An 87-Year-Old Woman With Acute Coronary Syndrome

You are called by the emergency department (ED) to provide urgent consultation for an 87-year-old woman with a chief complaint of chest pain and shortness of breath. The patient has a history of hypertension, hyperlipidemia, mild chronic obstructive pulmonary disease (40 pack-year smoking history; quit 30 years ago), chronic kidney disease (stage IIIB), mild cognitive impairment, osteoporosis status/post hip fracture 2 years ago, and osteoarthritis. She states that about 2 hours ago while making breakfast she developed substernal chest pressure associated with shortness of breath and mild sweating. The symptoms persisted and she contacted her daughter, who drove her to the ED, where she arrived about an hour ago. She was given nitroglycerin and morphine with complete resolution of her symptoms. There is no history of cardiac disease or similar symptoms.

Medications: aspirin 81 mg/day, pravastatin 20 mg/day, valsartan/hydrochlorothiazide 160 mg/25 mg/day, amlodipine 5 mg/day, donepizil 10 mg/qhs, vitamin D 2000 IU/day, calcium 800 mg/day, naproxen as needed.

PE: Elderly woman, no acute distress, alert and oriented. HR: 80, regular. BP: 150/80. RR 20. O2 saturation: 98% on 2L/NC. HEENT: unremarkable. Neck: no JVD or HJR. Lungs: mild bibasilar crackles. Heart: RRR, soft systolic ejection murmur, S4 gallop, no S3. Abdomen: soft, non-tender. Extremities: no edema. Neuro: grossly intact.

ECG: NSR, borderline LVH by voltage criteria, 0.5-1.0 mm down-sloping ST-segment depression in V4-V6 (new since prior ECG 4 months ago).
Troponin I: 1.06 ng/ml (normal <0.03 ng/ml).
BMP: creatinine 1.22 mg/dl, BUN 30 mg/dl; otherwise WNL.
CBC: hemoglobin 10.7 g/dl, hematocrit 31.5%, WBC 8.7, platelets 165,000.
Chest x-ray: basilar atelectasis, otherwise unremarkable.

Which of the following would be the most appropriate next step in this patient's management?

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