Ischemic heart disease, angina, and MI

Question 1

Can you recommend surgery to individual that doesn’t smoke, doesn’t have HTN or DM, has a normal EKG and exercises regularly without pain of SOB?

Answer 1

Yes - without additional testing
No extra risk factors
Regulat exercise without pain serves as a stress test

Question 2

Retrosternal pain (20 min x2 over 4 hrs)
Negative troponin and CPK
T wave flattening
No HTN or DM
LDL ok
3rd episode of ST depression that is relieved with nitro
BP 130/70 and HR 50

Answer 2

Admit and treat angina
Order stress test to evaluate angina

No need for cath lab yet

Question 3

Initial treatment for angina

Answer 3

Morphine (pain and anxiety), O2, Nitro (rapidly acting coronary vasodilator), Aspirin (anti-platelet effect)

Question 4

Follow up treatment for angina

Answer 4

Beta blocker: atenolol or metoprolol
CCB: amlodipine, long acting or sustained
Long-acting nitrate: isosorbide dinitrate and/or nitro tablets
162-325 mg/day aspirin

Question 5

After initial treatment for angina, a stress test shows no ST changes and patient is able to reach max HR, what should your approach be?

Answer 5

Tested treatment with stress test

Discharge and schedule follow up in 2 weeks

Question 6

Retrosternal pain with nausea and diaphoresis
Relieved with 2 nitro
EKG and enzymes unremarkable
Poorly controlled DM
High cholesterol
HTN
BP 138/88
Creatinine 1.8

Should you transport to cath lab 3 hrs away?

Answer 6

No, patient is NOT stable

Start by admitting then CAD therapy

Question 7

How do you classify unstable angina?

Answer 7

New onset
At rest
Crescendo

Question 8

Celecoxib’s effect on platelets?

Answer 8

Little or no effect on aggregation

COX-2 selective inhibitor

Question 9

COX-2 selective NSAIDs

Answer 9

Reduce side effects like bleeds/platelet inhibition
Only go to inflamed tissues

*Increased risk of CV events but hard to conclude increased risk in comparison to non-selective NSAIDs

Question 10

If patient had unstable angina and takes Celebrex, what treatment approach should be taken?

Answer 10

Add aspirin, stop celecoxib, and perform stress test

Question 11

Patient with unstable angina takes aspirin and nitrates and stress test leads to ST depression in V1-V4 that stop at rest. Patient is unable to reach max heart rate - what is next approach?

Answer 11

Anginal therapy already enhanced and stress test already performed

**Coronary angiography

Question 12

DM (poorly controlled), HTN, high cholesterol
SOB and sweating
Crackles and edema and S3
BP 150/90
EKG: atrial enlargement and ST depression
Diagnosis and treatment approach?

Answer 12

CHF

**Ischemic heart disease

Manage BP and CHF, then coronary angiography

Question 13

Treatment reducing mortality in patient with CHF, DM and ischemic heart disease?

Answer 13

Lisinopril and insulin

Angioplasty only reduces morbidity

Question 14

DM and HTN
SOB and sweating
HIGH BP and pulse
LBBB but neg troponin
JVD and Edema
Furosemide provides temporary relief, next recommendation?

Answer 14

Cath lab to evaluate ischemia

Question 15

17 hrs retrosternal chest pain
Inferior wall MI on EKG
BP 80/50
HR 120
How do you improve BP?

Answer 15

Give IV saline bolus

Question 16

3 hrs retrosternal chest pain
SOB and sweating
Anterior wall MI
Elevated CPK-MB and troponin
Three hours away from cath lab - what should you do?

Answer 16

Initiate thrombolytic therapy

Door to cath lab should be 90 min

Question 17

Contraindication for use of fibrinolytic therapy?

Answer 17

Closed head trauma 2 mo ago -> BRAIN BLEEED

Question 18

A patient presenting to the ED with acute onset chest pain is given nitroglycerin (NTG). Which of the following statements concerning this treatment is correct?

Answer 18

Sublingual administration avoids first pass metabolism

(NTG is contraindicated if the patient is to receive a beta blocker.
NTG decreases the work and O2 consumption of the heart.
Sublingual administration avoids first pass metabolism.
The patient will become refractory to the effects of NTG if more than two doses are given within 15 min.
This drug is typically given initially by IV infusion.)

Question 19

65 y/o male presents to the Emergency room with an acute ST segment elevation MI and ultimately undergoes coronary artery bypass grafting. He is discharged on an HMG-CoA reductase inhibitor, aspirin, and a beta blocker. What other intervention may help his overall mortality?

Answer 19

An ACE-inhibitor

(An ACE-inhibitor
Clopidogrel
Nitrates
Verapamil
Folic acid)

Question 20

A patient presents with ST segment elevation on ECG, elevated troponin, and chest pain. Cardiac catheterization is not available and he is treated with tenecteplase. The activity of which of the following will be elevated by this treatment?

Answer 20

Plasmin

(Factor Xa
Fibrin
Plasmin
Thrombin
Thromboplastin)

Question 21

42 y/o female comes into the emergency room with retrosternal chest pressure associated with diaphoresis and shortness of breath. It is brought on by jogging and in the ER relieved with two nitroglycerin. Her EKG is unremarkable. She does not smoke, have hypertension, her cholesterol is normal and she has no cardiac family history. You should stratify her by performing which test:

Answer 21

Exercise stress test without augmentation, after medical therapy maximized

(Cardiac catheterization
Echocardiogram stress test, after medical therapy maximized
Coronary bypass grafting
Exercise stress test without augmentation, after medical therapy maximized
Dobutamine stress test, after medical therapy maximized)

Question 22

Following an anterior wall MI, a patient goes into cardiogenic shock with a LVEF

Answer 22

Dopamine

(Dobutamine
Dopamine
Epinephrine
Inamrinone
Norepinephrine)