A 62-year-old man is brought to the emergency department due to sudden-onset, severe substernal chest pain that radiates to his left jaw. The pain started 45 minutes ago. His blood pressure is 120/80 mmHg, and his heart rate is 90/min. An electrocardiogram shows ST-segment elevations in leads V1 through V4. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and erectile dysfunction. He reports taking sildenafil 12 hours ago for erectile dysfunction. Which of the following medications is absolutely contraindicated in the initial management of this patient's acute presentation?
- Sublingual nitroglycerinCevap
- BChewable aspirin
- CUnfractionated heparin
- DMetoprolol tartrate
- EHigh-intensity atorvastatin
Cevap
Sublingual nitroglycerin is absolutely contraindicated due to the risk of profound hypotension when combined with a recent dose of sildenafil.
The correct answer is sublingual nitroglycerin. This patient is presenting with an acute ST-segment elevation myocardial infarction (STEMI) and requires standard acute coronary syndrome (ACS) management. However, he recently took sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor. PDE-5 inhibitors prevent the degradation of cyclic guanosine monophosphate (cGMP). Nitrates, such as sublingual nitroglycerin, stimulate the production of cGMP. Coadministration of nitrates and a PDE-5 inhibitor causes profound, synergistic vasodilation that can result in life-threatening hypotension and decreased coronary perfusion. Because sildenafil has a half-life of approximately 4 hours, all nitrate preparations are absolutely contraindicated for at least 24 hours after the last dose of sildenafil (and for 48 hours after tadalafil). Therefore, nitroglycerin must be completely avoided during the initial stabilization of this patient.
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Anahtar Kavram
Absolute contraindication of nitrates in patients who have recently taken phosphodiesterase-5 (PDE-5) inhibitors.