Ischemic Heart Disease, Angina, and Myocardial InfarctionCIS

Question 1

You initiate treatment with an oral agent that should reduce the frequency of chronic angina episodes by decreasing myocardial O2demand without causing systemic vasodilation. Which drug best fits this description?

Answer 1

metoprolol

Question 2

Drugs for Angina Prophylaxis

Answer 2

Cardioselective beta blockers

Calcium channel blockers

Long-acting nitrates

• Choice of drug depends on presence of contraindications and individual response of patient
• Combinations may be more effective than monotherapy

Question 3

Cardioselectivebeta blockers

Answer 3

–E.g., atenolol, metoprolol

–Nonselective agents also frequently used

Question 4

Calcium channel blockers

Answer 4

–Long-acting dihydropyridine, e.g. amlodipine or felodipine

–Non-dihydropyridine, e.g. verapamil or diltiazem

Question 5

Long-acting nitrates

Answer 5

–Oral: isosorbidedinitrateor nitroglycerin (NTG)

–Sublingual (tablet or spray): NTG as needed

Question 6

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?

Answer 6

Admission to the hospital and treatment with anti-anginal agents and stress test evaluation

Question 7

carvedilol and labetalol are beta blockers that cause

Answer 7

vasodiatlion by blocking alpha blockesr

Question 8

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:

Answer 8

Discharge her from the hospital with a follow up in two weeks.

Question 9

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:

•How would you classify (diagnose) this patient based upon how she first presented to the hospital?

Which of the patient’s current medications should be stopped immediately?

As a part of your risk stratification you choose which of the following work up options?

Answer 9

Admit her to the local hospital and begin aggressive medical therapy optimizing her coronary artery disease management

unstable angina

Celecoxib

Perform a stress test

Question 10

Unstable angina definition

Answer 10

–New onset
–At rest
–Crescendo

Question 11

In addition to the sublingual NTG already administered and O2, which of the following is recommended as initial therapy for this patient’s acute unstable angina?

Answer 11

Aspirin

Question 12

Drugs for Acute Angina

Answer 12

•Oxygen, especially if O2saturation

Question 13

•Aspirin for antiplatelet effects

Answer 13

–Clopidogrelis an alternative if aspirin is contraindicated

Question 14

•Nitroglycerin to produce systemic vasodilation

Answer 14

–Reduces myocardial O2demand by reducing preload

–Increases O2delivery by dilating coronaries

Question 15

•Morphine

Answer 15

–If chest pain is unresponsive to nitroglycerin
–Also relieves anxiety
–Associated with increased mortality in unstable angina/NSTEMI

also can dialate a little bit so it helps with that

Question 16

NSAID Cyclooxygenase (COX) Selectivity

Non-selective

Answer 16

• Inhibit both COX-1 (aka platelet COX) and COX-2
• Diclofenac, ibuprofen, indomethocin, naproxen, sulindac, many others
• Aspirin is an irreversibleCOX inhibitor
• Acetaminophen is a weak inhibitor of COX-1 and COX-2, but is not an NSAID because it has no significant anti-inflammatory effects

Question 17

NSAID Cyclooxygenase (COX) 
Selectivity

COX-2 Selective

Answer 17

• Celecoxib and meloxicam
• Several other “coxibs” withdrawn from the market
• No effect on platelets or bleeding time
• Significantly less GI ulcers

Question 18

NSAID Cyclooxygenase (COX) Selectivity, why do you stop both with a heart problem

Answer 18

increase cv risk with both thats why you stop it immediately

Question 19

NSAIDs and Cardiovascular Risk

Answer 19

• BothCOX-2 selective andnon-selective NSAIDs are associated with increased risk of adverse cardiovascular events
• Risk increases at higher doses
• New studies continue to evaluate whether the risk is higher or lower with any particular NSAID

Question 20

NSAIDs and Cardiovascular Risk

exception

Answer 20

aspirin is cardioprotectiveat low doses (75-325 mg daily) where antiplatelet effects predominate

Question 21

Perform an image augmented stress test with

Answer 21

lbbb

Question 22

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?

Answer 22

coronary angiogram

Question 23

• 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/hrchanged daily.
• His EKG is shown after he walks 200 feet in the ER hallway. st depression in 2356,

You are concerned about the nitroglycerin patch being “changed daily.” Which statement best summarizes your concern? Continuous treatment may lead to

Which of the following drugs are indicated to treat his worsening heart failure and uncontrolled hypertension?

After optimizing his CHF and blood pressure. Which diagnostic or therapeutic modality is most indicated?

In addition to coronary risk evaluation and treatment, your choices to reduce mortality should include:

Answer 23

nitrate tolerance

IV NTG and furosemide

coronary angiography

lisinopril and insulin

Question 24

Drugs Shown to Prevent MI and Death

Answer 24

• Beta-blockers: timolol, metoprolol, and propranolol
• Anti-platelet drugs: aspirin, ADP receptor blockers (e.g., clopidogrel)
• HMG-CoA reductase inhibitors (the –statins)
• ACE inhibitors (the –prils) and ARBs (the –sartans)

Question 25

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:

Answer 25

A cardiac catheterization to evaluate for ischemia

Question 26

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?

Answer 26

Intravenous normal saline bolus

Question 27

e increases

Answer 27

afterload

Question 28

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:

Which of the following would be a contraindication for the use of fibrinolytic (aka thrombolytic) therapy for this patient?

Answer 28

Initiate thrombolytic therapy

History of closed head trauma 2 months ago

Question 29

higher inr

Answer 29

increases bleeding changes

Question 30

don’t do thrombolytic after how many hours

Answer 30

12 or 3? I think he said 12

Question 31

absolute contraindication of thrombolytic therapy

Answer 31

intracranial hemorrhage

ischemic stroke 3 months ago unless stroke is within 3 hours

cerebral vascular malformation or metastatic intracranial malignancy

bleeding diathesis or active bleeding

head or facial trauma within 3 months

Question 32

relative contraindication of thrombolytic therapy

Answer 32

htn

ischemic stroke more than 3 months ago

dementia

intracranial disease that is not a absolute contraindication

greater than 10 minutes of resuscitation

internal bleeding or active peptic ulcer

concompressible vascular punctures

pregnancy

warfarin current

prior exposure within 5 days for these meds or allergy to the meds

Question 33

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 33

NTG decreases myocardial O2consumption and increases O2delivery to the heart.

Question 34

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 34

An ACE-inhibitor

Question 35

A 45 y/o male asks his physician for a prescription for sildenafil (Viagra) to improve his sexual performance. Because of risks from a serious drug interaction, this drug should not be prescribed if he is also taking a/an:

Answer 35

organic nitrate

Question 36

viagra

Answer 36

phosphodiesterase 5, degrades cgmp

Question 37

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 37

Exercise stress test without augmentation, after medical therapy maximized

Question 38

A 53 y/o female presents to the ED with severe chest pain. EKG changes indicate myocardial ischemia. Unknown to the ED team is the fact that the ischemia is due to coronary vasospasm, not coronary occlusion with thrombi. Given this etiology, which drug may make the vasospasm, and resulting ischemia, worse?

Answer 38

Atenolol

doesnt correctly treat the vasospasm

use nitrate or ccb to treat vasospasm