8/11- Ischemic Heart Disease: Interesting Cases Flashcards
What is the Framingham Risk Score? What are not included as risks?
Estimates the 10 yr risk for MI and coronary death (hard CHD events); determines “risk equivalence”
Depends on:
- Age
- Gender
- Total cholesterol
- HDL cholesterol
- Systolic BP
- Current smoking
- Diabetes*
Not included:
- Family history of premature CAD
- hs-CRP (high sensitivity CRP- indicative of inflammation)**
*Diabetes alone, doesn’t contribute much to CHD risk; really only factors in when pt is over 50ish (at this older age, diabetes in considered risk equivalent for CHD)
**hs-CRP considered an independent risk factor
Case 1)
- 48 yo Caucasian male p/w unusual Sx lately
- Started new exercise regimen; previously sedentary: walks 30 min and swims 30 min in the evening
- 6 mo ago, chest heaviness with SOB after 10 min of walking, increasing with additional exercise
- Occurs even at work
- Sx disappear completely after resting for 2 min
- He did not notice any change in the pattern angina in last 2 mo; no change in frequency, duration, or relief with rest
- He drinks 1-2 glasses of scotch daily in the evening
- Gained 20 pounds in the last 3 yrs
- Family Hx is negative for premature CAD, but is positive for HTN in his father
PE:
- Overweight, plethoric face
- HTN
- Normal heart sounds and pulses; no edema
- Clear lungs
Labs:
- ECG and CXR normal
- Total cholesterol 260 mg/dL
- Triglycerides 180 mg/dL
- HDL-C 40 mg/dL
- LDL not reported
This pts LDL-cholesterol is:
A. 220 mg%
B. 60 mg%
C. 184 mg%**
D. 76 mg%
E. Unknown
This pts LDL-cholesterol is:
A. 220 mg%
B. 60 mg%
C. 184 mg%
D. 76 mg%
E. Unknown
LDL = total cholesterol - HDL - TGs
In what people is family history of CAD relevant? Under what conditions?
1st degree relative (dad, mom, brother, sister)
- Clinical manifestation
- Younger than 55 (male) or 65 (female)
What 3 components comprise total cholesterol?
- LDL (TGs?)
- HDL
- vLDL
Case 1)
- 48 yo Caucasian male p/w unusual Sx lately
- Started new exercise regimen; previously sedentary: walks 30 min and swims 30 min in the evening
- 6 mo ago, chest heaviness with SOB after 10 min of walking, increasing with additional exercise
- Occurs even at work
- Sx disappear completely after resting for 2 min
- He did not notice any change in the pattern angina in last 2 mo; no change in frequency, duration, or relief with rest
- He drinks 1-2 glasses of scotch daily in the evening
- Gained 20 pounds in the last 3 yrs
- Family Hx is negative for premature CAD, but is positive for HTN in his father
PE:
- Overweight, plethoric face
- HTN
- Normal heart sounds and pulses; no edema
- Clear lungs
Labs:
- ECG and CXR normal
- Total cholesterol 260 mg/dL
- Triglycerides 180 mg/dL
- HDL-C 40 mg/dL
- LDL not reported
This pts LDL-cholesterol is not noted
In view of this pts clinical presentation and coronary risk factors, what is your most likely clinical diagnosis?
A. Unstable angina
B. Acute coronary syndrome
C. Chronic stable angina
D. Printzmetal’s angina (vasospasm)
E. Heart failure due to obesity
In view of this pts clinical presentation and coronary risk factors, what is your most likely clinical diagnosis?
A. Unstable angina
B. Acute coronary syndrome
C. Chronic stable angina
D. Printzmetal’s angina (vasospasm)
E. Heart failure due to obesity
Recall:
- Due to stable plaque causing fixed obstruction and exertional Sx of MI (usually when plaque reaches 70% diameter). Sx include exertional dyspnea at same/reproducible activity levels
(E doesn’t exist)
Case 1)
(The guy with: 6 mo ago, chest heaviness with SOB after 10 min of walking, increasing with additional exercise)
Which of the following diagnostic tests would you recommend in this patient to document evidence of exertional ischemia? Discuss your rationale for using any of the available non-invasive tests.
A. Coronary angiography
B. Treadmill exercise ECG test
C. Echocardiogram
D. Ambulatory ECG Holter Monitor
Which of the following diagnostic tests would you recommend in this patient to document evidence of exertional ischemia? Discuss your rationale for using any of the available non-invasive tests.
A. Coronary angiography
B. Treadmill exercise ECG test
C. Echocardiogram
D. Ambulatory ECG Holter Monitor
What is the most important mechanism of the anti-anginal effect of nitrates?
A. Increase oxygen supply by dilating coronary arteries
B. Reduce myocardial oxygen demands by reducing preload
C. Increase myocardial?
D. Increase oxygen supply by increasing?
What is the most important mechanism of the anti-anginal effect of nitrates?
A. Increase oxygen supply by dilating coronary arteries
B. Reduce myocardial oxygen demands by reducing preload
C. Increase myocardial?
D. Increase oxygen supply by increasing?
They do function A, but not the most important (also, vasodilation is relatively transient)
Unlike nitrates, beta blockers:
A. Reduce heart rate
B. Block AV conduction (prolong PR interval)
C. Dilate coronary arteries directly
D. A and B
Unlike nitrates, beta blockers:
A. Reduce heart rate
B. Block AV conduction (prolong PR interval)
C. Dilate coronary arteries directly
D. A and B
When starting an anti-ischemic drug in a pt with stable CHD, which would you generally prefer to use?
A. Isosorbide dinitrate
B. Metoprolol
C. Diltiazem
D. Verapamil
E. Amlodipine
When starting an anti-ischemic drug in a pt with stable CHD, which would you generally prefer to use?
A. Isosorbide dinitrate
B. Metoprolol
C. Diltiazem
D. Verapamil
E. Amlodipine
A beta blocker (Metoprolol) is always preferred as initial anti-ischemic drug in any pt with CHD
Why do you generally prefer using a beta blocker rather than nitrate or calcium channel blocker in stable CHD?
A. Proven prevention of sudden cardiac death
B. Proven prevention of MI
C. Proven prevention of ventricular fibrillation
D. All of the above
E. A And C
Why do you generally prefer using a beta blocker rather than nitrate or calcium channel blocker in stable CHD?
A. Proven prevention of sudden cardiac death
B. Proven prevention of MI
C. Proven prevention of ventricular fibrillation
D. All of the above
E. A And C
What are the pillars of treatment for angina (chronic—)? (3)
- Beta blocker
- Aspirin (to prevent MI)
- Statin
What drug suffix is used for beta blockers?
—olol
All of the following are nitrates except:
A. Nitroglycerin
B. Isosorbide dinitrate
C. Isosorbide mononitrate
D. Nitroderm
E. Verapamil
All of the following are nitrates except:
A. Nitroglycerin
B. Isosorbide dinitrate
C. Isosorbide mononitrate
D. Nitroderm
E. Verapamil
Nitroglycerin typically given sublingually
What drug suffix is used for Ca channel blockers?
–dipine
(Amlodipine, Felodipine, Nifedipine) BUT ALSO: Diltiazem/Verapamil
What drug suffix is used for angiotensin receptor blockers?
–sartan
Case 2)
- 50 yo African American man
- Chronic heavy smoker (70 pack yrs)
- P/w retrosternal chest discomfort occurring at rest, lasting 10-15 min and resolving on own
- Episodes associated with L arm heaviness and numbness
- Started 5 mo ago and occurred only during heavy exertion at that time
- Recently occurring at rest and waking from night
- Social alcohol drinker, no medications
- Family Hx positive for CAD (father had CABG at 38)
PE: Normal
Lab: Normal
In view of this patient’s clinical presentation and coronary risk factors, what is your most likely clinical diagnosis?
A. Unstable angina
B. Subacute myocardial infarction
C. Stable exertional angina
D. Printzmetal’s angina
E. Panic or anxiety attacks
In view of this patient’s clinical presentation and coronary risk factors, what is your most likely clinical diagnosis?
A. Unstable angina
B. Subacute myocardial infarction
C. Stable exertional angina
D. Printzmetal’s angina
E. Panic or anxiety attacks
(B doesn’t exist; no such thing as a “subacute MI”) If there’s a change in angina pattern within 2 mo, that’s characteristic of unstable angina
Three types of unstable angina:
- Chest pain at rest (rest angina; this pt)
- Chest pain worsening over time (increasing angina)
- Chest pain at very low threshold (new-onset angina)
Case 2)
- 50 yo African American man
- Chronic heavy smoker (70 pack yrs)
- P/w retrosternal chest discomfort occurring at rest, lasting 10-15 min and resolving on own
- Episodes associated with L arm heaviness and numbness
- Started 5 mo ago and occurred only during heavy exertion at that time
- Recently occurring at rest and waking from night
- Social alcohol drinker, no medications
- Family Hx positive for CAD (father had CABG at 38)
PE: Normal
Lab: Normal
What are this pt’s coronary risk factors?
A. Male gender, age > 45 yo
B. Smoker, male gender, age > 45 yo
C. Male gender, age > 45 yo, and FH of premature CAD
D. Smoker, male gender, age > 45 yo, and FH of premature CAD
E. Smoker, drinker, male gender, age > 45 yo, FH of premature CAD
What are this pt’s coronary risk factors?
A. Male gender, age > 45 yo
B. Smoker, male gender, age > 45 yo
C. Male gender, age > 45 yo, and FH of premature CAD
D. Smoker, male gender, age > 45 yo, and FH of premature CAD
E. Smoker, drinker, male gender, age > 45 yo, FH of premature CAD
- Alcohol consumption is not a risk factor
Which of the following tests would you recommend in this pt to confirm your clinical diagnosis?
A. Coronary angiography
B. Treadmill exercise ECG test
C. Echocardiography
D. Ambulatory ECG Holter Monitor
Which of the following tests would you recommend in this pt to confirm your clinical diagnosis?
A. Coronary angiography
B. Treadmill exercise ECG test
C. Echocardiography
D. Ambulatory ECG Holter Monitor
- Never do a stress test if pt has rest angina!
Which of the following drugs should be added on top of the following:
- Heparin
- Aspirin
- Nitrates
- Beta blockers
in a high risk acute coronary syndrome pt?
A. Fibrinolytic drug such as Streptokinase
B. Clopidogrel
C. Ca channel blocker
D. IV GP IIb/IIIa inhibitor
E. B or/and D
A. Fibrinolytic drug such as Streptokinase
B. Clopidogrel
C. Ca channel blocker
D. IV GP IIb/IIIa inhibitor
E. B or/and D
Why do we use potent inhibitors of platelet aggregation (clopidogrel, IIb/IIIa inhibitors) in ACS?
A. ACS is due to acute platelet aggregation and subsequent clot (thrombus) within the coronary artery triggered by plaque rupture
B. Potent inhibitors of platelet aggregation prevent the evolution and propagation of the coronary thrombus
C. Both
D. Neither
Why do we use potent inhibitors of platelet aggregation (clopidogrel, IIb/IIIa inhibitors) in ACS?
A. ACS is due to acute platelet aggregation and subsequent clot (thrombus) within the coronary artery triggered by plaque rupture
B. Potent inhibitors of platelet aggregation prevent the evolution and propagation of the coronary thrombus
C. Both
D. Neither
Case 3)
- 42 yo African American woman p/w 2 hr Hx of sudden crushing retrosternal chest pain radiating into neck and jaw
- Associated with diaphoresis and severe bleching; nausea and dizziness
PE:
- Pale and sweaty; acute distress
- Mild fine basal crackles in lungs bilaterally
- Clammy extremities; weak pulses
Labs:
- CBC normal
- ECG showed ST segment elevation in V1-V4; occasional ventricular premature beats were noted
What is your most likely clinical and ECG diagnosis?
A. Acute inferior MI
B. Acute transmural ischemia
C. Acute pericarditis
D. Acute coronary syndrome
E. Acute anterolateral MI
What is your most likely clinical and ECG diagnosis?
A. Acute inferior MI
B. Acute transmural ischemia
C. Acute pericarditis
D. Acute coronary syndrome
E. Acute anterolateral MI
Can see ST segment elevation
Case 3)
- 42 yo African American woman p/w 2 hr Hx of sudden crushing retrosternal chest pain radiating into neck and jaw
- Associated with diaphoresis and severe bleching; nausea and dizziness
PE:
- Pale and sweaty; acute distress
- Mild fine basal crackles in lungs bilaterally
- Clammy extremities; weak pulses
Labs:
- CBC normal
- ECG showed ST segment elevation in V1-V4; occasional ventricular premature beats were noted
Which of the following drugs are life saving in this pt?
A. Fibrinolytic drug
B. Aspirin
C. SL nitroglycerin
D. Ca channel blocker
E. A and B
Which of the following drugs are life saving in this pt?
A. Fibrinolytic drug
B. Aspirin
C. SL nitroglycerin
D. Ca channel blocker
E. A and B
- Basically never give Fibrinolytic drug in STEMI (b/c can typically do cath before)
Case 3)
- 42 yo African American woman p/w 2 hr Hx of sudden crushing retrosternal chest pain radiating into neck and jaw
- Associated with diaphoresis and severe bleching; nausea and dizziness
PE:
- Pale and sweaty; acute distress
- Mild fine basal crackles in lungs bilaterally
- Clammy extremities; weak pulses
Labs:
- CBC normal
- ECG showed ST segment elevation in V1-V4; occasional ventricular premature beats were noted
What would you now use if the ECG and chest pain were unchanged after the initial drug?
A. Thrombolytic drug
B. Beta-blocker
C. Ca channel blocker
D. Aspirin
E. ACEI
?
Which of the following is an indication for a fibrinolytic drug such as t-PA, TNK-t-PA or r-PA?
A. Acute STEMI
B. Acute NSTEMI
C. Unstable angina
D. Acute coronary syndrome
E. A or B
Which of the following is an indication for a fibrinolytic drug such as t-PA, TNK-t-PA or r-PA?
A. Acute STEMI
B. Acute NSTEMI
C. Unstable angina
D. Acute coronary syndrome
E. A or B
Why NOT use a fibrinolytic drug such as t-PA, TNK-t-PA, or r-PA in NSTEMI or Unstable angina?
A. Acute STEMI is the ONLY ACS characterized by a COMPLETE occlusion by a fibrin rich clot
B. Unstable angina and NSTEMI are characterized by an incompletely occlusive platelet rich clot
C. Fibrinolytics lyse fibrin
D. All of the above
Why NOT use a fibrinolytic drug such as t-PA, TNK-t-PA, or r-PA in NSTEMI or Unstable angina?
A. Acute STEMI is the ONLY ACS characterized by a COMPLETE occlusion by a fibrin rich clot
B. Unstable angina and NSTEMI are characterized by an incompletely occlusive platelet rich clot
C. Fibrinolytics lyse fibrin
D. All of the above
In addition to anti-platelet and anti-anginal drugs, what is your mainstay treatment (for NSTEMI?)
A. Immediate fibrinolytic therapy
B. Primary PCI in the cath lab (need 120 min to “activate” the cath lab)
C. Ca Channel Blocker
D. A and/or B
In addition to anti-platelet and anti-anginal drugs, what is your mainstay treatment (for NSTEMI?)
A. Immediate fibrinolytic therapy
B. Primary PCI in the cath lab (need 120 min to “activate” the cath lab)
C. Ca Channel Blocker
D. A and/or B
