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A 62-Year-Old Man Comes to the Emergency Department Because of Nausea

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A 62-year-old man comes to the emergency department because of nausea and abdominal pain.  He describes the pain as a pressure located in the epigastric area which feels like it is "pushing up" into his chest.  It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before.  The pain initially improved while leaning forward, but it is now present in any position.  The patient has no shortness of breath or palpitations.  He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin.  He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more.
His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min.  Pulse oximetry shows 98% oxygen saturation on room air.  The patient is in moderate pain and is diaphoretic.  There is a 2/6 systolic murmur at the apex which radiates to the axillae.  The lungs are clear to auscultation.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:
A 62-year-old man comes to the emergency department because of nausea and abdominal pain.  He describes the pain as a pressure located in the epigastric area which feels like it is pushing up into his chest.  It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before.  The pain initially improved while leaning forward, but it is now present in any position.  The patient has no shortness of breath or palpitations.  He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin.  He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more. His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min.  Pulse oximetry shows 98% oxygen saturation on room air.  The patient is in moderate pain and is diaphoretic.  There is a 2/6 systolic murmur at the apex which radiates to the axillae.  The lungs are clear to auscultation.  The remainder of the physical examination is within normal limits. Laboratory results are as follows: A 12-lead electrocardiogram is shown in this exhibit. Which of the following is the most appropriate next step in the management of this patient? A) Coronary angiography B) CT scan of the aorta C) Exercise nuclear stress test D) Ibuprofen and colchicine E) Proton-pump inhibitor
A 12-lead electrocardiogram is shown in this exhibit.
A 62-year-old man comes to the emergency department because of nausea and abdominal pain.  He describes the pain as a pressure located in the epigastric area which feels like it is pushing up into his chest.  It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before.  The pain initially improved while leaning forward, but it is now present in any position.  The patient has no shortness of breath or palpitations.  He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin.  He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more. His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min.  Pulse oximetry shows 98% oxygen saturation on room air.  The patient is in moderate pain and is diaphoretic.  There is a 2/6 systolic murmur at the apex which radiates to the axillae.  The lungs are clear to auscultation.  The remainder of the physical examination is within normal limits. Laboratory results are as follows: A 12-lead electrocardiogram is shown in this exhibit. Which of the following is the most appropriate next step in the management of this patient? A) Coronary angiography B) CT scan of the aorta C) Exercise nuclear stress test D) Ibuprofen and colchicine E) Proton-pump inhibitor
Which of the following is the most appropriate next step in the management of this patient?

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