ischemic heart disease, angina and MI CIS (Martin and Unrein) 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 shown:
Normal EKG….
what should you do..
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 50. What is your management approach?
what drugs would you give this patient?
The patient’s anti-anginal medications are adjusted as discussed and she is place 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:
Admission to the hospital and treatment with anti-anginal agents and stress test evaluation
Morphine, O2, Nitroglycerin, Aspirin
“MONA”
Morphine for pain and to relieve anxiety
O2, especially if O2 saturation
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 and 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.
..
As a part of you risk stratification and treatment you choose which of the following work up and treatment options?
Add clopidogrel, aspirin and perform a stress test
Add aspirin, stop the celecoxib and perform a image augmented stress test
Refer her for coronary bypass grafting
Add aspirin, stop the celecoxib and stress test
Add clopidogrel, stop celecoxib and perform a chemical stress test
Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management
she has unstable angina - at rest occurs, crescendo, new onset
Add aspirin, stop the celecoxib and stress test
what does celecoxib do…
Celecoxib has little or no effect on platelet aggregation
celecoxib is associated with an increased risk of serious adverse CV events compared to placebo
COX2 inhibitor so prothrombotic state
a patient with unstable angina…
The patient is treated with aspirin, nitrates and on a standard Bruce protocol exercise stress test has ST segment depressions in leads V1-4 that resolve by stopping the stress test. She did not reach her maximum heart rate. What should be your next approach?
A) Coronary angiogram
70 y/o male with long standing history of diabetes and hypertension presents to the emergency room with worsening shortness of breath and diaphoresis with activity.
This has become progressively worse over the last month.
On physical Exam his blood pressure is 150/90, pulse is 80 and respirations 20. He has crackles is his lungs at the bases bilaterally, +3 edema, and an S3.
His HBA1C is 8.0, 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 is shown after he walks 200 feet in the ER hallway.
Shows ST segment depressions and left atrial hypertrophy - he has ischemic heart disease
After optimizing his CHF and blood pressure. Which diagnostic or therapeutic modality is most indicated?
In this patient, In addition to coronary risk evaluation and treatment, your choices to reduce mortality should include:
Coronary angiography
Lisinopril (ACE inhibitor) and insulin
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 cardiac catheterization to evaluate for ischemia
she is unstable
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?
IV normal saline bolus!
inferior wall MI is associated with the right sided heart–> so it is volume dependent ***
nitro works on the venous side of the system, so you would reduce VR to heart- could be detrimental
NE- don’t give this b/c it would increase O2 demand
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:
Answers: Initiate thrombolytic therapy Assessment of ejection fraction Refer her for coronary bypass grafting Transfer the patient to the hospital with cardiac catheterization lab Chemical stress testing with imaging
Which of the following would be a contraindication for the use of fibrinolytic therapy for this patient?
BP 142/90
INR =1.2
Onset of symptoms > 3 hours ago
History of closed head trauma 2 months ago
Platelet count 175,000/mm3
initiate thrombolytic therapy
contraindications?
history of closed head trauma 2 months ago
90 minutes is the golden number - after this time then thrombolysis is the golden treatment
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?
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.
Sublingual administration avoids first pass metabolism.
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?
An ACE-inhibitor Clopidogrel Nitrates Verapamil Folic acid
ACE inhibitor
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? Factor Xa Fibrin Plasmin Thrombin Thromboplastin
Plasmin
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:
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
Exercise stress test without augmentation, after medical therapy maximized
Following an anterior wall MI, a patient goes into cardiogenic shock with a LVEF
Dopamine
