A 62-year-old man presents 90 minutes after onset of crushing chest pain. ECG shows ST elevation in leads II, III, and aVF, with reciprocal ST depression in I and aVL. Bedside echocardiography shows right ventricular dilation with right ventricular wall motion abnormality. He is hypotensive at 85/55 mmHg despite IV fluids. Which drug is CONTRAINDICATED in this setting?
- A Aspirin
- B Nitroglycerin ✓
- C Morphine
- D Unfractionated heparin
Correct answer: B. Nitroglycerin
Explanation
This presentation is consistent with acute inferior STEMI complicated by right ventricular infarction, evidenced by ST elevation in right-sided leads (not shown but expected) and echocardiographic RV changes. In RV infarction, cardiac output depends critically on preload; nitrates (nitroglycerin) cause venodilation and abrupt preload reduction, precipitating severe hypotension and cardiovascular collapse. IV saline loading is the cornerstone of management. Aspirin, anticoagulation, and early reperfusion are indicated.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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