NBME 10 and 11. stress testing + CAD Flashcards
NBME 10 143Q. kiti ats
Coronary angiography (Choice A) may be indicated if acute coronary syndrome is identified as the cause of the patient’s presentation. He has multiple risk factors for coronary artery disease, and the report of angina that came on with exertion is highly concerning. There is not yet enough information available to proceed to cardiac catheterization, but if cardiac biomarkers are increased and the ECG shows ST segment changes or other evidence of ischemia, the patient should undergo coronary arteriography and potential revascularization.
Exercise stress test (Choice C) should not be performed in the acute setting. The patient requires more urgent work-up of his decompensated heart failure. Exercise stress testing is contraindicated in the setting of symptomatic aortic stenosis and unstable angina, and pharmacologic stress testing should be used instead.
NBME 11 157Q.
55 y/o + 3-month history of episodes of mild, intermittent, mid chest pain. He says that the episodes occur 3 days weekly and last 2 to 3 minutes. The pain has not increased since his episodes began, and it is relieved by rest and use of antacids. He has not had shortness of breath, nausea, wheezing, or light-headedness. He has hypertension and asthma. His medications are lisinopril, hydrochlorothiazide, and albuterol. He does not smoke cigarettes. He drinks four glasses of wine on weekends. He works as an automobile mechanic. Pulse 78; RR 16; BP 142/84; SpO2 97 proc. Cardiopulmonary examination shows no abnormalities. An ECG shows a normal sinus rhythm and no ST-T wave changes. Which of the following is the most appropriate next step in diagnosis?
Exercise stress test
An exercise stress test can help diagnose CAD, which may require intervention.
NBME 11 157Q.
CAD. Atherosclerotic plaque -> myocardium may not receive sufficient oxygen to meet its metabolic demands during times of increased work, such as exercise.
This mismatch in supply and demand of oxygen results in myocardial ischemia and can cause angina. If myocardial ischemia is severe enough and not reversed, which occurs in cases of plaque rupture, it results in myocardial infarction.
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NBME 11 157Q. Exercise stress tests, including …..are employed in an attempt to identify areas of decreased perfusion.
stress echocardiography
NBME 11 157Q. If an exercise stress test discloses signs of severe coronary artery disease, what might needed?
cardiac catheterization may be necessary.
NBME 11 157Q. kiti ats. Cardiac catheterization would be appropriate in a patient with?????
MI or acute coronary syndrome (ACS).
NBME 11 157Q. kiti ats. CP of ACS?
Severe, non- remitting chest pain, shortness of breath, diaphoresis, or nausea, and ECG does not show ST segment elevation or depression.
NBME 11 157Q. kiti ats.
Quantitative coronary artery calcium scoring (Choice C) can be done to assess ….???
cardiovascular risk in asymptomatic patients with intermediate risk for CAD
NBME 11 157Q. kiti ats. Rest-redistribution thallium scan (Choice D) is typically done in patients????
known to have CAD to evaluate for viable versus nonviable myocardium and assess for the chance of functional recovery after revascularization.
NBME 11 157Q. kiti ats.
No further testing (Choice E) would be inappropriate in this patient who may be presenting with angina. Evaluation of CAD should be done to decrease risk for myocardial infarction, heart failure, and overall morbidity and mortality.
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NBME 11 79Q. A 47-year-old woman with type 2 diabetes mellitus comes to the physician because of a1-month history of indigestion after large meals and a 2-week history of poor exercise tolerance. She can no longer walk up one flight of stairs without becoming short of breath. She also has hypertension, hyperlipidemia, and osteoarthritis that affects both knees. Her mother had a myocardial infarction at the age of 60 years. The patient’s medications are long-acting insulin, atorvastatin, enalapril, and 81-mg aspirin daily. She has never smoked cigarettes. She is 168 cm (5 ft 6 in) tall and weighs 82 kg (180 lb); BMI is 29 kg/m . Examination
shows no abnormalities. A resting ECG shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?
Adenosine nuclear stress test
vs Exercise stress test - This patient has exertional dyspnea and osteoarthritis, both of which are likely to interfere with her ability to achieve the necessary level of exertion required for an exercise stress test.
NBME 11 79Q. Adenosine nuclear stress test is the most appropriate next step in evaluation of ???
of this patient’s new onset exercise intolerance
NBME 11 79Q. This patient has many risk factors of coronary artery disease including type 2 DM, HTN, family history of MI in a first-degree relative. This confluence of factors places her at an intermediate level of risk, and she should undergo further risk stratification with stress testing.
NBME 11 79Q. Exercise stress testing on a treadmill is appropriate for patients with normal resting ECGs and an ability to exercise.
NBME 11 79Q. in case patient has bilateral knee osteoarthritis and inability to walk up two flights of stairs means that she will be unlikely to achieve the necessary level of exercise required for an exercise stress test.
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NBME 11 79Q.
adenosine nuclear stress testing. Baseline perfusion images are taken before the administration of adenosine and compared to images obtained after the intravenous administration of adenosine. Adenosine is a potent coronary vasodilator. In patients without obstructive coronary disease, the infusion of adenosine will result in marked vasodilation and increased perfusion throughout the heart. On the other hand, patients with obstructive coronary disease typically have coronary arteries that are near maximally dilated at a point distal to the obstruction, so administration of adenosine will result in little to no increase in perfusion distal to the obstruction.
NBME 11 79Q. kiti ats.
Cardiac catheterization - for Tx of ACS
Echocardiography (Choice D) provides information about the ejection fraction, cardiac chamber size, and the function of the cardiac valves, but it is not a useful modality for determining if a patient has coronary artery disease
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NBME 11 29Q.
A 25-year-old man comes to the physician for an examination prior to starting an exercise program consisting of swimming four times weekly. He feels well but wants to change his sedentary lifestyle. He has smoked one-half pack of cigarettes daily for 9 years. His father had a myocardial infarction at the age of 52 years. The patient is 178 cm (5 ft 10 in) tall and weighs 109 kg (240 lb); BMI is 34 kg/m . His pulse is
76/min, and blood pressure is 138/76 mm Hg. The remainder of the examination and an ECG show no other abnormalities. In addition to obtaining serum lipid studies and recommending that the patient stop smoking, which of the following is the most appropriate next step in management?
Approval of the exercise program
Approval of the exercise program and consistent participation are likely to have the greatest effects on the patient’s health and future cardiovascular disease risk profile at this time. Increased BMI and a sedentary lifestyle are associated with a variety of adverse outcomes including myocardial infarction, coronary artery disease, stroke, and overall mortality. The first-line preventative strategy involves lifestyle modification with improvement of diet and exercise. Regular aerobic exercise results in improved serum lipid studies, better control of hypertension, and decreased lifetime risk for cardiovascular disease. Patients who are overweight or obese may also benefit from additional weight loss programs and dietary modification.
NBME 10 67Q.
Five days after admission to the hospital because of inoperable descending thoracic aortic aneurysm with dissection, a 73-year-old man has moderate back pain. <….> His temperature is 38.3°C (101°F), pulse is 110/min, and blood pressure is 180/106 mm Hg. Examination shows livedo reticularis over the dorsum of the left lower leg. There are petechiae over the dorsa of the feet and several small, purplish black lesions over the left first, second, and third toes and the right second and third toes. The toes are tender to palpation. + renal dysfunction <….> Maltese crosses are noted. Which of the following is the most likely diagnosis?
Multiple cholesterol emboli syndrome
NBME 10 67Q. Cholesterol embolization syndrome occurs secondary to….?
secondary to the embolization of atherosclerotic plaque contents (eg, cholesterol crystals) from a proximal large artery (eg, aorta) to distal small arteries and arterioles.
This results in occlusion of the distal arterial vasculature with cholesterol emboli, which induces a localized inflammatory response and end-organ damage.
NBME 10 67Q. cholesterol embolism. Dermatologic manifestations of this phenomenon are ?
localized petechiae, livedo reticularis, and blue toe syndrome
Histology of skin lesions discloses biconvex needle-shaped clefts within the arterial lumen left by dissolved cholesterol crystals.
NBME 10 67Q.
cholesterol embolism. labs?
increased creatinine (RENAL DYSFUNCTION) and leukocytosis with eosinophilia.
NBME 10 67Q.
Risk factors for cholesterol embolization syndrome include? 3
- Trauma,
- interventional procedures that increase the risk for damage and dislodgement of atherosclerotic plaques such as cardiac catheterization,
- and aortic dissection.
NBME 10 67Q. Cholesterol emboli can also involve other organs, potentially resulting in renal failure, colonic ischemia, cerebrovascular accidents, and skeletal muscle ischemia.
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NBME 10 67Q. cholesterol embolism. Onset and Tx?
Onset is usually acute, and treatment is supportive.
