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JAMA Performance Improvement
March 27, 2018

β-Blockers in Myocardial InfarctionIssues With Standard Admission Order Sets

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
JAMA. 2018;319(12):1269-1270. doi:10.1001/jama.2018.0845

A 58-year-old man with untreated hypertension, type 2 diabetes mellitus, and tobacco use was admitted with crushing left-sided chest pain and shortness of breath. He was diagnosed as having an ST-elevation myocardial infarction (STEMI). Emergency percutaneous coronary intervention (PCI) of the right coronary artery was successful. During the procedure, he was noted to have elevated left ventricular filling pressure. After PCI, he was free of chest pain but was bradycardic (heart rate, 53/min) with normal blood pressure (143/82 mm Hg). An electrocardiogram demonstrated atrial fibrillation and complete heart block with a junctional escape at 54/min. The admitting physician placed orders via the electronic medical record using the “STEMI admission order set” and the patient was admitted to the coronary care unit. There, the patient received medications including atorvastatin, 80 mg, and carvedilol, 3.125 mg, within an hour of admission. Over the next few hours, he developed worsening shortness of breath, bradycardia (lowest heart rate, 40/min), and hypotension (lowest blood pressure, 93/63 mm Hg), with crackles noted on auscultation of the lung fields consistent with developing cardiogenic shock.

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