AD is a 68yo male (92kg) who is brought to the ED as a STEMI alert after experiencing sudden onset chest pain and diaphoresis while on a walk with his wife. The EKG performed by EMS shows ST segment elevation in the inferior leads with reciprocal changes in the lateral leads. Upon presentation his heart rate is 82, BP 136/72, and O₂ saturation 98% on room air. A repeat EKG in the ED shows the same patterns as the one performed by EMS. The physician activates the STEMI team and directs ED staff to prepare the patient for cath lab.

ACS1) You see one of the newer nurses placing the patient on nasal cannula despite his current O₂ saturation of 98%. When questioned, he responds that you’re supposed to give every STEMI patient oxygen as it helps them feel better. Which of the following is the most appropriate response?

ACS2) Since the discussion on oxygen in STEMI patients, one of the nurses approaches you asking about the MONA mnemonic for treating STEMI patients. She recalls that it stands for morphine/oxygen/nitroglycerin/aspirin but wonders if you have any other clinical pearls about it. Which of the following is a true statement you can offer to that nurse?

RK is a 59yo female (101kg) who is brought to the ED as a post-cardiac arrest patient. Paramedics report she has an extensive cardiac history with previous CABG. She was eating dinner with her family when she suddenly grabbed her chest and lost consciousness. Her daughter is in nursing school and immediately began performing CPR. Once EMS arrived, they noted the patient to be in ventricular fibrillation, and obtained ROSC after 1 shock. Their post-ROSC EKG shows a ST segment elevation in the lateral leads, with reciprocal changes in the septal leads, which is confirmed with in-house EKG prompting the ED physician to call a STEMI alert. Upon presentation RK looks visibly ill, she is pale and diaphoretic, HR 98, BP 104/52, RR 24, O₂ saturation 88% on 15L non-rebreather. The ED team is concerned that she may go into cardiac arrest again. Unfortunately, the cath lab calls back saying that they have cases ongoing in both of their rooms, so there will be a delay in taking RK up. Due to her critical presentation, the ED physician decides to proceed with alteplase administration due to the delay in catheterization.

ACS3) Which of the following is the most appropriate dosing of alteplase for RK?

TX is a 64yo male (82kg) who presents to the ED with chest pain that started while hanging holiday decorations. He reports a history of high blood pressure and high cholesterol, for which he takes enalapril and rosuvastatin. He states that he doesn’t think he needs to be here, but his husband insisted he come in. Upon initial examination his blood pressure is 162/86, HR 74, RR 18, O₂ saturation 99% on RA. Initial lab work is unremarkable except for an elevated troponin. EKG shows various ischemic changes, but no ST segment elevation. He is diagnosed with an NSTEMI.

ACS4) In addition to aspirin, and ticagrelor, the physician approaches you asking for a recommendation regarding anticoagulation therapy for TX. He notes that cardiology does not think that he needs to go to the cath lab, but should be medically managed instead. Which of the following is the most appropriate recommendation regarding anticoagulation for TX?

FM is a 42yo male (87kg) who presents to the ED complaining of a severe headache. He notes that he has been diagnosed with high blood pressure in the past, but does not take any medication for it as he “doesn’t think [he] needs it.” His blood pressure in triage is 212/122, HR 78, O₂ saturation 98% on room air. A stat head CT shows no sign of intracranial pathology.

HTN1) Which of the following outlines the best classification and treatment strategy for FM’s elevated blood pressure at this point?

HTN2) Labs are drawn on FM, his BMP comes back normal except for a SCr of 2.1. Looking back in the chart, FM’s baseline SCr appears to be 0.8, and he denies any diagnosed history of renal dysfunction. Which of the following now represents the best initial plan for reducing FM’s blood pressure?

BL is a 78yo female (67kg) who presents to the ED with difficulty breathing and coughing up pink foam. She has a history of high blood pressure, but has not taken her medications (lisinopril and hydrochlorothiazide) for several days as she left them at home when she came into town for a family reunion. She reports that she thinks her blood pressure is high because her family “stresses [her] out” and she has been eating a lot of rich foods outside her usual diet, but that the trouble breathing came on rapidly in the last couple of hours. Her initial blood pressure is 202/146, RR 34, O₂ saturation 86% on room air, with work of breathing visibly increased.

HTN3) The physician believes that BL has SCAPE. While the respiratory therapist places her on BiPAP, he asks for your recommendation regarding medication therapies. Which of the following is the most appropriate recommendation for BL?

TW is a 72 yo male (82kg) who presents to the ED complaining of heart palpitations for approximately 2 hours. He said this has happened once before about a year ago, but he didn’t seek care at that time. He as a history of hypertension and hyperlipidemia for which he takes losartan and simvastatin. Upon initial exam his heart rate is 153, BP 141/76, and O₂ saturation 98%. His EKG shows atrial fibrillation with rapid ventricular response (RVR).

AF1) Since there is a medical student rotating in your ED today, you ask them what they recommend to control TW’s heart rate. They explain that either agent can be used for chronic maintenance but aren’t sure if that holds true when the patient has RVR. Which of the following is the best teaching point regarding metoprolol and diltiazem for RVR?

AF2) The team decides to initiate diltiazem for TW. He is given 15mg IV push and initiated on a continuous infusion at 5mg/hr. This results in his heart rate remaining at 153, but his blood pressure dropping to 87/58. Which of the following is the most appropriate next step in controlling TW’s heart rate?

AF3) Since you were so helpful earlier, the medical student approaches you to ask about a study they read recently suggesting that magnesium may be useful for AFib RVR and asks you your opinion on the data. Which of the following is the most accurate response?