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Medicine Well-structured answers for better
scores.
What causes stable angina? - Answer Fixed atherosclerotic lesions in the coronary aa
What is the worst risk factor for stable angina? - Answer Diabetes mellitus
What is the goal of LDL in a patient with CAD? - Answer <100 mg/dL
How long does the pain of stable angina typically last? - Answer 1-5 minutes, <10-15min
total
Often gradual in onset
Brought on by emotion or exertion and relieved with rest an d nitroglycerin
No chest wall tenderness
Max heart rate equation - Answer 220-age
What are ECG changes seen in a positive stress test? - Answer ST segment depression
Also positive if the patient develops chest pain, hypotension, significant arrhythmias
Metabolic Syndrome X - Answer Any combination of hypercholesterolemia,
hypertriglyceridemia, impaired glucose tolerance, diabetes, hyperuricemia, HTN
Key underlying factor is insulin resistance
Syndrome X - Answer Exertional angina with normal coronary arteriogram. Patients have
chest pain after exertion but no coronary stenosis at cardiac cath.
Exercise testing and nuclear imaging show evidence of myocardial ischemia.
Excellent prognosis
Chemicals used in chemical stress test - Answer Adenosine and dipyrdiamole cause
coronary vasodilation. Diseased coronary aa are already maximally dilated so they will receive
less blood flow with the entire system is vasodilated.
Dobutamine increases myocardial oxygen demand by increasing HR, BP and cardiac
contractility
What is the definitive test for CAD? - Answer Coronary angiography
Stenosis >70% may be significant
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Standard of care for stable angina - Answer ASA and beta-blocker (both reduce mortality)
and nitrates for chest pain
Beta-blockers: atenolol and metoprolol
CCBs can be used with beta blockers +/- nitrates are not effective. No effect on mortality. Cause
coronary vasodilation, afterload reduction and reduces contractility.
If CHF is present, rx with ACEi +/- diuretics
Types of revascularization in high-risk CAD - Answer Note they do not reduce the
incidence of MI but will improve symptoms.
1. PCI (angioplasty): balloon and stenting. Best if used in proximal lesions. Restenosis is a
significant problem within first 6mo.
2. CABG: used in three vessel disease with >70% stenosis in each vessel, left main coronary
disease with >50% stenosis, and left ventricular dysfunction
COURAGE trial - Answer No difference in all cause mortality and nonfatal MIs between
patients with stable angina treated with maximal medical therapy alone vs. medical therapy with
PCI and bare metal stenting
Acute coronary syndrome - Answer Refers to USA, NSTEMI or STEMI. Results from
plaque rupture and coronary occlusion.
Unstable angina - Answer Oxygen demand is unchanged but the supply is decreased
secondary to reduced resting coronary flow.
USA vs. NSTEMI - Answer Based on cardiac enzymes only. NSTEMI has elevated
troponin or CK-MB.
Both lack ST segment elevations and pathologic Q waves on ECG.
Treatment for USA - Answer Oxygen, cts cardiac monitoring, nitrates and morphine for
pain control. Treat as an MI but no fibrinolysis.
ASA, clopidgrel, beta-blockers, LMWH, nitrates, electrolyte replacement
CURE trial - Answer Showed clopidogrel reduces incidence of MI in patients with USA
compared to ASA alone
Patients should be treated with ASA and clopidogrel for 9-12mo
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ESSENCE trial - Answer Showed that in USA and NSTEMI, risk of death, MI or
recurrent angina was lower in the enoxaprin group than in the heparin group and the need for
revascularization is lower in the enoxaparin group.
Give for at least 2 days.
TIMI risk score - Answer Used to guide conservative vs aggressive treatment in USA
CARE trial - Answer Patients with prior history of MI were given statin or placebo. Statin
group was reduced risk of death, reduced risk of stroke and reduction in need for CABG or
angioplasty.
Give statin regardless of LDL level.
Variant angina - Answer Transient coronary vasospasm that occurs at rest and is
associated with ventricular dysrhythmias. Classically occurs ta night.
ECG: transient ST elevation
Definitive test is angiography that shows vasospasm with given IV ergonovine or acetylcholine
Treat with vasodilators
Presentation of right ventricular infarct - Answer Inferior ECG changes
Hypotension, elevated JVP, hepatomegaly and clear lungs.
Preload dependent so do not give nitrates or diuretics or the CV system will collapse
ECG changes in anterior infarct - Answer ST elevation in V1-V4
Q waves in leads V1-V4
Posterior infarct ECG changes - Answer Large R wave in V1 and V2
ST depression in V1 and V2
Upright and prominent T waves in V1 and V2
Lateral infarct ECG changes - Answer Q waves in leads I and aVL (late change)
Inferior infarct ECG changes - Answer Q waves in leads II, III, aVF
What does ST segment depression indicate? - Answer Subendocardial injury
What does ST segment elevation indicate? - Answer Transmural injury
What are the only medications shown to reduce mortality in MI? - Answer Beta blockers,
ACEi, ASA
Troponins - Answer I&T
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Most important test to order in MI
Increases within 3-5 hrs, peaks at 24-48hr, back to normal in 5-14d
Obtain every 8hrs for 24hrs
Troponin I can be falsely elevated in patients with renal failure
CK-MB - Answer Increases within 4-8hr, peaks at 24, normal in 48-72hr.
Most helpful in detecting a recurrent infarction.
PROVE IT-TIMI 22 trial - Answer Start atorvastatin 80mg over other statins before
discharging a STEMI patient
CAPRICORN trial - Answer Beta blocker Carvedilol reduces risk of death in patients with
post-MI LV dysfunction
PAMI trial - Answer PTCA reduces mortality more than t-PA in a STEMI
Time from door to balloon should be <90 minutes
Which thrombolytic drug has the best outcomes in STEMIs? - Answer Alteplase but it is
very expensive
Alternatives include streptokinase, tenecteplase, reteplase, urokinas and lanoteplase
Contraindications to thrombolytic therapy: recent head trauma or CPR, previous stroke, recent
invasive procedure or surgery, dissecting AA, active bleeding or bleeding diathesis
What it the most common cause of in-hospital mortality? - Answer Pump failure - CHF
If mild: rx with ACEi or diuretic.
If severe it may lead to cardiogenic shock
Most common cause of death in first few days after MI? - Answer VT or Vfib
Free wall rupture - Answer Usually occurs during first 2 weeks after MI
90% mortality rate
Usually leads to tamponade and hemiperiardium
When after an MI does rupture of IV septum occur? - Answer 10 days after MI
Papillary muscle rupture - Answer Produces MR so the patient will present with a new
murmur
