Section 2: Angina, Lipid Mgnt and Sex and the Heart Flashcards
Give the definition of Acute Coronary Syndrome (ACS)
- Causes acute chest pain
- Can be with exercise or at rest
- Can have ST segment elevation, depression, or even a normal EKG
- Not based on enzyme levels, angiography, or stress test results
- Based on a history of chest pain with features suggestive of ischemic disease
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1652-1654). . Kindle Edition.
What is the best initial Rx for all cases of ACS?
Aspirin
Aspirin can be administered —— or —— and absorbed under the tongue. It has an instant effect on inhibiting platelets.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1657-1658). . Kindle Edition.
Orally or chewed
Aspirin alone reduces mortality by — percent for acute myocardial infarction and by — percent for “unstable angina,” which may become a non-ST segment elevation myocardial infarction (NSTEMI).
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1660). . Kindle Edition.
25%
50%
— (1) — and — (2) — should also be administered in acute coronary syndromes, but they do not lower mortality. — (3) — has no benefit if the patient is not hypoxic.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1660-1662). . Kindle Edition.
- Nitrates
- Morphine
- Oxygen
— (1) — or — (2) — is added to aspirin for all patients with an acute myocardial infarction.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1662-1664). . Kindle Edition.
- Prasugrel
- Clopidogrel
How soon must percutaneous coronary intervention (PCI) be perfomed in a patient with ACS?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1671). . Kindle Edition.
Within 90 minutes
True or False
Angiography is superior to medical therapy (aspirin, beta blockers, statins) for patients with stable angina?
False
If PCI cannot be performed within 90 minutes of arrival in the emergency department, what should the patient receive?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1678-1679). . Kindle Edition.
Thrombolytics
List the indications for thrombolytics
- Chest pain for < 12 hours and has ST segment elevation in 2 or more leads
- A new left bundle branch block (LBBB)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1681-1682). . Kindle Edition.
——- lower mortality, but the timing of their administration is not critical.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1686-1687). . Kindle Edition.
Beta blockers
Should ACE inhibitors or angiotensin receptor blockers be given to all patients with ACS?
Yes
A 72-year-old man comes to the emergency department having had chest pain for the last hour. His initial EKG shows ST segment elevation in leads V2– V4. Aspirin has been given. Which of the following will most likely benefit this patient?
a. CK-MB
b. Stress test
c. Angioplasty
d. Metoprolol
e. Diltiazem
f. Atorvastatin
g. Digoxin
h. Amiodarone
i. Oxygen, morphine, and nitrates
j. Thrombolytics
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1695-1705). . Kindle Edition.
C. Angioplasty will lower the risk of mortality most for this patient. If it can be obtained within 90 minutes, angioplasty is the best therapy. Metoprolol lowers mortality but is not dependent on how soon you give it, as long as the patient receives it before going home.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1706-1708). . Kindle Edition.
What has the single greatest efficacy? in lowering mortality in STEMI.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1711). . Kindle Edition.
Urgent angioplasty or
PCI
True or False
Statin medications, such as atorvastatin, should be given to all patients with an acute coronary syndrome, regardless of what the EKG shows or troponin or CK-MB levels.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1715-1717). . Kindle Edition.
True
List the therapies used in Acute Coronary Syndromes that always lower mortality
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1718-1719). . Kindle Edition.
- Aspirin
- Thrombolytics
- Primary angioplasty
- Metoprolol
- Statins
- Clopidogrel or prasugrel
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1724-1729). . Kindle Edition.
List the therapies used in Acute Coronary Syndromes that lower mortality when there is low ejection fraction
- ACE inhibitors OR
- ARBs
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1730-1732). . Kindle Edition.
List the therapies used in Acute Coronary Syndromes that do not lower mortality
- Oxygen
- Morphine
- Nitrates
- Calcium channel blockers
- Lidocaine
- Amiodarone
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1733-1738). . Kindle Edition.
Indications for Prasugrel or clopidogrel in ACS
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1745-1749). . Kindle Edition.
- There is aspirin allergy
- The patient undergoes angioplasty and stenting
- There is acute MI
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1745-1749). . Kindle Edition.
Indications for calcium channel blockers (verepamil, diltiazem) in ACS
- The patient has an intolerance to beta blockers, such as severe reactive airway disease (asthma)
- There is cocaine-induced chest pain
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1753-1756). . Kindle Edition.
Indications for a pacemaker in acute MI
- Third-degree AV block
- Mobitz II, second-degree AV block
- Bifascicular block
- New left bundle branch block
- Symptomatic bradycardia
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1759-1765). . Kindle Edition.
Indications for lidnocaine or amiodarone in acute MI
- Only when there is ventricular tachycardia or ventricular fibrillation
- Do not give antiarrhythmic medications to prevent ventricular arrhythmias.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1768-1771). . Kindle Edition.
True or False
All the complications of myocardial infarction result in hypotension.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1773). . Kindle Edition.
True
Cardiogenic shock following an MI:
- What is the diagnostic test
- What is the Rx
- Echo, Swan-Ganz (right heart) catheter
- ACEI, urgent revascularization
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1779-1781). . Kindle Edition.
Valvular rupture following an MI:
- What is the diagnostic test
- What is the Rx
- Echo
- ACEI, nitroprusside, intra-aortic balloon pump as a bridge to surgery
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1783-1785). . Kindle Edition.
Septal rupture following an MI:
- What is the diagnostic test?
- What is the Rx?
- Echo, right heart catheter showing a step up in saturation from the right atrium to right ventricle
- ACEI, nitroprusside, and urgent surgery
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1787-1788). . Kindle Edition.
Myocardial wall rupture following an MI:
- What is the diagnostic test?
- What is the Rx?
- Echo
- Pericardiocentesis, urgent cardiac repair
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1790-1792). . Kindle Edition.
Sinus bradycardia following an MI:
- What is the diagnostic test?
- What is the Rx?
- EKG
- Atropine, followed by pacemaker if there are still symptoms
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1794-1795). . Kindle Edition.
Third degree (complete) heart block following an MI:
- What is the diagnostic test?
- What is the Rx?
- EKG, canon “a” waves
- Atropine and a pacemaker even if symptoms resolve
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1797-1799). . Kindle Edition.
Right ventricular infarction following an MI:
- What is the diagnostic test?
- What is the Rx?
- EKG showing right ventricular leads
- Fluid loading
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1800-1802). . Kindle Edition.
List the post-MI discahrge instructions
All patients post-MI should go home on aspirin, clopidogrel (or prasugrel), a beta blocker, a statin, and an ACE inhibitor.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1804-1805). . Kindle Edition.
A patient’s wife comes to take her husband home after an MI and asks how long they should wait before they have sex. What do you tell her?
a. No waiting necessary
b. 2– 6 weeks
c. After echocardiography
d. They should wait for a normal angiography.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1806-1811). . Kindle Edition.
B. Some waiting is necessary to have sex after an infarction. Sex minimally increases the risk of infarction. The duration and the intensity of exertion are sufficient to provoke ischemia in some cases.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1812-1814). . Kindle Edition.
List the predominant differences in the management of non-ST segment elevation MI (NSTEMI)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1816-1818). . Kindle Edition.
- No thrombolytic use
- Heparin is used routinely. Low molecular weight (LMW) heparin is superior to the IV form
- Glycoprotein IIb/ IIIa inhibitors lower mortality, particularly in those undergoing angioplasty
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1816-1818). . Kindle Edition.
A 54-year-old man with a history of diabetes and hypertension comes to the emergency department with crushing, substernal chest pain that radiates to his left arm. The pain has been on and off for several hours, with this last episode being 30 minutes in duration. He has had chest pain on exertion before, but this is the first time it has developed at rest. The EKG is normal. Aspirin, oxygen, and nitrates have been given. Troponin levels are elevated. Which of the following is most likely to benefit this patient?
a. Low molecular weight heparin
b. Thrombolytics
c. Diltiazem
d. Morphine
e. CK-MB levels
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1819-1827). . Kindle Edition.
A. Heparin is the only one of these choices that has been shown to produce lower mortality. Thrombolytics do not lower mortality, unless there is ST elevation or a new LBBB. Positive cardiac enzymes are not an indication for thrombolytics. Other answers that could be right if they were choices are GPIIb/ IIIa inhibitors, such as eptifibatide, tirofiban, or abciximab, or the use of angioplasty/ PCI.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1828-1832). . Kindle Edition.
What is the single greatest benefits from GPIIb/ IIIa inhibitors in ACS?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1833-1834). . Kindle Edition.
When used in combination with angioplasty and stent placement. Abciximab does not benefit ST segment elevation MI.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1834-1835). . Kindle Edition.
When are thrombolytics used in stable angina?
Thrombolytics are only used if there is ST segment elevation or a new LBBB within 12 hours of the onset of chest pain.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1837-1839). . Kindle Edition.
List the 2 routinely indicated medications for stable angina
What are their benefits?
Aspirin and Metoprolol
Because they reduce mortality
True or False
Nitrates should be used for those with angina pain
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1843). . Kindle Edition.
True
Indications for ACE inhibitors and ARBs for stable angina
- Congestive heart failure (CHF)
- Systolic dysfunction
- Low ejection fraction
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1846). . Kindle Edition.
Common side effect of ACE inhibitors and ARBs
Hyperkalemia
What is predominantly used to determine who is a candidate for coronary artery bypass grafting (CABG).
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1849-1850). . Kindle Edition.
Coronary angiography
Which of the following is the main difference between saphenous vein grafts and internal mammary artery grafts?
a. There is less need for aspirin and metoprolol with internal mammary artery grafts.
b. Warfarin is necessary with saphenous vein grafts.
c. Internal mammary artery grafts remain open for 10 years.
d. Heparin is necessary for vein grafts.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1856-1861). . Kindle Edition.
C. The main difference between saphenous vein grafts and internal mammary artery grafts is that vein grafts start to become occluded after 5 years but internal mammary artery grafts are often patent at 10 years. There is no difference in the need for medications.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1863-1864). . Kindle Edition.
List the medications used for stable angina (pain)
- Aspirin + metoprolol (mortality benefit)
- Nitrates (pain) ACE/ ARB (low ejection fraction)
- Clopidogrel or prasugrel (acute MI or cannot tolerate aspirin)
- Statins (LDL > 70– 100)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1853-1855). . Kindle Edition.
Indications for coronary artery bypass graft
- Three coronary vessels with > 70 percent stenosis
- Left main coronary artery stenosis > 70 percent
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1867-1869). . Kindle Edition.
List the coronary artery disease equivalents
- Diabetes mellitus
- Peripheral artery disease
- Aortic disease
- Carotid disease
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1870-1875). . Kindle Edition.
What is the single strongest indication for lipid-lowering therapy (statin)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1877). . Kindle Edition.
An acute coronary syndrome and an LDL > 130.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1877-1878). . Kindle Edition.
What is the goal of therapy for LDL level in those with CAD?
LDL < 100.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1878-1879). . Kindle Edition.
LDL goal in a diabetic + CAD
LDL <70
List the risk factors in lipid management
- Tobacco use (cigarette smoking)
- High blood pressure (≥ 140/ 90 mm Hg or on blood pressure medication)
- Low HDL cholesterol (< 40)
- Family history of early coronary heart disease (female relatives < 65, male relatives < 55)
- Age (males ≥ 45, females ≥ 55)
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1890-1892). . Kindle Edition.
Many medications, such as statins, cholestyramine, gemfibrozil, ezetimibe, and niacin, lower LDL, lower triglycerides and total cholesterol, and raise HDL. Which of the following is the most important reason for using statins?
a. Fewer adverse effects
b. Lower cost
c. Greater patient acceptance
d. Greatest mortality benefit
e. Greatest effect on lowering LDL
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1893-1900). . Kindle Edition.
D. The statins have a greater effect on lowering mortality compared with the other medications.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1901-1902). . Kindle Edition.
When is the goal of therapy an LDL < 70?
a. CHF
b. Diabetes
c. Coronary disease and carotid disease
d. Coronary disease and diabetes
e. Diabetes and hypertension
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1907-1911). . Kindle Edition.
D. The goal of LDL can be < 70 for patients at the very highest risk of infarction. This includes those with acute coronary syndromes or the combination of coronary disease and a very severe risk factor, such as diabetes.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1907-1911). . Kindle Edition.
What is the most common adverse effect of statin medications?
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1914-1915). . Kindle Edition.
Liver toxicity
True or False
Rhabdomyolysis is the most common adverse effect of statins.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 1916). . Kindle Edition.
False
Give statins with —— and an LDL ——-.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1912-1913). . Kindle Edition.
CAD
>100
A man develops erectile dysfunction after an infarction. What is the most common cause?
a. Metoprolol
b. Nitrates
c. ACE inhibitors
d. Aspirin
e. Anxiety
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1919-1924). . Kindle Edition.
E. Anxiety is the most common cause of erectile dysfunction postinfarction. Although beta blockers may be the most common medication associated with erectile dysfunction, anxiety is still a more common cause of erectile dysfunction than beta blockers.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1925-1927). . Kindle Edition.
A man develops erectile dysfunction postinfarction. You are planning to start sildenafil. Which of the following medications must you stop?
a. Metoprolol
b. Nitrates
c. ACE inhibitors
d. Aspirin
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1928-1932). . Kindle Edition.
B. Nitrates are contraindicated when medications such as sildenafil are to be used. When used at the same time, they can cause a dangerous level of hypotension.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1934-1935). . Kindle Edition.
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