Coronary artery disease Flashcards
You are the back-up cardiologist on-call for the weekend at your local hospital. You receive a phone call at 11:30 pm Saturday night from the ED physician. He is calling you because he has been unable to reach the primary cardiologist on-call for the past 2 hrs. A 50-year-old man presented to the ED 2 hrs ago with 3 hrs of substernal chest pressure with radiation into his jaws. The patient has no prior history of heart disease. He takes no medications. CAD risk factors include MI in his father at age 56, cigarette smoking 2 packs/day for 33 yrs, borderline HTN, no diabetes, and unknown lipid status. Physical exam upon presentation revealed BMI 32.4; BP 145/92 mmHg; HR 112 bpm; lungs clear; heart apical impulse not palpable, normal S1 and S2, soft apical S4, no S3 or murmur or rub; extremities no edema; peripheral pulses normal. The ECG showed Q waves and 3 mm ST segment elevation in the inferior leads. The patient was treated with SL NTG, aspirin and tPA followed by a heparin drip. His chest pain resolved and he has been pain-free for the past hour. The ST elevation resolved but the Q waves in the inferior leads persist. The ini-tial Troponin T was 0.03 ng/ml (normal < 0.10 ng/ml). His ECG monitor shows 8 to 10 single ventricular premature contractions per min. You visit and examine the patient and confirm the findings of the ED physician.
The next step in this patient’s management should be:
a. CT chest scan with contrast to rule out aortic dissection
b. Coronary angiography
c. Echocardiogram
d. Lidocaine 100 mg IV bolus followed by lidocaine 2 mg/min IV drip
e. Metoprolol 50 mg PO followed by metoprolol 50 mg PO BID.
e. Metoprolol 50 mg PO followed by metoprolol 50 mg PO BID.
Which of the following statements concerning post-MI exercise stress ECG test-ing is true?
a. If a patient has had coronary angiography, exercise stress testing adds little to future risk stratification
b. The most useful prognostic variable is ST-segment depression
c. In uncomplicated patients treated with thrombolytic therapy, stress testing an safely be performed at 24 to 48 hrs
d. Patients selected for angiography should first undergo stress imaging to aid in the functional assessment of any borderline coronary stenoses seen at angiography
a. If a patient has had coronary angiography, exercise stress testing adds little to future risk stratification
All of the following are considered absolute contraindications to the administration of a thrombolytic agent to a patient with an AMI except:
a. Embolic CVA 6 mos earlier
b. Remote history of incidentally discovered unruptured cerebral aneurysm on CT brain scan
c. Gastrointestinal bleed secondary to duodenal ulcer 4 wks earlier
d. Severe dementia
a. Embolic CVA 6 mos earlier
The administration of aspirin in AMI:
a. Has been shown to reduce 30-day mortality only among patients with ST elevation on the initial ECG
b. Is less beneficial in patients treated with thrombolytic therapy than other patients
c. Is statistically as effective as streptokinase at reducing 30-day mortality but is added in benefit when used in conjunction with streptokinase or another thrombolytic agent.
d. Is optional in the setting of AMI if the patient is therapeutic on warfarin (INR 2–3)
c. Is statistically as effective as streptokinase at reducing 30-day mortality but is added in benefit when used in conjunction with streptokinase or another thrombolytic agent.
All of the following interventions have a blood pressure-lowering effect EXCEPT:
a. A diet that reduces caloric intake by 1000 cal/day
b. Reduction of dietary sodium
c. Daily magnesium supplements
d. Tobacco cessation
e. Reduction of ethanol consumption to less than 1 oz/day
c. Daily magnesium supplements
All the following are true concerning the use of beta blockers in AMI except:
a. More than 50% of patients have contraindications to their use when first seen in the ED
b. There are data indicating that their use reduces the frequency of myocardial rupture
c. Their beneficial effect is partly due to an increase in myocardial blood flow
d. They should generally be administered acutely even to patients known to have a chronically low EF of 35%
a. More than 50% of patients have contraindications to their use when first seen in the ED
A 62-year-old diabetic smoker arrives at the local community hospital after 6 hrs of continuous crushing substernal chest pain. There is 2-mm ST elevation in leads V2–V4. Vital signs are: HR 80 bpm, BP 126/78 mmHg, respiratory rate 18/min. Physical exam demonstrates mild JVD, but clear lungs and no S3. The nearest catheterization laboratory is 60 mins away by ambulance. A helicopter is unavailable because of adverse weather conditions.
The most appropriate treatment option is:
a. Aspirin, heparin, IIb/IIIa inhibitor, clopidogrel, metoprolol
b. Aspirin, heparin, IIb/IIIa inhibitor, metoprolol, tPA
c. Aspirin, heparin, metoprolol, tPA
d. Aspirin, heparin, IIb/IIIa inhibitor, metoprolol, transfer to awaiting catheterization laboratory
e. Half strength streptokinase, aspirin, heparin, metoprolol
d. Aspirin, heparin, IIb/IIIa inhibitor, metoprolol, transfer to awaiting catheterization laboratory
Which of the following is least likely to be a cause of unstable angina?
a. Anemia
b. Fever
c. Hypothyroidism
d. Severe AS
e. Severe HTN
c. Hypothyroidism
Each of the following statements regarding hsCRP is true EXCEPT:
a. Statin reduce hsCRP in a manner directly related to their LDL-lowering effect.
b. An hsCRP level > 3 mg/L in a patient with unstable angina is associated with an increased risk of recurrent coronary events.
c. An elevated level of hsCRP is predictive of the onset of type 2 DM.
d. TZD drugs, used in the management of DM, reduce levels of hsCRP.
e. The CV benefit of ASA therapy appears to be greatest in patients with elevated hsCRP levels.
a. Statin reduce hsCRP in a manner directly related to their LDL-lowering effect.
Which of the following drugs has been shown to decrease CV events in patients with unstable angina who are allergic to aspirin?
a. Ticlopidine
b. Sulfinpyrazone
c. Dipyridamole
d. All of the above
e. None of the above
a. Ticlopidine
Lipid-lowering agents:
a. Are effective for reducing long-term mortality, even in patients with advanced CAD
b. Should not be used early in the post-infarction period
c. May paradoxically increase mortality in patients with low levels of HDL cholesterol
d. Were frequently stopped because of congestive hepatitis in trials among patients with a history of heart failure
a. Are effective for reducing long-term mortality, even in patients with advanced CAD
Angiography after MI:
a. Predicts patients who will have reinfarction
b. Predicts mortality
c. Often leads to revascularization
d. Is a cost-effective risk-stratification strategy
e. Is necessary in all patients after MI
c. Often leads to revascularization
All of the following are true about the GUSTO I trial except:
a. 20% of patients had an uncomplicated MI
b. The 30-day mortality rate was 1%, and the 1-yr additional mortality rate was 3.5%
c. Patients with uncomplicated infarction by day 4 had 1% 30-day and 2.6% additional 1-yr mortality rates
d. Age, hypotension, Killip class II or higher, increased HR, and location of infarct were the five most important clinical predictors of morality at 30 days
a. 20% of patients had an uncomplicated MI
For patients not receiving thrombolysis or primary percutaneous transluminal coronary angioplasty:
a. Mortality is lower than in candidates for thrombolysis
b. Angiography and stress testing are useful to select patients for revascularization versus medical therapy
c. Ancillary therapy (aspirin, beta blockers, ACE inhibitors) is unimportant
d. Revascularization prolongs survival in asymptomatic patients with well-preserved EF and single-vessel (not left main) disease
b. Angiography and stress testing are useful to select patients for revascularization versus medical therapy
Each of the following statements about pharmacological therapy for secondary preventionof CAD is correct EXCEPT:
a. Long-term aspirin use following MI reduces cardiovascular mortality, infarction, and stroke rates
b. Following an MI, beta-blocker use reduces mortality by 30 to 40% over the next 2 - 3 years
c. ACEI administered after MI confer a mortality reduction only in patients with left ventricular dysfunction.
d. Administration of HMG CoA reductase inhibitors reduces CVD after MI in Patients
c. ACEI administered after MI confer a mortality reduction only in patients with left ventricular dysfunction.
Which of the following is correct concerning invasive and non-invasive assessment of arrhythmia potential after MI?
a. Complex ventricular ectopy predicts risk of recurrent MI but not cardiac death
b. Late potentials on signal-averaged ECG are of little predictive value
c. Decreased HR variability fails to identify high-risk patients
d. The therapeutic implications of positive noninvasive test results are uncertain
e. Invasive EP testing early after MI is predictive of long-term ventricular arrhythmias
d. The therapeutic implications of positive noninvasive test results are uncertain
