180 mm Hg. (b)Anticoagulation is a relative contraindication. Many patients
who suffer from an ST-elevation MI are on aspirin and other antiplatelet and
anticoagulant therapies. (c)Major surgery less than 3 weeks prior to admin-
istration of thrombolytics is a relative contraindication. (d)Active peptic
ulcer disease is a relative contraindication.
16.The answer is e.(Rosen, pp 1084-1085.)This patient is hypotensive
and exhibits signs and symptoms of heart failure (dyspnea, fatigue, respira-
tory crackles, and chest pain) and is in atrial fibrillation (irregular, narrow
complex). Any patient with unstable vital signswith a tachydysrhythmia
should receive a dose of sedation and undergo synchronized cardiover-
sionstarting at 100 J.
(a)Diltiazem, a CCB, is used as a rate-control agent for patients in
atrial fibrillation. If the patient was not hypotensive or exhibiting signs of
heart failure, diltiazem is used to slow the ventricular response. (b)Meto-
prolol is sometimes used to control ventricular rate in atrial fibrillation;
however, it is contraindicated in patients with heart failure. In addition, it
has a greater negative inotropic effect than CCBs, thereby causing hypoten-
sion more often. (c)Digitalis is another option to control the ventricular
response in atrial fibrillation; however, its relatively slow onset precludes it
from use in the acute setting. (d)Coumadin is an anticoagulant that is
administered to a select group of patients in chronic atrial fibrillation to
prevent thrombus formation. It is also used to anticoagulate stable patients
who have been in atrial fibrillation for longer than 48 hours and are going
to be pharmacologically or electrically cardioverted. Cardioversion of atrial
fibrillation (if longer than 48 hours) carries the risk of thromboembolism.
17.The answer is d.(Rosen, p 1122.)This patient has decompensated
CHF with pulmonary edema. Nitroglycerinis the most effective and most
rapid means of reducing preloadin a patient with CHF. Nitrates decrease
myocardial preload and, to a lesser extent, afterload. Nitrates increase venous
capacitance, including venous pooling, which decreases preload and myocar-
dial oxygen demand. It is most beneficial when the patient who presents with
CHF is also hypertensive. It is administered sublingually, intravenously, or
transdermally.
(a)Metoprolol, a β-blocker is contraindicated in acute decompensated
heart failure. (b)Morphine sulfate reduces pulmonary congestion through
a central sympatholytic effect that causes peripheral vasodilation. This
decreases central venous return and reduces preload. However, morphine
Chest Pain and Cardiac Dysrhythmias Answers 33