questions 3

Ischemic Heart Disease

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Topic updated on 06/15/17 7:54pm

Snapshot
  • A 67-year-old door-to-door meat salesman is brought to the emergency department by ambulance after complaining to his coworkers of sudden onset chest tightness and shortness of breath. He has pain in his chest that radiates to his left arm and jaw.  He has a past medical history of type II diabetes mellitus.  He has a 45 pack-year smoking history, takes aspirin and simvastatin, and has a BMI of 37.
Introduction
  • Primary cause of ischemic heart disease is atherosclerotic occlusion of the coronary arteries
    • major risk factors include
      • diabetes mellitus (most important and considered a CAD equivalent)
      • smoking (#1 preventable factor)
      • HTN
      • high cholesterol / Hyperlipidemia (total cholesterol - HDL ratio > 5.0)
      • family history
      • age > 45 men, > 55 women
    • minor risk factors include
      • obesity
      • lack of estrogens
      • homocystinuria
      • cocaine use
      • amphetamine use
Presentation
  • Symptoms
    • range from asymptomatic
      • particularly in older women and diabetics
    • to substernal tightness and/or pain
    • and shortness of breath
    • often diagnosed and characterized as
      • stable angina
        • predictable; presents with consistent amount of exertion
        • patient can achieve relief with rest or nitroglycerin
        • indicative of a stable, flow-limiting plaque
      • unstable angina
        • unpredictable; often presents at period of inactivity
        • defined as any new angina or rapidly worsening stable angina
        • limited improvement with nitroglycerin, and usually recurs soon afterward
        • indicative of a ruptured plaque with subsequent clot-formation in vessel lumen
  • Physical exam
    • in asymptomatic patients is usually normal
    • can demonstrate mitral regurgitation murmur and/or S4 during episodes
    • may also include signs of CHF from prior MI including
      • elevated JVD
      • lower extremity edema
      • crackles
    • and other signs of vascular disease including 
      • bruits
      • ischemic ulcers
      • and diminished pulses
Evaluation
  • Cardiac catheterization for definitive diagnosis   
    •  locate and assess severity of the lesion(s)    
  • CXR
    • to rule out aortic dissection
  • Elevated cardiac biomarkers
    • troponin, CK, and/or CK-MB may be present
  • EKG 
    • shows ST elevation or depression depending on severity of ischemia
    • and Q waves
  • Stress-testing  
    • to evaluate simultaneously with EKG, echo, and radionuclide perfusion studies
    • for patients without a history of prior coronary artery disease, all antianginal medications (beta-blockers, nitrates, calcium channel blockers) should be held for 48 hours before a stress test
    • for pharmacological stress tests using adenosine or regadenoson, use of dipyridamole should be held for 48 hours and intake of caffeine held for 12 hours to minimize false negative findings of ischemia
Differential
  • Myocardial infarction, aortic dissection, GERD, pericarditis, pulmonary embolism, spontaneous pneumothorax, esophageal spasm, and musculoskeletal disorders
Treatment
  • In acute coronary syndrome use 
    • morphine
    • oxygen
    • nitroglycerin
    • aspirin
    • ACEI's
    • may also use β-blockers, GPIIb/IIIa antagonists, angioplasty
  • Drugs that improve post-MI mortality rates include
    • Aspirin
    • β-blockers
    • ACEIs
    • ARBs
    • and HMG-CoA reductase inhibitors
    • NOT calcium channel blockers
Prognosis, Prevention, and Complications
  • Must control diabetes
    • considered a CAD equivalent causing
    • MI to often present atypically in these patients
  • Manage hypertension (<140/90 mmHg)
  • Manage cholesterol levels (<70 mg/dL)
  • Encourage smoking cessation and alcohol obstention
  • MI prevention with
    • Aspirin or clopidogrel (for ASA sensitivities)
  • Angina prevention with
    • β-blockers 
      • to lower HR
      • increase myocardial perfusion time
      • and decrease cardiac work load
    • nitrates + calcium channel blockers in severe or recurring cases


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Qbank (3 Questions)

TAG
(M3.CV.65) A 65-year-old man presents to the emergency department with left-sided chest pain. He says the pain occurs at rest and is localized exclusively to the chest without radiation to the extremities. The patient has had chest pain with exertion for the past three years, but over the past year his symptoms have occurred following activities of daily living. The current episode provoked anxiety and led him to seek medical treatment. Past medical history includes hypertension that he treated successfully with exercise and diet modifications. While speaking with the emergency department physician, the patient reports that the pain has resolved. Electrocardiogram (EKG) shows left bundle branch block (LBBB) unchanged from a prior EKG taken 3 years ago. Serum troponin tests are normal. Which of the following is the most appropriate next step in management in this patient? Topic Review Topic

1. Discharge the patient with nitroglycerin
2. Discharge the patient with aspirin, atorvastatin, and hydrochlorothiazide
3. Discharge the patient with a follow-up appointment to see a cardiologist
4. Admit the patient and schedule an adenosine perfusion stress test
5. Admit the patient and schedule an exercise ECG

PREFERRED RESPONSE ▶
TAG
(M3.CV.4065) A 67-year-old male with a history of prior myocardial infarction and catherization-confirmed coronary heart disease presents to his cardiologist. He notes that he has had increased chest pain on exertion for the past 2 months. He also reports two episodes of chest pain at rest in the past month. His current medications include carvedilol daily and nitroglycerin as needed. The cardiologist orders a cardiac stress test to be performed as an outpatient. Which of the following advice should the patient be given regarding preparation for the test? Topic Review Topic

1. Do not take carvedilol and nitroglycerin for 1 day prior to the test
2. Do not take carvedilol and nitroglycerin for 4 days prior to the test
3. Take carvedilol alone on the day prior to the test
4. Take nitroglycerin alone on the day prior to the test
5. Continue to take carvedilol and nitroglycerin as instructed

PREFERRED RESPONSE ▶
TAG
(M2.CV.59) A 58-year-old African-American male is scheduled to undergo a cardiac treadmill stress test in 2 weeks. His family physician recommended the test, as the patient would like to begin a new exercise program in order to begin training to run a half-marathon later this year. His past medical history includes hypertension, which has been well-controlled with amlodipine, hyperlipidemia, for which he is taking simvastatin, and non-insulin dependent diabetes treated with metformin. His history is negative for prior myocardial infarction, heart failure, angina, or any form of coronary artery disease. Which of the following instructions should be given to the patient regarding his upcoming stress test? Topic Review Topic

1. Do not consume caffeine or caffeine-containing substances for 5 days prior to the stress test
2. Stop taking aspirin 1 week prior to the stress test
3. Stop taking amlodipine 2 days prior to the stress test
4. Take double the normal dose of metformin and avoid eating the morning of the test
5. Stop smoking 10 days before the stress test

PREFERRED RESPONSE ▶

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