A 60-year-old male patient is receiving aspirin, atorvastatin, isosorbide mononitrate, and a beta-blocker for chronic stable angina. He presents to the ER with episodes of unusually severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action?
This patient presents with acute coronary syndrome (ACS) as indicated by an increase in the frequency and severity of his previously stable angina. The unchanged ECG and normal cardiac biomarkers indicate unstable angina (UA) rather than non-ST segment elevation myocardial infarction (NSTEMI). Patients with ACS should be admitted to a cardiac unit and their medical regimen intensified, in this case with the addition of antithrombotic therapy (IV unfractionated heparin or subcutaneous low-molecular-weight heparin) and additional antiplatelet therapy (such as clopidogrel). Intravenous nitrates, glycoprotein IIb/IIIa inhibitors, and early coronary angiography can be considered. There is no role for digoxin, which would increase myocardial oxygen consumption and exacerbate the situation. Thrombolytic therapy is reserved for the treatment for ST-segment elevation myocardial infarction (STEMI), where occlusive intracoronary thrombosis is demonstrated in 70% of patients. ACS is usually associated with unstable plaque and platelet activation but not major coronary thrombosis. The patient is at high risk for myocardial necrosis and should be admitted to the hospital for stabilization; simple observation and failure to intensify his treatment would be inappropriate.
Admit the patient and add intravenous digoxin
Admit the patient and begin low-molecular-weight (LMW) heparin and clopidogrel
Admit the patient for thrombolytic therapy
Admit the patient for observation with no change in medication
C.V.S.