View source for WBR0356

 {{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 52 year old female presented to urgent care with  acute chest pain associated with nausea, and vomiting, which radiated  to her left arm for the last 30 minutes. Electrocardiogram reveals ST segment elevation in II, III, aVF . Aspirin was administered. A medical center with a catheterization laboratory was within 30 minutes distance. What is the most appropriate step in  the management of this patient?
|Explanation=Management of myocardial infarction depends on the time between the onset of symptoms and arrival in the ER. Typical “door to needle time” (for thrombolysis) is said to be 30 minutes but the mortality benefit extends until 12 hours after the onset of pain. Thombolysis is considered the best option only when angioplasty is not feasible. Otherwise angioplasty is the best treatment and typical door to balloon time is less than 90 minutes. In this case, the onset of pain was 30 minutes ago and time of travel to the medical center with a catheterization lab is 30 minutes, so the patient could undergo catheterization with less than a 90 minute door to balloon time.  Thus, the best choice here is to transfer the patient immediately to the nearest medical center

'''Educational Objective:''' Door to needle time for thrombolysis ought to be under 30 minutes but its mortality benefit extends  until 12 hours after pain onset. Door to balloon time for angioplasty should be less than 90 minutes. The decision of whether to perform thrombolysis or angioplasty depends on whether or not a sufficiently low door to balloon time can be achieved. 

'''References:''' Page 67, 68, 69  Master the boards step 2 CK second edition
|AnswerA=Immediately start thrombolysis
	

|AnswerAExp='''Incorrect''' Thrombolysis would be the answer  when we cannot arrange for a catheterization laboratory within 90 minutes.
|AnswerB=Start Heparin
|AnswerBExp='''Incorrect''' Heparin is part of the initial treatment of Non ST elevation myocardial infarction after aspirin administration
|AnswerC=Start beta blockers
|AnswerCExp='''Incorrect''' Beta blockers are important in the management of myocardial infarction but not time specific
|AnswerD=Immediately transfer the patient to the medical center
|AnswerDExp=Door to balloon time for angioplasty should be less than 90 minutes. The decision of whether to perform thrombolysis or angioplasty depends on whether or not a sufficiently low door to balloon time can be achieved
|AnswerE=Start Statins
|AnswerEExp='''Incorrect''' Statins are important in lipid management with mortality benefits in Myocardial infarction patients but not time specific.
|RightAnswer=D
|Approved=Yes
}}