A 53-year-old man presents to the emergency department (ED) with chest pain that started the previous night. The pain began about 30 minutes after he had smoked marijuana and inhaled cocaine. He describes the pain as tightness in the left side of the chest that radiates into the neck; he also has a tingling sensation in both the left side of the neck and the left arm.
Initially, the pain was accompanied by mild dyspnea and light-headedness but was not associated with palpitations, nausea, or vomiting. After the patient rested, the pain subsided somewhat and he was able to fall asleep for several hours; however, when he awakened, it was still present. Two sublingual nitroglycerin tablets administered on his arrival at the ED relieved his chest discomfort.
HISTORY
The patient denies a history of similar episodes. He
had formerly used cocaine on the weekends, but he insists
that he has not done so for 18 months as a condition
of his employment.
He has a 10-year history of hypertension and takes nifedipine(Drug information on nifedipine) (sustained-release), 60 mg/d. There is a strong family history of coronary disease: his mother died in her 50s of an acute myocardial infarction (MI), and his sister sustained an acute MI at about the same age. He uses alcohol(Drug information on alcohol) on weekends but has never smoked cigarettes.
PHYSICAL EXAMINATION
The patient is anxious, has a headache, and is still
having episodes of chest pressure, although they are
much less intense. Heart rate is 58 beats per minute; respiration
rate, 18 breaths per minute; and blood pressure,
149/82 mm Hg. Oxygen saturation is 97% on room air.
Heart examination reveals regular heart rate and rhythm
without murmurs or gallops. There are no carotid bruits,
and the chest is clear. Peripheral pulses are good; no
edema.
LABORATORY AND IMAGING RESULTS
Electrolyte levels, biochemistry panels, and a hemogram
are normal. Myoglobin level is 101 ng/mL, and
cardiac troponin I level is normal at 0.1 ng/mL. Creatine
kinase is 681 U/L (normal is less than 200 U/L), but MB
fraction is 1% (normal). An ECG shows a PR interval of
0.28 seconds, complete right bundle branch block (RBBB),
and Q waves in the initial deflections of leads II, III, and
aVF. T waves are upright in II, III, and aVF and inverted in
the precordial leads.
Which of the following is the most appropriate management strategy
for this patient?
A. Reassure the patient that the chest pain is cocaine-related and will
improve in the next several hours and discharge him with a supply of
nitroglycerin.
B. Retain the patient in the hospital’s 23-hour chest pain observation unit
to rule out MI; use nitroglycerin and verapamil as needed.
C. Retain the patient in the hospital’s 23-hour chest pain observation unit
to rule out MI; use nitroglycerin and propranolol(Drug information on propranolol) as needed.
D. Retain the patient in the hospital’s 23-hour chest pain observation unit
to rule out MI, use nitroglycerin and verapamil(Drug information on verapamil) as needed, and evaluate
for underlying coronary artery disease (CAD).
