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Answer 3
  1. Activate the coronary intervention team for emergent cardiac catheterization within 90 minutes of first medical contact. This patient presented with an acute ST-segment elevation myocardial infarction (STEMI) of the anterior and septal walls with features of cardiogenic shock. Patients with STEMI and cardiogenic shock benefit from early reperfusion via percutaneous coronary intervention with potential intra-aortic balloon placement.3 The patient should be treated with dual antiplatelet therapy as well as anticoagulation with either heparin or enoxaparin prior to cardiac catheterization.3 If findings of a possible mechanical complication of MI are present (eg, ventricular septal rupture, papillary muscle rupture, left ventricular free wall rupture) or if the patient has a high likelihood of needing coronary bypass surgery, then clopidogrel may be withheld due to higher risk of bleeding complications during the perioperative period.3 This patient has no indication of a mechanical complication of MI, and obtaining a transthoracic echocardiogram may further delay the time to reperfusion. IV fluids are only useful in the setting of right ventricular infarction to restore preload. IV dobutamine is generally not indicated in the setting of acute MI because it can worsen myocardial ischemia. Evidence suggests that patients with acute STEMI and cardiogenic shock have better outcomes with primary angioplasty than with thrombolytic reperfusion.3 Starting a glycoprotein IIb/IIIa inhibitor and waiting 24 hours to perform cardiac catheterization in a patient with untreated MI complicated by cardiogenic shock would worsen the patient’s chances of survival.

    3. Antman EM, Hand M, Armstrong PW, et al; Canadian Cardiovascular Society; American Academy of Family Physicians; American College of Cardiology; American Heart Association. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published erratum appears in J Am Coll Cardiol 2008;51:977]. J Am Coll Cardiol 2008;51:210–47.

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