Percutaneous Coronary Intervention (PCI)

• 68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of n/v
and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG is
unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure is
149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications include
omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy: lisinopril,
angioedema
• What is the TIMI risk score of this patient and how would you interpret it? 
• 68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema

• What is the TIMI risk score of this patient and how would you interpret it? 
     2 points (1 for Age >65, positive cardiac marker)
     Low risk: 8% risk at 14 days of all-cause mortality, new or recurrent MI, or severe recurrent ischemia
requiring urgent revascularization 
• 68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema

• What therapies would you like to start in this patient immediately?

Morphine
Oxygen
Nitroglycerin
Aspirin
68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema
• AB is scheduled to go to the cath lab for evaluation of PCI. What medications would you like to start?
68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema
• AB is scheduled to go to the cath lab for evaluation of PCI. What medications would you like to start
meanwhile?
UFH
Ticagrelor 180 mg x 1
ARB 
Spironolactone? 
Switch metoprolol tartrate 50 mg BID to succinate 100 mg daily
Switch simvastatin 40 mg daily to atorvastatin 40 mg daily
68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema
• AB receives a drug-eluting stent x 1 and is ready to be discharged. Unfortunately, ticagrelor co-
pay comes back $500/month, and patient is unable to afford. What additional medications would
you recommend and what duration?
68 YO male with a history of hypertension and hyperlipidemia presents with sudden onset of
n/v and chest pain (8-10) radiating to his left arm x 1 episode that lasted 15 minutes. His ECG
is unremarkable, but he has positive cardiac enzymes. SaO2 88% on room air. LVEF 35%. Blood pressure
is 149/90 mm Hg, and all laboratory results are normal with SCr 1.0 mg/dL. Home medications
include omeprazole 40 mg daily, simvastatin 40 mg daily, and metoprolol 50 mg BID. Allergy:
lisinopril, angioedema
• AB receives a drug-eluting stent x 1 and is ready to be discharged. Unfortunately, ticagrelor co-pay
comes back $500/month, and patient is unable to afford. What additional medications would you
recommend and what duration?
Aspirin 81 daily indefinitely
Clopidogrel 300 mg x 1 LD, followed by 75 mg daily for at least 1 year 
NGT indefinitely 
Switch omeprazole to famotidine 20 mg daily