CAD (23%) Flashcards
CAD portion of ABIM-CD Recert
What is the next management step for a patient with NSTEMI and high risk criteria such as elevated biomarkers, ECG abnormalities, elevated TIMI risk score?
Coronary angiography within 48 hours followed by percutaneous intervention/surgical revasc if indicated.
What is a Class IA recommendation for post-MI patients done as an outpatient after discharge?
Cardiac rehabilitation
What is the genetic classification for familial hypercholesterolemia?
Most common: Monogenic Autosomal Dominant
(defect in gene that encodes the apo B/E (LDL) receptor.
What is the most common genetic defect for Familial Hypercholesteralemia?
Defect in the gene that encodes the apo B/E (LDL) receptor.
What is the frequency range for myalgia symptoms in statin use?
5-10%
Of myalgia/myopathy/rhabdomyolysis: which one:
Muscle symptoms without CPK elevation?
myalgia
Of myalgia/myopathy/rhabdomyolysis: which one:
Muscle symptoms with CPK >10x ULN.
myopathy
Of myalgia/myopathy/rhabdomyolysis: which one:
Muscle symptoms with marked CPK elevation typically >10 ULN with creatinine elevation and often with urinary myoglobin?
Rhabdomyolysis (<0.1%)
What is the reversal agent for bivalirudin?
Prothrombin Complex
In ACS with planned PCI, which antiplatelet medication should never be given if there is a history of TIA/CVA?
Prasugrel
Prasugrel cannot be given to patients with a prior history of TIA/CVA as an absolute contraindication (TRITON-TIMI 38 - net harm was demonstrated)
In patients with metabolic syndrome, what is the particle size of LDL (normal, larger than normal, smaller than normal) ?
Smaller than normal.
The LDL particle sizes in metabolic syndrome are smaller and denser, and are more atherogenic than normal sized particles.
Lipid characteristics in metabolic syndrome:
- Small, dense LDL particles
- Elevated serum endothelin
- Elevated homcysteine level
- Low HDL
Which of the statins has been seen to reduce the incidence of diabetes?
Pravastatin
What is the incidence of heterozygous Familial Hypercholesterolemia?
1 in 500 persons
Also remember FH is autosomal dominant.
(Homozygous FH: 1 in 1 million individuals)
What is the recommended minimum duration of DAPT in patient with BMS or DES after NSTEMI?
12 months.
Aspirin indefinitely
What is the Duke Treadmill score range for Intermediate Risk?
-10 to +4
What is Incidence of Familial combined hyperlipidemia?
1 in 33 to 1 in 100.
- Arcus cornea and xanthelasma can be seen.
- Xanthomas are rarely present (unlike heterozyg FH)
- Think of this with TC 250-350, overweight, hypertension, insulin resistance, TG >140
What is the normal coronary artery response to intracoronary acetylcholine?
Vasodilation
What is the response to coronary arteries to intracoronary acetylcholine in the setting of endothelial dysfunction?
Vasoconstriction
normal coronary arteries will vasodilate with Ach
What is the type of myocardial infarction suggested by elevated JVP, clear lung auscultation, and ECG with ST segment elevation in leads II/III/aVF ?
Inferior wall MI with right ventricular infarction.
What is the major result of this study?
PROVE-IT/TIMI-22
Post-MI patients treated with more potent statin atorvastatin vs pravastatin had a 16% relative risk reduction.
What is the major result of this study?
JUPITER
Patients without documented CAD and median LDL of 108, rosuvastatin offered a greater benefit in patients with CRP>2
What is the major result of this study?
WOSCOPS, AFCAPS/TexCAPS (in general)
Statins reduce CVD events at approximately 1% reduction in CVD events for every 1% reduction in LDL
WOSCOPS and AFCAPS/TexCAPS were primary prevention trials.
What is the major result of this study?
4S, CARE, PIPID, HPS (in general)
Statins reduce secondary events.
These are secondary prevention trials.
What are the ages in male and female relatives for which cardiac risk factors are calculated?
Male relative less than 55 years old.
Female relatives less than 65 years old.
What is the clinical significance of a diagonal crease in the earlobe from tragus to the lobule at a 45 degree angle?
Increased risk of premature coronary artery disease.
This is Frank’s Sign.
It is thought to indicate premature aging and loss of dermal and vascular elastic fibers.
Which post-MI mechanical complication is this?
Inferior MI s/p TPA. Dyspnea 12 hrs later, lying supine.
New systolic thrill, large V wave on PCWP tracing.
Acute VSD
“Patient lying flat is acute VSD”
In Post-MI mechanical complications, which papillary muscle is more prone to rupture?
Posteromedial papillary muscule.
Because it has a single blood supply (only from PDA)
Easier to knock out the PM pap.
Which Post MI mechanical complication:
Flash pulmonary edema occurring between 2 and 7 days after MI
Papillary Muscle Rupture
<1% of infarcts
Can occur with subendocardial infarcts.
Tends to be the PM pap muscle (single blood supply- the PDA)
Causes acute severe torrential MR
May not have a murmur because happens rapidly.
What is the urgent treatment needed for acute papillary muscle rupture?
URGENT SURGERY.
The clock is ticking.
(may be able to temporize while waiting for OR with IABP)
Which Post MI mechanical complication?
Occurs 3-5 days after infarction, but can be within 1st 24 hours particularly in patients who have been treated with fibrinolytic therapy. Harsh systolic murmur.
“Precordial Thrill”. Patient lying flat.
VSD
Which Post-MI mechanical complication:
New Murmur, patient lying flat.
Acute VSD
CAD s/p MI, EF 38%, nonsustained VT on holter, Class II CHF. Recs?
EP study for sudden cardiac death risk stratification, ICD if sustained VT is induced
(EF is over 35%, so does not meet implant criteria on own)
In patients with established stable CAD, is there a benefit to add clopidogrel to aspirin?
No significant benefit.
CHARISMA trial. Had increase moderate bleeding in asa/clopidogrel
What is the reversal agent for hirudin?
Prothrombin Complex
