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A 67-year-old man with a history of hypertension, hyperlipidemia, and tobacco use was found by family members with left-sided paralysis, rightward eye deviation, and change in mental status and was brought to the emergency department (ED). Computed axial tomography (CAT) of the brain performed in the ED (Figure 31-1) showed a large acute nonhemorrhagic right hemispheric infarct within the vascular territory of the right middle cerebral artery. The infarct involved large portions of the frontal, temporal, and parietal lobes as well as underlying basal ganglia structures. The proximal right middle cerebral artery was hyperdense, consistent with thrombosis within the vessel. The patient was not administered thrombolytic therapy because of the unknown onset of symptoms. The local ED physicians decided to transfer the patient immediately to the nearest tertiary medical center. On arrival to the intensive care unit, the patient was awake and alert but with a left hemiparesis and left hemineglect. Upon admission he complained of dyspnea but no chest pain.

Heart rate (HR) was 77 bpm and regular, blood pressure (BP) 89/55 mm Hg, respiratory rate (RR) 15 breaths/min, temperature (T) 36.5°C (97.7°F), and arterial oxygen saturation (Sao2) 98% on 6 L oxygen. Cardiovascular examination was notable for jugular venous distention with an estimated jugular venous pressure of 9 cm H2O. The first and second heart sounds were noted to be normal and regular. There was a III/VI holosystolic murmur at the apex. The lungs were clear to auscultation bilaterally. Initial laboratory test results were notable for a blood urea nitrogen (BUN) of 65 mg/dL, creatinine of 1.5 mg/dL, white blood cell (WBC) count of 16,700/μL, hemoglobin (Hb) of 12.2 g/dL, and platelets of 413,000/μL. Cardiac biomarkers were elevated with a creatinine kinase of 821 U/L, a troponin T of 4.33 ng/mL, and a creatine kinase MB (CK-MB) of 12.0 ng/mL. An electrocardiogram (ECG) and chest x-ray were performed on admission (Figures 31-2 and 31-3).

Figure 31-1.

Computed axial tomography (CAT) scan of the brain.

Figure 31-3.

Twelve-lead electrocardiogram.

What should be the first step in managing this patient?

This patient presents with acute ischemic stroke and myocardial infarction. There is evidence of hemodynamic deterioration; therefore, a decision regarding management of acute coronary syndrome (ACS) must be made quickly. Management of acute ischemic stroke is discussed in Chapter 5.

How would you classify this patient's clinical presentation? How do you define acute coronary syndrome?

This patient presents with ECG and laboratory evidence of myocardial infarction. The initial ECG showed ST depressions anteriorly, which should alert the clinician to ...

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