The correct answer is B. The patient's presentation is highly worrisome for an acute coronary syndrome and therefore requires a coronary angiogram. From his past medical history, the patient has known coronary artery disease. His recent history is a classic description of crescendo angina. On presentation, he complains of chest pain at rest and negative cardiac markers indicating likely unstable angina. His vital signs are stable and there is no evidence of acute congestive heart failure or pulmonary edema by CXR and oxygen saturation. The EKG indicated an old inferior myocardial infarction, but more importantly, the EKG shows T-wave inversions in the anteroseptal precordial leads. This may suggest critical left main coronary artery disease or stenosis (Wallen sign). The patient needs to undergo coronary angiography for several reasons. First, data has shown improved outcomes in patients with unstable angina and primary coronary intervention, so if there is a culprit lesion that can be fixed, (i.e., by stenting), it should be. Secondly, the anterior wall of the left ventricle is at risk. The patient has already had damage to his right ventricle (inferior Q waves), and now his left wall is threatened. Third, the EKG indicates Wallen sign: T-wave inversions in v1-v3 or v4. This correlates to possible left main coronary artery (LMCA) disease. LMCA stenosis risks both the anterior wall and the lateral wall of the left ventricle. Due to the large area at risk, the patient must undergo CABG , and not PTCA. However, without coronary angiography, it is unknown whether the patient has LMCA disease or a proximal LAD lesion.
It is inappropriate to admit him for observation only (choice A). Although the patient has been placed on adequate medications and may potentially improve on medical management, several studies have shown improved outcomes in patients taken to catheterization with acute coronary syndromes. In addition the EKG suggests that the anterior wall may be at risk and this would have serious consequences if allowed to proceed to infarction. The goal is to re-establish perfusion to that area as soon as possible.
The patient is stable and it is not known for certain whether or not he requires a CABG (choice C) for LMCA. If he simply has a proximal LAD lesion, he can undergo PCI without a need for cardiac surgery.
His vital signs are stable and he is not in cardiogenic shock. In addition, he has no history of valvular disease. Therefore, there is no indication for an intra-aortic balloon pump (choice D).
Criteria for thrombolytics (choice E) requires ST segment elevations >1 mm in 2 contiguous leads, ST segment depressions >2mm in the anterior leads (v1-v2), or new left-bundle branch block. The patient does not meet these criteria.
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