerenone. This patient had an anterior ST-elevation myocardial infarction (STEMI) complicated by moderate left ventricular (LV) dysfunction and heart failure. Optimizing this patient’s medical therapy is fundamental to preventing further impairment of LV function and promoting favorable LV remodeling. Although beta-blockers and angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers [ARBs]) form the backbone of postinfarction medical therapy aimed at preserving LV function, it is important to recognize when additional agents may be indicated. The EPHESUS trial established the benefits of aldosterone antagonism with eplerenone in patients with acute myocardial infarction and concomitant LV dysfunction, and current guidelines recommend adding an aldosterone antagonist to ACE inhibitor and beta-blocker therapy in STEMI patients with LV ejection fraction of 40% or less and either heart failure symptoms or diabetes mellitus. Because of the potassium-sparing effect of eplerenone, serum potassium levels should be carefully monitored. Eplerenone should be used with caution in those with underlying kidney disease.

Long-acting nitrates, such as isosorbide mononitrate, have no role in the management of patients immediately after STEMI. Nitrates may be used for future angina or may be coupled with hydralazine in those with persistent LV dysfunction despite maximally tolerated doses of a beta-blocker and ACE inhibitor; however, administering isosorbide mononitrate is not the most appropriate next step in this patient’s management.

Although an ARB such as valsartan may be useful as an alternative to ACE inhibitor therapy, adding an ARB to a medication regimen that already includes an ACE inhibitor and beta-blocker has been associated with an excess of adverse events and is therefore not recommended.

Warfarin therapy is recommended to reduce the risk for systemic embolization in patients with LV apical clots following large anterior myocardial infarction, although this recommendation is not based on a large randomized dataset. In this patient, no clots were noted on the echocardiogram, and empiric anticoagulation is not indicated according to current guidelines.

Key Point

ADVERTISEMENT

  • In patients with STEMI, LV ejection fraction of 40% or less, and either heart failure symptoms or diabetes mellitus, an aldosterone antagonist is recommended in addition to ACE inhibitor and beta-blocker therapy.

This content is excerpted from MKSAP 18 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 18 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Imagine viewing health care from space

February 1, 2019 Kevin 0
…
Next

How to write a physician CV

February 2, 2019 Kevin 0
…

Tagged as: Cardiology

Post navigation

< Previous Post
Imagine viewing health care from space
Next Post >
How to write a physician CV

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

Related Posts

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 35-year-old woman with constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 60-year-old woman with persistent constipation

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 45-year-old woman with type 2 diabetes mellitus

    mksap
  • Qualifying conditions for medical marijuana

    Patricia Frye
  • Settlements in the opioid cases need these non-negotiable conditions

    Rosanne Aulino, RN
  • What does Kelly Loeffler’s health plan do to coverage for preexisting conditions?

    Robert Laszewski

More in Conditions

  • Finding healing in narrative medicine: When words replace silence

    Michele Luckenbaugh
  • Why coaching is not a substitute for psychotherapy

    Maire Daugharty, MD
  • Why doctors stay silent about preventable harm

    Jenny Shields, PhD
  • Why gambling addiction is America’s next health crisis

    Safina Adatia, MD
  • How robotics are reshaping the future of vascular procedures

    David Fischel
  • How the shingles vaccine could help prevent dementia

    Marc Arginteanu, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • From survival to sovereignty: What 35 years in the ER taught me about identity, mortality, and redemption

      Kenneth Ro, MD | Physician
    • When doctors forget how to examine: the danger of lost clinical skills

      Mike Stillman, MD | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...