Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 - 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

This is a great question and one that was brought to the provincial level to achieve consensus. It highlights the reality which is that its just not possible to write a directive for each patient encounter, since there can be a tremendous amount of variability.

In situations like this, its important to ask yourself what the primary issue is, or what the greatest threat to life is. Many patients who are at risk of having a cardiac event (MI) may also have a history of CHF, and it can sometimes be difficult to determine what issue is driving the other.

In this case, it is likely that the STEMI is causing, or exacerbating the CHF, and as such, following the cardiac ischemia directive and administering only up to 3 X 0.4 mg doses would be appropriate. For what its worth, the reduced number of doses in STEMIs are to reduce adverse outcomes associated with liberal NTG use, and as such, administering higher doses of NTG may affect the patient adversely.

Remember that CPAP is a potential option for this patient population if indications are met. This may have more of a morbidity and mortality benefit than nitro and may result in substantial CHF symptom improvement.

Acute Cardiogenic Pulmonary Edema,Airway/Breathing,Cardiac Ischemia,Cardiac/Circulation,Continuous Positive Airway Pressure (CPAP)

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