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.
Laboratory:
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.
The correct answer is: E. Elicitation of patient preferences.
This elderly woman with multiple medical problems presents with an acute coronary syndrome (ACS) with evidence for a non-ST-segment elevation myocardial infarction (NSTEMI). At the time of consultation, she is symptom-free and hemodynamically stable. In order to determine how best to proceed, it is essential to obtain more information about her functional status and, in particular, her preferences with respect to how aggressively to manage her current ACS. Relevant questions should include whether she has an advance directive and/or whether she has made explicit statements about how she would like to be managed in the setting of a potentially life-threatening condition. The patient's daughter should be involved in these discussions unless the patient requests otherwise. The various diagnostic and therapeutic options, along with their attendant risks and benefits, should be briefly described using language that the patient and daughter can comprehend. An opportunity should be provided for questions, and all questions should be answered as directly and honestly as possible. Based on these discussions, the most appropriate course of action can be determined through a process of shared decision-making.
An important caveat is that there have been no trials to evaluate diagnostic or therapeutic strategies for ACS or NSTEMI in patients in this age group, and studies involving younger subjects generally exclude those with multiple chronic conditions, especially significant renal impairment or cognitive dysfunction. Therefore, there is no evidence to support any of the options listed in responses A-D, and test selection is largely empiric, thus highlighting the importance of shared decision-making.
Coronary angiography should be considered if the patient desires aggressive care, including revascularization if indicated, especially in the event of recurrent chest discomfort or hemodynamic instability. However, coronary angiography is not without risk, e.g., development of contrast-induced nephropathy. Echocardiography to assess left ventricular function and to evaluate for the presence of other structural abnormalities may be indicated at some point but it is unlikely to affect her acute-phase management. Similarly, a stress test or coronary CT angiogram may be helpful for subsequent risk stratification but neither is indicated for diagnostic purposes in the ED since she fulfills criteria for diagnosis of type I NSTEMI.
References
- Kim DH, Rich MW. Patient-centred care of older adults with cardiovascular disease and multiple chronic conditions. Can J Cardiol 2016;32:1097-107.
- American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. J Am Geriatr Soc 2012;60:e1-e25.
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