Step Up to Medicine

Question 1

Exercise-induced ischemia

Answer 1

Causes subendocardial ischemia –> ST segment depression

Question 2

Positive stress test

Answer 2

If patient develops any of the following during exercise:

ST depression

Chest pain

Hypotension

Significant arrhythmias

Question 3

Pharmacologic stress test

Answer 3

Do this if patient cannot exercise

Use IV adenosine, dipyridamole to vasodilate coronary arteries (diseased coronary arteries already max dilated at rest so receive relatively LESS blood flow when entire coronary system pharmacologically vasodilated)

Use dobutamine to increase myocardial O2 demand (increase HR, BP, contractility)

Question 4

Treatment for stable angina

Answer 4

RF management: DM, HTN, HLD, obseity, diet/exercise

Aspirin, beta blockers (atenolol, metoprolol), nitrates, CCBs (second line if beta blockers/nitrates don’t work)

COURAGE trial showed no diff between medical therapy and PCI/stent!

Question 5

Indications for CABG

Answer 5

3 vessel disease with >70% stenosis in each vessel

Left main coronary artery disease with >50% stenosis

LV dysfunction

Question 6

Acute coronary syndrome (ACS)

Answer 6

Unstable angina: no e/o elevated torponin or CK-MB

NSTEMI

STEMI

Question 7

Treatment of unstable angina

Answer 7

Aggressive medical management (like MI but no fibrinolysis): ASA, clopidogrel, beta blockers, enoxaparin (LMWH), nitrates, O2, abciximab

Relpace lytes

Morphine controversial (pain relief but may mask sx)

NOT thrombolytic therapy, NOT CCBs

Question 8

Factors that increase risk of ischemic event if pt has unstable angina or NSTEMI

Answer 8

Age >65

>3 risk factors for CAD

Known CAD (>50% stenosis)

At least 2 episodes severe angina in past 24 hr

ASA use in past 7 days

Elevated serum cardiac enzymes

ST changes >0.5mm