Answer: This is a great question and one that was brought to the provincial level to achieve consensus. It highlights the reality which is that it’s just not possible to write a directive for each patient encounter, since there can be a tremendous amount of variability.
In situations like this, it’s 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 it’s 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.