CIS- chest pain and pharmacotherapy Flashcards
60 y/o male comes to the office for preoperative cardiac evaluation for an elective hernia repair. He has never smoked and does not have high blood pressure or diabetes. He walks five miles a day without chest pain or shortness of breath. His EKG is normal.
Your next diagnostic intervention should be:
Recommend him for surgery without any further cardiovascular evaluation
55 y/o female presents to the emergency room with two episodes of retrosternal chest pain, each lasting 20 minutes and over the last 4 hours. She has never had anything like this before. Her EKG shows T-wave flattening and her initial CPK and troponin levels are negative. She has no history of hypertension or diabetes. There is no heart disease in her family. Her LDL cholesterol is 98. While in the emergency room she has a third episode of chest pain that is associated with ST depression and relieved with nitroglycerin. Her EKG findings return to her baseline with T-wave flattening. Her blood pressure is 130/70 her heart rate is 70. What is your management approach?
Admission to the hospital and treatment with anti-anginal agents and stress test evaluation
The patient’s anti-anginal medications are adjusted as discussed and she is placed on an exercise treadmill with a standard Bruce protocol and reaches her maximum heart rate and has no ST changes. Your clinical approach should be to?
Discharge her from the hospital with a follow up in two weeks.
You initiate treatment with an oral agent that should reduce the frequency of chronic angina episodes by decreasing myocardial O2 demand without causing systemic vasodilation. Which drug best fits this description?
Amlodipine Aspirin Isosorbide dinitrate Metoprolol Verapamil
Metoprolol
B1 antagonist
A, C and E are all vasodilators
avoid/ use caution with what combination of drugs?
beta blocker and non-DHP calcium channel blocker
78 y/o woman presents to the hospital on a Saturday in rural Colorado. She has 45 minutes of retrosternal chest pain associated with nausea and diaphoresis. The pain is relieved after two sublingual nitroglycerin tablets. She has a history of NIDDM, HTN and hypercholesterolemia. The local hospital does not have a cath lab. The closest referral hospital is three hours away. Her EKG and cardiac enzymes are unremarkable. Her serum creatinine is 1.8. Her blood pressure is 138/88 pulse is 64 and her HBA1C is 8.5. Her cholesterol is 250 with an LDL of 170.
Current medications are
Metformin 500mg twice daily (for diabetes)
Lovastatin 20mg daily (for elevated cholesterol)
Celecoxib 200mg twice daily (for arthritis)
Lisinopril 10 mg daily (for HTN)
Your approach should be to:
A. Transfer the patient immediately to the referral center for cardiac catheterization
B. Initiate thrombolytic therapy
C. Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management
D. Coronary artery bypass grafting
E. Transfer the patient immediately to the referral center for thrombolytic therapy
Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management
How would you classify (diagnose) this patient based upon how she first presented to the hospital?
Unstable angina
What should we give in addition to NTG and O2?
aspirin
Which of her drugs should be stopped immediately?
Celecoxib. In fact, all NSAIDS are bad news except low-dose aspirin. Renal effects, etc. Clobidogrel is only used if aspirin contraindicated
What’s next?
perform a stress test.
If results are bad–> conduct a coronary angiogram
70 y/o male with long standing history of diabetes and hypertension presents to the emergency room with chest pain, worsening shortness of breath and diaphoresis. This has become progressively worse over the last month.
On physical exam he is cyanotic, blood pressure is 160/94, pulse is 80 and respirations 20. He has crackles is his lungs at the bases bilaterally, +3 edema, and an S3.
His HBA1C is 9.0, his LDL cholesterol is 170, and serum creatinine is 1.1.
He is currently on metoprolol succinate 100mg qd, and nitroglycerin patch 0.4mg/hr changed daily.
His EKG shows ischemic events in ST segment depression.
Which of the following drugs are indicated to treat his worsening heart failure and uncontrolled hypertension?
A. IV NTG and furosemide B. NTG patch 0.6 mg/hr and furosemide C. Spironolactone and HCTZ D. Verapamil and furosemide E. Verapamil and HCTZ
B. NTG patch 0.6 mg/hr and furosemide
After optimizing his CHF and blood pressure. Which diagnostic or therapeutic modality is most indicated?
coronary angiography
In addition to coronary risk evaluation and treatment, your choices to reduce mortality should include:
??? sounds like dealing with the diabetes, etc.
77 y/o female with a history of diabetes and hypertension presents with sudden onset of diaphoresis and shortness of breath. In the emergency room blood pressure is 180/100 and pulse is 110. Her EKG shows a LBBB and her troponin is negative. She has JVD and pulmonary edema on examination. After giving her furosemide to give her some immediate symptom relief, your best recommendation is:
A. An ace inhibitor because she is diabetic
B. A cardiac stress test to evaluate for ischemia
C. A cardiac catheterization to evaluate for ischemia
D. Chemical stress testing with imaging
E. Fibrinolytic therapy for an MI
C. A cardiac catheterization to evaluate for ischemia
56 y/o male presents with a 17 hour history of persistent retrosternal chest pressure. He has an inferior wall MI on the EKG. His blood pressure is 80/50, heart rate is 120. What should you do to improve the patient’s blood pressure?
A) Intra-aortic balloon pump synchronous counterpulsation
B) Intravenous normal saline bolus
C) Intravenous nitroglycerin
D) Intravenous nitroprusside
E) Intravenous norepinephrine
Intravenous normal saline bolus
The nitro will vasodilate–> make things worse
NE will increase the workload of the heart
48 y/o male presents to the emergency room with three hours retrosternal chest pain, shortness of breath and diaphoresis. His EKG indicates an anterior wall MI. He has elevated CPK-MB and troponin levels. He is three hours away from the nearest cardiac catheterization Lab. You should:
A. Initiate thrombolytic therapy
B. Assessment of ejection fraction
C. Refer her for coronary bypass grafting
D. Transfer the patient to the hospital with cardiac catheterization lab
E. Chemical stress testing with imaging
Initiate thrombolytic therapy
time is muscle
Which of the following would be a contraindication for the use of fibrinolytic (aka thrombolytic) therapy for this patient?
A. BP 142/90 B. INR = 1.2 C. Onset of symptoms > 3 hours ago D. History of closed head trauma 2 months ago D. Platelet count 175,000/mm3
History of closed head trauma 2 months ago
