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A 45-year-old mildly overweight smoker presents with occasional episodes of nocturnal


substernal chest pain that wakes her up from sleep. The episodes last 15-20 minutes
and resolve spontaneously. She denies any illicit drug use. She leads a sedentary
lifestyle but states that she can climb two flights of stairs without any discomfort. Her
pulse is 78/min and regular, blood pressure is 130170 mmHg and respirations are
13/min. Auscultation of her heart and lungs is unremarkable. Extended ambulatory ECG
monitoring reveals transient ST segment elevations in leads V4-V6 during the pain
attack. The pathophysiology of this patient's condition is most similar to that of which of
the following?

0 A. Lacunar stroke
0 B. Intermittent claudication
0 C. Abdominal aortic aneurysm
0 D. Raynaud phenomenon
0 E. Pulmonary embolism

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Q. ld : 2722 Previous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 45-year-old mildly overweight smoker presents with occasional episodes of nocturnal


substernal chest pain that wakes her up from sleep. The episodes last 15-20 minutes
and resolve spontaneously. She denies any illicit drug use. She leads a sedentary
lifestyle but states that she can climb two flights of stairs without any discomfort. Her
pulse is 78/min and regular, blood pressure is 130/70 mmHg and respirations are
13/min. Auscultation of her heart and lungs is unremarkable. Extended ambulatory ECG
monitoring reveals transient ST segment elevations in leads V4-V6 during the pain
attack. The pathophysiology of this patient's condition is most similar to that of which of
the following?

A. Lacunar stroke [2%]


B. Intermittent claudication (32%)
C. Abdominal aortic aneurysm (2%)
D. Raynaud phenomenon (62%)
E. Pulmonary embolism [2%)

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Ex planat io n: User

This patient has variant angina, also known as Prinzmetal's angina. It is caused by
temporary spasm of the coronary arteries, as opposed to atherosclerotic narrowing which
is seen in myocardial infarction. Young women are classically affected, and the greatest
risk factor for variant angina is smoking. Aside from smoking, there is often an absence
of cardiovascular risk factors. Variant angina is associated with other vasospastic
disorders, such as Raynaud's phenomenon and migraine headaches. The episodes
often occur in the middle of the night (midnight to 8 am) and are precipitated by exercise,
hyperventilation, emotional stress, cold exposure or cocaine use. The angina episodes
are accompanied by transient ST elevations with return of ST segments to baseline upon
resolution of symptoms. This is in contrast to the ST depressions seen in unstable
angina, and the longer duration of ST elevations seen in myocardial infarction. Medical
therapy for variant angina typically involves calcium channel blockers or nitrates.

(Choice A) Lacunar strokes occur in the setting of hypertension, and affect small,
penetrating arteries which supply the basal ganglia, subcortical white matter, and pons.
Occlusion of these small arteries by microatheroma and lipohyalinosis is the mechanism
of lacunar stroke -not vasospasm.

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C. Abdominal aortic aneurysm [2%)


D. Raynaud phenomenon [62%)
E. Pulmonary embolism [2%)

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Explanation: User ld

This patient has variant angina, also known as Prinzmetal's angina. It is caused by
temporary spasm of the coronary arteries, as opposed to atherosclerotic narrowing which
is seen in myocardial infarction. Young women are classically affected, and the greatest
risk factor for variant angina is smoking. Aside from smoking, there is often an absence
of cardiovascular risk factors. Variant angina is associated with other vasospastic
disorders, such as Raynaud's phenomenon and migraine headaches. The episodes
often occur in the middle of the night (midnight to 8 am) and are precipitated by exercise,
hyperventilation, emotional stress, cold exposure or cocaine use. The angina episodes
are accompanied by transient ST elevations with return of ST segments to baseline upon
resolution of symptoms. This is in contrast to the ST depressions seen in unstable
angina, and the longer duration of ST elevations seen in myocardial infarction. Medical
therapy for variant angina typically involves calcium channel blockers or nitrates.

(Choice A) Lacunar strokes occur in the setting of hypertension, and affect small,
penetrating arteries which supply the basal ganglia, subcortical white matter, and pons.
Occlusion of these small arteries by microatheroma and lipohyalinosis is the mechanism
of lacunar stroke - not vasospasm.

(Choices B & C) Intermittent claudication is leg pain that occurs with exercise and is due
to atherosclerotic narrowing of the arteries feeding the leg. The mechanism is similar to
that of typical angina--not variant angina. Abdominal aortic aneurysms are also the result
of atherosclerotic disease.
(Choice E) The most common cause of pulmonary embolism is embolization of blood
clots from the deep veins of the lower extremities. Variant angina does not involve
embolic phenomena.

Educational objective:
Variant Angina (or Prinzmetal's angina) is a vasospastic disorder that typically occurs in
young female smokers. Chest pain usually occurs in the middle of the night, and
episodes are associated with transient ST elevations on ECG.

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Item ~?Mark <? [> ai ~ ~ , GJIIA)
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A 47-year-old Caucasian female presents with occasional episodes of nocturnal


substernal chest pain that wakes her up during sleep. The pain episodes last 15-20
minutes and resolve spontaneously. She denies any illicit drug use. She leads a
sedentary lifestyle but states that she can climb two flights of stairs without any
discomfort. She has no history of hypertension or diabetes. Her pulse is 75/min and
regular, blood pressure is 134/70 mmHg and respirations are 14/min. Extended
ambulatory ECG monitoring reveals transient ST segment elevation in leads I, aVL, and
V4-V6 during the episodes. Which of the following is the best treatment for this patient?

o A. Diltiazem
o B. Propranolol
o C. Aspirin
o D. Ezetimibe
o E. Digoxin
o F. Simvastatin
o G. Heparin
o H. Streptokinase

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0. ld: 2723 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 47-year-old Caucasian female presents with occasional episodes of nocturnal


substernal chest pain that wakes her up during sleep. The pain episodes last 15-20
minutes and resolve spontaneously. She denies any illicit drug use. She leads a
sedentary lifestyle but states that she can climb two flights of stairs without any
discomfort. She has no history of hypertension or diabetes. Her pulse is 75/min and
regular, blood pressure is 134/70 mmHg and respirations are 14/min. Extended
ambulatory ECG monitoring reveals transient ST segment elevation in leads I, aVL, and
V4-V6 during the episodes. Which of the following is the best treatment for this patient?

A. Diltiazem [52%)
B. Propranolol [1 5%]
C. Aspirin [26%)
D. Ezetimibe [1%]
E. Digoxin [1%)
F. Simvastatin [2%)
G. Heparin [1%)
H. Streptokinase [1%]

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Explanation: User ld
This patient has variant angina (or Prinzmetal's angina), which causes chest pain by
coronary vasospasm. It typically occurs in young females, and the greatest risk factor for
variant angina is smoking. Aside from smoking, affected patients often lack
cardiovascular risk factors. The episodes characteristically occur at night (from midnight
to 8 am} and can be associated with transient ST elevations on ECG. The treatment of
this condition involves elimination of risk factors such as smoking, as well as
pharmacologic therapy with calcium channel blockers or nitrates. These medications
work in variant angina by promoting vasodilation and preventing vasoconstriction.
(Choice B) Nonselective p-Biockers such as propranolol should be avoided in variant
angina because p2 receptor inhibition can lead to worsened coronary vasospasm.
(Choice C) Aspirin should also be avoided. in variant angina because it causes
prostacyclin inhibition, which may promote coronary vasospasm.
Patients with variant
Explanation: User ld
This patient has variant angina (or Prinzmetal's angina), which causes chest pain by
coronary vasospasm. It typically occurs in young females, and the greatest risk factor for
variant angina is smoking. Aside from smoking, affected patients often lack
cardiovascular risk factors. The episodes characteristically occur at night (from midnight
to 8 am) and can be associated with transient ST elevations on ECG. The treatment of
this condition involves elimination of risk factors such as smoking, as well as
pharmacologic therapy with calcium channel blockers or nitrates. These medications
work in variant angina by promoting vasodilation and preventing vasoconstriction.

(Choice B) Nonselective 13-Biockers such as propranolol should be avoided in variant


angina because 132 receptor inhibition can lead to worsened coronary vasospasm.
(Choice C) Aspirin should also be avoided in variant angina because it causes
prostacyclin inhibition, which may promote coronary vasospasm.
(Choices 0 & F) Patients with variant angina often lack cardiovascular risk factors such
as hypercholesterolemia. In the absence of lipid abnormalities, variant angina
management does not entail cholesterol lowering medications. If this patient's lipids were
found to be abnormal on a screening test, then lipid-lowering medications could be
considered.
(Choice E) Digoxin is typically used to increase contractility in patients with congestive
heart failure or as a rate control agent in patients with atrial fibrillation or flutter, none of
which are a problem for this patient.
(Choice G) Heparin is an anticoagulant. Vasospasm - and not the coagulation cascade -
is the cause of variant angina. Heparin plays no role in the management of
uncomplicated variant angina.
(Choice H) Streptokinase is used for thrombolysis in the treatment of a STEMI if
percutaneous coronary intervention is not rapidly available. However, this patient's
presentation is more consistent with variant angina than myocardial infarction.
Educational objective:
Pharmacologic management of variant angina involves calcium channel blockers and/or
nitrates to prevent coronary vasoconstriction. Nonselective 13-Biockers and aspirin
should be avoided because they can promote vasoconstriction.

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Item ~?Mark <? [> ai ~ ~ , GJIIA)
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A 43-year-old man comes to the office due to frequent epigastric burning not relieved by
antacids for the past 4 months. The sensation is typically brought on by heavy lifting at
work and takes 10-15 minutes to go away. The patient has had no associated arm or
neck pain, cough, shortness of breath, or difficulty swallowing. His medical history is
significant for systemic lupus erythematosus diagnosed 5 years ago, for which he takes
low-dose prednisone and hydroxychloroquine. He is a lifetime nonsmoker. A year ago,
the patient's wife was diagnosed with peptic ulcer disease that required treatment with
antibiotics. On physical examination, blood pressure is 140/90 mm Hg and pulse is
80/min and regular. Breath sounds are equal on both sides. No wheezes or crackles are
heard. First and second heart sounds are present. No heart murmurs or rubs are noted.
The abdomen is soft and nontender to deep palpation. There is no skin rash or
peripheral edema. ECG is normal. Which of the following is the best next step in
management of this patient?

0 A. Abdominal CT scan with/without contrast


0 B. Abdominal ultrasound
0 C. Chest CT scan without contrast
0 D. Coronary angiography
0 E. Echocardiogram
0 F. Esophageal motility studies
0 G. Exercise ECG
0 H. Stool He/icobacter pylori antigen testing
0 I. Upper gastrointestinal endoscopy

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A 43-year-old man comes to the office due to frequent epigastric burning not relieved by
antacids for the past 4 months. The sensation is typically brought on by heavy lifting at
work and takes 10-15 minutes to go away. The patient has had no associated arm or
neck pain, cough, shortness of breath, or difficulty swallowing. His medical history is
significant for systemic lupus erythematosus diagnosed 5 years ago, for which he takes
low-dose prednisone and hydroxychloroquine. He is a lifetime nonsmoker. A year ago,
the patient's wife was diagnosed with peptic ulcer disease that required treatment with
antibiotics. On physical examination, blood pressure is 140/90 mm Hg and pulse is
80/min and regular. Breath sounds are equal on both sides. No wheezes or crackles are
heard. First and second heart sounds are present. No heart murmurs or rubs are noted.
The abdomen is soft and nontender to deep palpation. There is no skin rash or
peripheral edema. ECG is normal. Which of the following is the best next step in
management of this patient?

A. Abdominal CT scan with/without contrast [3%)


B. Abdominal ultrasound [2%)
C. Chest CT scan without contrast [2%]
D. Coronary angiography [1 %)
E. Echocardiogram [4%]
F. Esophageal motility studies [5%]
G. Exercise ECG [56%]
H. Stool Helicobacter pylori antigen testing [1 4%]
I. Upper gastrointestinal endoscopy [1 3%]

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Explanation: User ld

Classification of angina

Typical location (eg, substernal), quality (eg, pressure)


& duration (eg, >20 min)
Classic
Provoked by exercise/emotional upheaval
Relieved with nitroglycerin or rest

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H. Stool He/icobacter pylori antigen testing [1 4%)


I. Upper gastrointestinal endoscopy [1 3%)

- .. '
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Explanation: User ld

Classificat ion of angina

Typical location (eg, substernal), quality (eg, pressure)


& duration (eg, >20 min)
Classic
Provoked by exercise/emotional upheaval
Relieved with nitroglycerin or rest

Atypical 2 of 3 classic angina characteristics

Non-anginal 0 or 1 of 3 classic angina characteristics


UWorld

This patient's clinical presentation - epigastric burning provoked by exertion (heavy


lifting) and relieved over several minutes by rest - is concerning for atypical angina
(given the lack of typical chest discomfort). Systemic lupus erythematosus is a known
risk factor for accelerated atherosclerosis and premature coronary heart disease.
Myocardial ischemia in patients with stable angina occurs when myocardial oxygen
demand exceeds oxygen supply. Symptoms typically have gradual onset with exertion
and are relieved with rest or termination of the provoking activity. Exercise ECG is
recommended as an initial stress test for diagnosis and risk stratification of most patients
with suspected stable ischemic heart disease.
Coronary angiography is performed in patients with high-risk findings on initial stress
testing. It is also indicated in patients with high pretest probability of ischemic heart
disease (Choice 0). Exercise stress echocardiogram is occasionally used for the
diagnosis of ischemic heart disease as it may show changes associated with ischemia on
exertion; however, a resting echocardiogram alone may be unremarkable (Choice E).
(Choices A and B) This patient has a normal abdominal examination and no symptoms
suggesting any acute abdominal pathology. Further imaging with abdominal CT scan or

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
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Myocardial ischemia in patients with stable angina occurs when myocardial oxygen
demand exceeds oxygen supply. Symptoms typically have gradual onset with exertion
and are relieved with rest or termination of the provoking activity. Exercise ECG is
recommended as an initial stress test for diagnosis and risk stratification of most patients
with suspected stable ischemic heart disease.

Coronary angiography is performed in patients with high-risk findings on initial stress


testing. It is also indicated in patients with high pretest probability of ischemic heart
disease (Choice 0). Exercise stress echocardiogram is occasionally used for the
diagnosis of ischemic heart disease as it may show changes associated with ischemia on
exertion; however, a resting echocardiogram alone may be unremarkable (Choice E).

(Choices A and B) This patient has a normal abdominal examination and no symptoms
suggesting any acute abdominal pathology. Further imaging with abdominal CT scan or
ultrasound is not indicated.

(Choice C) There are no symptoms or signs of pulmonary or thoracic pathology (cough,


hemoptysis, dyspnea); therefore, chest CT imaging is not indicated.

(Choices F, H, and I) The presence of epigastric discomfort on exertion that is not


relieved by antacids is concerning for cardiac pathology. Evaluation for possible
gastrointestinal etiology (eg, peptic ulcer disease, esophageal motility disorders) should
be considered in patients with no evidence of myocardial ischemia on initial evaluation.

Educational objective:
Exercise stress ECG is recommended as an initial test for diagnosis and risk stratification
in most patients with suspected stable ischemic heart disease.

References:
1. 2012 ACCF/AHAIACP/AA TS/PCNAISCAIISTS guideline for the diagnosis
and management of patients with stable ischemic heart disease: a
report of the American College of Cardiology Foundation/American
Heart Association task force on practice guidelines, and the American
College of Physicians, American Association for Thoracic Surgery,
Preventive Cardiovascular Nurses Association, Society for
Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons.
2. Diagnostic indicators of non-cardiovascular chest pain: a systematic
review and meta-analysis.

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Media Exhibit

probability of coronary artery disease

Pretest probability of coronary artery disease

Low Asymptomatic people of all ages


(<10%) Atypical chest pain in women age <50

Atypical angina in men of all ages


Intermediate
(20%-80%) Atypical angina in women age >50
Typical angina in women age 30-50

High Typical angina in men age >40


(>90%) Typical angina in women age >60

~UWolid

~nary artery disease - -- Ill 0


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Item ~?Mark <? [> ai ~ ~ , GJIIA)
0. ld: 3945 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

A 60-year-old man comes to the office for evaluation of a 6-month history of intermittent
chest pain. He describes substernal tightness and pain that occur when he walks quickly
or climbs stairs. The symptoms last about 10 minutes and slowly fade away with rest.
These episodes do not happen at rest. The patient has a known history of coronary
artery disease with coronary artery bypass grafting surgery 7 years ago. Other medical
problems include hypertension and hyperlipidemia. Blood pressure is 140/78 mm Hg and
pulse is 78/min and regular. There are no murmurs on cardiac auscultation. Lungs are
clear bilaterally. Treadmill stress test is performed. Seven minutes into the test, the
patient develops chest pain and the treadmill is stopped. Sublingual nitroglycerin is
administered, which almost immediately relieves the patient's pain. What is the
predominant mechanism responsible for the rapid pain relief in this patient?

0 A. Coronary vasodilation
0 B. Decreased left ventricular contractility
0 C. Decreased left ventricular wall stress
0 D. Dilation of small arteries
0 E. Negative chronotropic effect

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A 60-year-old man comes to the office for evaluation of a 6-month history of intermittent
chest pain. He describes substernal tightness and pain that occur when he walks quickly
or climbs stairs. The symptoms last about 10 minutes and slowly fade away with rest.
These episodes do not happen at rest. The patient has a known history of coronary
artery disease with coronary artery bypass grafting surgery 7 years ago. Other medical
problems include hypertension and hyperlipidemia. Blood pressure is 140/78 mm Hg and
pulse is 78/min and regular. There are no murmurs on cardiac auscultation. Lungs are
clear bilaterally. Treadmill stress test is performed. Seven minutes into the test, the
patient develops chest pain and the treadmill is stopped. Sublingual nitroglycerin is
administered, which almost immediately relieves the patient's pain. What is the
predominant mechanism responsible for the rapid pain relief in this patient?

A. Coronary vasodilation [43%)


B. Decreased left ventricular contractility [4%)
., C. Decreased left ventricular wall stress [46%)
D. Dilation of small arteries [6%)
.J E. Negative chronotropic effect [1%)

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Explanation: User ld
This patient with coronary artery disease has a classic presentation of chronic stable
angina (exertional chest pain relieved by rest), with rapid relief of his symptoms following
the administration of sublingual nitroglycerin. Nitrates exert their effect by direct
vascular smooth muscle relaxation causing systemic venodilation and an increase in
peripheral venous capacitance. Their primary anti-ischemic effect is mediated by
systemic vasodilation and decrease in cardiac preload resulting in a decrease in left
ventricular end-diastolic and end-systolic volume. This, in turn, leads to a reduction in
left ventricular systolic wall stress - which reflects afterload and is proportional to
(pressure radius I thickness) - and a decrease in myocardial oxygen demand,
resulting in relief of anginal symptoms.
Although nitrates act as coronary vasodilators (via direct relaxation of coronary vascular
smooth muscle cells), the beneficial effect of this mechanism is uncertain (Choice A).
The coronary arterioles in the area of flow-limiting coronary stenosis are already dilated
by innate mechanisms, allowing maintenance of resting blood flow across the stenotic
lesion. Nitrate-induced coronary vasodilation paradoxically decreases coronary

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Item ~\='Mark <? [> at ~ ~ , GJIIA)
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Explanation: User ld
This patient with coronary artery disease has a classic presentation of chronic stable
angina (exertional chest pain relieved by rest), with rapid relief of his symptoms following
the administration of sublingual nitroglycerin. Nitrates exert their effect by direct
vascular smooth muscle relaxation causing systemic venodilation and an increase in
peripheral venous capacitance. Their primary anti-ischemic effect is mediated by
systemic vasodilation and decrease in cardiac preload resulting in a decrease in left
ventricular end-diastolic and end-systolic volume. This, in turn, leads to a reduction in
left ventricular systolic wall stress - which reflects afterload and is proportional to
(pressure radius I thickness)- and a decrease in myocardial oxygen demand,
resulting in relief of anginal symptoms.
Although nitrates act as coronary vasodilators (via direct relaxation of coronary vascular
smooth muscle cells), the beneficial effect of this mechanism is uncertain (Choice A).
The coronary arterioles in the area of flow-limiting coronary stenosis are already dilated
by innate mechanisms, allowing maintenance of resting blood flow across the stenotic
lesion. Nitrate-induced coronary vasodilation paradoxically decreases coronary
perfusion pressure across the stenotic lesion by diverting blood flow to arterioles
supplying the normal myocardium.
(Choices e and E) Beta blockers and calcium channel blockers exert an antianginal
effect partially via a decrease in the heart rate (negative chronotropic effect) or
contractility (negative inotropic effect). Nitrates do not have a direct effect on cardiac
chronotropy; they may cause decreased inotropy due to decreased preload, but their
antianginal effect is thought to be due primarily to a reduction in wall stress.
(Choice 0) At low doses (such as those used in sublingual nitroglycerin preparations),
nitrates have only a modest effect on arterial and arteriolar dilation and cause minimal or
no change in systemic vascular resistance. Higher doses can lead to a drop in systemic
blood pressure.
Educational objective:
Sublingual nitroglycerin is used as a first-line agent for rapid relief of symptoms in
patients with angina pectoris. The antiischemic effect of nitrates is mediated by systemic
vasodilation with a decrease in left ventricular end-diastolic volume and wall stress
resulting in decreased myocardial oxygen demand.

References:
1. Mechanisms of action of nitrates.

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A 65-year-old male presents to your office with a six-month history of periodic substernal
pain. The pain episodes are experienced during strong emotion, last for 10-15 minutes,
and resolve spontaneously. He has a long history of hypertension and diabetes mellitus,
type 2. His right foot was amputated two years ago due to diabetes-related
complications. You suspect angina pectoris and decide to perform myocardial perfusion
scanning. It reveals uniform distribution of isotope at rest, but inhomogenesity of the
distribution after dipyridamole injection. You conclude that the patient has ischemic heart
disease. Which of the following effects of dipyridamole helped you in making the
diagnosis?

o A Increased heart contractility


o B. Coronary steal
0 C. Dilation of diseased vessels
o D. Inhibition of platelet aggregation
o E. Placebo effect

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A 65-year-old male presents to your office with a six-month history of periodic substernal
pain. The pain episodes are experienced during strong emotion, last for 10-15 minutes,
and resolve spontaneously. He has a long history of hypertension and diabetes mellitus,
type 2. His right foot was amputated two years ago due to diabetes-related
complications. You suspect angina pectoris and decide to perform myocardial perfusion
scanning. It reveals uniform distribution of isotope at rest, but inhomogenesity of the
distribution after dipyridamole injection. You conclude that the patient has ischemic heart
disease. Which of the following effects of dipyridamole helped you in making the
diagnosis?

A. Increased heart contractility (31 %1


B. Coronary steal [48%1
C. Dilation of diseased vessels [16%1
D. Inhibition of platelet aggregation (5%1
E. Placebo effect (1%1

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Explanation : User ld

The history is suggestive of angina pectoris in this patient (episodes of substernal pain
provoked by emotion). Exercise testing is not possible, because this patient's activity is
limited by amputation. Myocardial perfusion scanning can be employed instead using
dipyridamole to reveal the areas of restricted myocardial perfusion. Dipyridamole and
adenosine are coronary vasodilators. Infusion of these substances in patients without
coronary artery disease, increases coronary blood flow three to five times above the
baseline levels. However, In patients with coronary artery disease, the diseased vessels
distal to the obstruction are already maximally dilated (Choice C), and their ability to
increase myocardial perfusion is limited; therefore, redistribution of coronary blood flow to
'non-diseased' areas occurs, and the perfusion of 'diseased' segments diminishes. This
phenomenon demonstrated by dipyridamole is called coronary steal and is used to
diagnose ischemic heart disease.

Dipyridamole is a potent antiplatelet aggregate (Choice 0), but this property is not
employed to assist in diagnosis. Increased cardiac contractility (Choice A) can occur as
the result of vasodilatation, but it is a secondary phenomenon. Placebo effect (Choice
E) is irrelevant in this case.

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scanning. It reveals uniform distribution of isotope at rest, but inhomogenesity of the
distribution after dipyridamole injection. You conclude that the patient has ischemic heart
disease. Which of the following effects of dipyridamole helped you in making the
diagnosis?

A. Increased heart contractility (31 %]


B. Coronary steal [48%]
C. Dilation of diseased vessels (16%]
D. Inhibition of platelet aggregation (5%]
E. Placebo effect [1%]

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Explanation : User ld

The history is suggestive of angina pectoris in this patient (episodes of substernal pain
provoked by emotion). Exercise testing is not possible, because this patient's activity is
limited by amputation. Myocardial perfusion scanning can be employed instead using
dipyridamole to reveal the areas of restricted myocardial perfusion. Dipyridamole and
adenosine are coronary vasodilators. Infusion of these substances in patients without
coronary artery disease, increases coronary blood flow three to five times above the
baseline levels. However, in patients with coronary artery disease, the diseased vessels
distal to the obstruction are already maximally dilated (Choice C), and their ability to
increase myocardial perfusion is limited; therefore, redistribution of coronary blood flow to
'non-diseased' areas occurs, and the perfusion of 'diseased' segments diminishes. This
phenomenon demonstrated by dipyridamole is called coronary steal and is used to
diagnose ischemic heart disease.

Dipyridamole is a potent antiplatelet aggregate (Choice 0), but this property is not
employed to assist in diagnosis. Increased cardiac contractility (Choice A) can occur as
the result of vasodilatation, but it is a secondary phenomenon. Placebo effect (Choice
E) is irrelevant in this case.

Educational Objective:
Dipyridamole can be used during myocardial perfusion scanning to reveal the areas of
restricted myocardial perfusion. The redistribution of the coronary blood flow to
'non-diseased' segments induced by this drug is called coronary steal phenomenon.

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A 55-year-old man comes to the physician with a 6-month history of periodic substernal
chest pressure. He experiences this pressure while walking uphill or climbing 2 flights of
stairs. His past medical history is significant for hyperlipidemia and his medications
include a statin. He smokes 1 pack a day and consumes alcohol occasionally. His blood
pressure is 142/88 mm Hg and pulse is 75/min. Resting electrocardiogram is normal.
Treadmill stress test shows horizontal ST-segment depression in leads II, Ill, and aVF at
73% of maximally predicted heart rate. Exercise echocardiography demonstrates normal
resting left ventricular systolic function with inferior wall hypokinesis at peak exercise. In
addition to low-dose aspirin and sublingual nitroglycerin as needed, which of the
following is th e best initial therapy to treat this patient's current condition?

0 A. Amlodipine
0 B. Chlorthalidone
0 C. lsosorbide dinitrate
0 D. Lisinopril
0 E. Metoprolol
0 F. Ranolazine

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A 55-year-old man comes to the physician with a 6-month history of periodic substernal
chest pressure. He experiences this pressure while w alking uphill or climbing 2 flights of
stairs. His past medical history is significant for hyperlipidemia and his medications
include a statin. He smokes 1 pack a day and consumes alcohol occasionally. His blood
pressure is 142/88 mm Hg and pulse is 75/min. Resting electrocardiogram is normal.
Treadmill stress test shows horizontal ST-segment depression in leads II, Ill, and aVF at
73% of maximally predicted heart rate. Exercise echocardiography demonstrates normal
resting left ventricular systolic function with inferior wall hypokinesis at peak exercise. In
addition to low-dose aspirin and sublingual nitroglycerin as needed, which of the
following is the best initial therapy to treat this patient's current condition?

A. Amlodipine (3%)
B. Chlorthalidone [2%]
C. lsosorbide dinitrate [5%)
D. Usinopril (26%)
E. Metoprolol (63%]
F. Ranolazine (1 %]

Proceed to Next Item

Explanation: User

Treatment for stable chronic angina

Beta blocker
1st-line therapy for anginal symptoms, improves exercise tolerance
Relieves angina by decreasing myocardial contractility & heart rate
Improves survival in those with myocardial infarction

Calcium channel blocker


Antianginal
Can combine with beta blocker if angina persists or as alternate therapy
Improves angina by causing peripheral & coronary vasodilation

Nitrates
Short-acting form is used in the acute setting
... -- . .. . .. . . .. . . .. .... .
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Explanation : User ld

Treatm ent for stab le ch ronic angina

Beta blocker
1st-line therapy for anginal symptoms, improves exercise tolerance
Relieves angina by decreasing myocardial contract ility & heart rate
Improves survival in t hose with myocardial infarct ion

Calcium channel blocker


Antianginal
Can combine with beta blocker if angina persists or as alternate t herapy
Improves angina by causing peripheral & coronary vasodilation

Nitrates
Short-act ing form is used in the acute setting
Long-acting form is an add-on therapy for persistent angina

Aspirin
Statin
Preventive Smoking cessation
Regular exercise & weight loss
Control of blood pressure & diabetes

> USMUW>old. UC

This patient has coronary artery disease with symptoms and clinical findings suggesting
stable angina pectoris. Stable angina is described as chest discomfort occurring
predictably with exertion or activity and relieved with rest. The 3 main classes of
antianginal drugs for treating stable angina pectoris include beta blockers, calcium
channel blockers, and nitrates.

Beta blockers are recommended as fi rst-line therapy for controlling anginal symptoms
and improving exercise tolerance in stable angina pectoris. They reduce myocardial
oxygen demand by decreasing heart rate and myocardial contractility. Beta blockers
should be avoided in patients with hypotension or bradycardia. Because this patient has
no contraindication to beta blockers, these drugs should be the next step in management.

Feedback EnQ ock


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(!) USMLEWorld.LlC

This patient has coronary artery disease with symptoms and clinical findings suggesting
stable angina pectoris. Stable angina is described as chest discomfort occurring
predictably with exertion or activity and relieved with rest. The 3 main classes of
antianginal drugs for treating stable angina pectoris include beta blockers, calcium
channel blockers, and nitrates.

Beta blockers are recommended as first-line therapy for controlling anginal symptoms
and improving exercise tolerance in stable angina pectoris. They reduce myocardial
oxygen demand by decreasing heart rate and myocardial contractility. Beta blockers
should be avoided in patients with hypotension or bradycardia. Because this patient has
no contraindication to beta blockers, these drugs should be the next step in management.

(Choices A and C) Short-acting nitrates are indicated for acute angina. Long-acting
nitrates (eg, isosorbide dinitrate, isosorbide mononitrate) or calcium channel blockers
(eg, diltiazem, felodipine) are used for chronic stable angina patients with
contraindications to beta blockers or inability to tolerate their side effects. They can also
be used in combination with beta blockers if initial therapy with beta blockers alone is not
effective.

(Choice B) Thiazide diuretics (chlorthalidone, hydrochlorothiazide) are an effective Initial


therapy for patients with essential hypertension. They are not effective for Improving or
reducing angina pectoris.

(Choice 0 ) Angiotensin-converting enzyme Inhibitors (eg, lisinopril) are used for


hypertension, especially In patients with diabetes, chronic kidney disease, and
congestive heart failure with reduced left ventricular systolic function. There is no
evidence that they reduce symptoms or improve outcomes in stable angina pectoris.

(Choice F) Ranolazine is a late sodium channel blocker used occasionally in stable


angina patients with recurrent symptoms who are taking a combination of beta blockers,
calcium channel blockers, or nitrates. It is not recommended as initial therapy for stable
angina pectoris.

Educational objective:
Beta blockers are recommended as first-line th erapy for controlling symptoms and
improving exercise tolerance in patients with stable angina pectoris. Calcium chann el
blockers or long- acting nitrates are used if beta blockers are contraindicated, poorly
tolerated due to significant side effects, and/or in combination wit h beta blockers when
initial therapy with beta blockers alone is not effective.

References:
.. .... --- -----

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Beta blockers are recommended as first-line therapy for controlling anginal symptoms
and improving exercise tolerance in stable angina pectoris. They reduce myocardial
oxygen demand by decreasing heart rate and myocardial contractility. Beta blockers
should be avoided in patients with hypotension or bradycardia. Because this patient has
no contraindication to beta blockers, these drugs should be the next step in management.

(Choices A and C) Short-acting nitrates are indicated for acut e angina. Long-acting
nitrates (eg, isosorbide dinitrate, isosorbide mononitrate) or calcium channel blockers
(eg, diltiazem, felodipine) are used for chronic stable angina patients with
contraindications to beta blockers or inability to tolerate their side effects. They can also
be used in combination with beta blockers if initial therapy with beta blockers alone is not
effective.

(Choice B) Thiazide diuretics (chlorthalidone, hydrochlorothiazide) are an effective initial


therapy for patients with essential hypertension. They are not effective for improving or
reducing angina pectoris.

(Choice D) Angiotensin-converting enzyme inhibitors (eg, lisinopril) are used for


hypertension, especially In patients with diabetes, chronic kidney disease, and
congestive heart failure with reduced left ventricular systolic function. There is no
evidence that they reduce symptoms or improve outcomes in stable angina pectoris.

(Choice F) Ranolazine is a late sodium channel blocker used occasionally in stable


angina patients with recurrent symptoms who are taking a combination of beta blockers,
calcium channel blockers, or nitrates. It is not recommended as initial therapy for stable
angina pectoris.

Educational objective:
Beta blockers are recommended as first-line therapy for controlling symptoms and
improving exercise tolerance in patients with stable angina pectoris. Calcium channel
blockers or long- acting nitrates are used if beta blockers are contraindicated, poorly
tolerated due to significant side effects, and/or in combination with beta blockers when
initial therapy with beta blockers alone is not effective.

References:
1. Treatment of stable angina pectoris.
2. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAUSTS guideline for the diagnosis
and management of patients with stable ischemic heart disease :
executive summary.

Time Spent: 2 seconds Copyright UWorld Last updated: [11 /25/2016)

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A 58-year-old woman is evaluated for chest discomfort that occurs while climbing stairs
and walking uphill. She also complains of associated shortness of breath. She has no
known history of coronary artery disease or stroke. Her past medical history is significant
for anxiety disorder, hypertension, hyperlipidemia, type 2 diabetes mellitus, and acid
reflux disease. Her body mass index is 30 kg/m2 Baseline electrocardiogram shows
normal sinus rhythm. Chemistry panel shows normal electrolyte levels and creatinine of
1.1 mg/dL. An exercise (treadmill) stress test is scheduled to diagnose coronary artery
disease. Which of the following daily medications should be held 24-48 hours before the
test?

Long-acting
Metoprolol Ramipril Chlorthalidone Simvastatin
nifedipine

0 A Yes Yes No No No

0 B. Yes Yes Yes Yes No

0 C. Yes No No No No

0 D. No Yes Yes No No

0 E. No No Yes No Yes

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A 58-year-old woman Is evaluated for chest discomfort that occurs while climbing stairs
and walking uphill. She also complains of associated shortness of breath. She has no
known history of coronary artery disease or stroke. Her past medical history is significant
for anxiety disorder, hypertension, hyperlipidemia, type 2 diabetes mellitus, and acid
reflux disease. Her body mass index is 30 kg/m. Baseline electrocardiogram shows
normal sinus rhythm. Chemistry panel shows normal electrolyte levels and creatinine of
1.1 mg/dl. An exercise (treadmill) stress test is scheduled to diagnose coronary artery
disease. Which of the following daily medication s should be held 24-48 hours before the
test?

L ong-acting
Metoprolol Ramipril Chlorth alidone Simvastatin
nifedipine

A Yes Yes No No No (61%)

B. Yes Yes Yes Yes No (16%)

C. Yes No No No No [17%)

D. No Yes Yes No No [4%)

E. No No Yes No Yes [2%)

Proceed to Next Item

Explan at ion : User

Medications to wit hhold prior to car diac stress testing

Hold for 48 hours Beta blockers, calcium channel blockers, nitrates

Hold for 48 hours prior to


Dipyridamole
vasodilator stress test

Hold for 1 2 hours prior to


Caffeine-containing food or drinks
vasodilator stress test

Feedback EnQock
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Explanat ion : User ld

Medications to wit h hold prior to ca rdiac st ress t esting

Hold for 48 hours Beta blockers, calcium channel blockers, nitrates

Hold for 48 hours prior to


Dipyridamole
vasodilator st ress test

Hold for 12 hours prior to


Caffeine-containing food or drinks
vasodilator stress test

Angiotensin-converting enzyme inhibitors,


Cont inue angiotensin receptor blockers, digoxin, statins,
diuretics

Stress testing is an important modality for initial evaluation and diagnosis of patients with
symptoms suggesting coronary artery disease (CAD). Coronary angiography is
considered the gold standard for diagnosis, but it is invasive and expensive. Therefore, it
is not a suitable initial diagnostic test for those with low-to-intermediate pretest
probability of CAD. Stress testing (exercise or pharmacologic stress) can detect
underlying reversible ischemia or prior myocardial infarction through electrocardiogram
changes, perfusion defects, or wall-motion abnormalities.

A detailed medication and dietary history should be obtained prior to stress testing as a
variety of medications and dietary supplements can interfere with its accuracy (Table).
Beta blockers, calcium channel blockers, and nitrates are antianginal agents that reduce
the extent and severity of ischemia during exercise stress testing. These medications
should be withheld for at least 48 hours prior to stress testing (Choice C). However,
they should be continued in patients with known CAD undergoing stress testing to
assess the efficacy of antianginal therapy. The decision to withhold medications should
also be carefully tailored to the individual to minimize the risk of rebound hypertension or
arrhythmias.
Item lliJ?M k <J [> jj ~ l!lj , ~
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Hold for 12 hours prior to


Caffeine-containing food or drinks
vasodilator stress test

Angiotensin-converting enzyme inhibitors,


Continue angiotensin receptor blockers, digoxin, statins,
diuretics
) USMUWoo1d. uc

Stress testing is an important modality for initial evaluation and diagnosis of patients with
symptoms suggesting coronary artery disease (CAD). Coronary angiography is
considered the gold standard for diagnosis, but it is invasive and expensive. Therefore, it
is not a suitable initial diagnostic test for those with low-to-intermediate pretest
probability of CAD. Stress testing (exercise or pharmacologic stress) can detect
underlying reversible ischemia or prior myocardial infarction through electrocardiogram
changes, perfusion defects, or wall-motion abnormalities.

A detailed medication and dietary history should be obtained prior to stress testing as a
variety of medications and dietary supplements can interfere with its accuracy (Table).
Beta blockers, calcium channel blockers, and nitrates are antianginal agents that reduce
the extent and severity of Ischemia during exercise stress testing. These medications
should be withheld for at least 48 hours prior to stress testing (Choice C). However,
they should be continued in patients with known CAD undergoing stress testing to
assess the efficacy of antianglnal therapy. The decision to withhold medications should
also be carefully tailored to the individual to minimize the risk of rebound hypertension or
arrhythmias.

(Choice B) Diuretics do not directly affect the accuracy of stress testing. However,
diuretic- induced hypokalemia (potassium <3 mEq/L) can cause ST-segment depression
and false- positive results on exercise stress testing. Testing should be delayed until
potassium has been repleted in those patients.

(Choices 0 and E) Angiotensin-converting enzyme inhibitors, angiotensin receptor


blockers, and statins do not affect the diagnostic accuracy of stress testing for CAD.
These medications should not be withheld prior to stress testing.

Educational objective:
Beta blockers, calcium channel blockers, and nitrates are antianginal agents that should
be withheld for at least 48 hours prior to cardiac stress testing. However, these
medications should be continued in patients with known coronary artery disease
undergoing stress testing to assess the efficacy of antianginal therapy.

Time Spent: 2 seconds Copyright UWorld Last updated: (06/15/2016]

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Media Exhibit

probability of coronary artery disease

Pretest probability of coronary artery disease

Low Asymptomatic people of all ages


(<10%) Atypical chest pain in women age <50

Atypical angina in men of all ages


Intermediate
(20%-80%) Atypical angina in women age >50
Typical angina in women age 30-50

High Typical angina in men age >40


(>90%) Typical angina in women age >60

~UWolid
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A 34-year-old woman comes to the physician with a several-month history of chest pain.
The pain is left-sided, does not change with deep inspiration, and typically lasts several
hours. She currently has the pain; it is unrelated to physical activity but worsens with
emotional stress. The patient has no cough, syncope, or shortness of breath. She has
no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes
no medications and. has no drug allergies. Her blood pressure is 11 0/70 mm Hg and
pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation.
Electrocardiogram (ECG) shows normal sinus rhythm with no significant abnormalities.
Which of the following is the best next step in the management of this patient?

0 A. Exercise electrocardiogram testing


0 B. Exercise myocardial perfusion imaging
0 C. Lower-extremity venous ultrasonography
0 D. No further testing for coronary artery disease
0 E. Transthoracic echocardiography

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A 34-year-old woman comes to the physician with a several-month history of chest pain.
The pain is left-sided, does not change with deep inspiration, and typically lasts several
hours. She currently has the pain; it is unrelated to physical activity but worsens with
emotional stress. The patient has no cough, syncope, or shortness of breath. She has
no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes
no medications and has no drug allergies. Her blood pressure is 11 0/70 mm Hg and
pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation.
Electrocardiogram (ECG) shows normal sinus rhythm with no significant abnormalities.
Which of the following is the best next step in the management of this patient?

A Exercise electrocardiogram testing [21%]


B. Exercise myocardial perfusion imaging [5%]
C. Lower-extremity venous ultrasonography [1%]
D. No further testing for coronary artery disease [65%]
E. Transthoracic echocardiography [8%]

Proceed to Next Item

Explanation: User ld

Evaluation of chest pain

Pretest probability of
coronary artery disease

Low Intermediate High

No additional Able to exercise Start pharmacologic


diagnostic testing therapy for CAD
Yes No

Normal ECG Pharmacologic stress


imaging test
IExpert evaluation I
Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
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Evaluation of chest pain

Pretest probability of
coronary artery disease

Low Intermediate High

No additional Able to exercise Start pharmacologic


diagnostic testing therapy for CAD
Yes No

Normal ECG Pharmacologic stress j Expert evaluation I


imaging test
Yes No

Exercise Exercise
ECG test imaging test
Positive Positive Positive

Coronary
angiography
UWorld

The pretest probability of coronary artery disease (CAD) is based on age, gender,
cardiac risk factors, and chest pain characteristics. Low-risk patients include men age
<40 and women age <50 with atypical chest pain and no significant cardiac risk factors
(eg, non-smoker, no family history of premature CAD).
A positive stress test in patients at low risk for CAD is likely to be a false positive, which
can lead to further unnecessary testing or procedures. Conversely, a negative test in
high-risk patients is likely a false negative. For this reason, patients with high-risk
features for symptomatic CAD should be definitively evaluated with coronary
angiography. Stress testing (eg, exercise electrocardiography, myocardial perfusion
imaging) is most helpful for risk stratification in patients with intermediate-risk features
(Choices A and B). The choice of test is determined based on baseline
electrocardiogram (ECG) findings and the ability to exercise.

This patient has had chest pain for several months that is unrelated to physical activity.
She is vouno. has no risk factors for develooment of oremature CAD. and her ECG was

Feedback EnQ ock


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UWorld

The pretest probability of coronary artery disease (CAD) is based on age, gender,
cardiac risk factors, and chest pain characteristics. Low-risk patients include men age
<40 and women age <50 with atypical chest pain and no significant cardiac risk factors
(eg, non-smoker, no family history of premature CAD).

A positive stress test in patients at low risk for CAD is likely to be a false positive, which
can lead to further unnecessary testing or procedures. Conversely, a negative test in
high-risk patients is likely a false negative. For this reason, patients with high-risk
features for symptomatic CAD should be definitively evaluated with coronary
angiography. Stress testing (eg, exercise electrocardiography, myocardial perfusion
imaging) is most helpful for risk stratification in patients with intermediate-risk features
(Choices A and B). The choice of test is determined based on baseline
electrocardiogram (ECG) findings and the ability to exercise.

This patient has had chest pain for several months that is unrelated to physical activity.
She is young, has no risk factors for development of premature CAD, and her ECG was
normal. In light of this, she has a low pretest probability of CAD and additional testing for
CAD not advised.

(Choice C) This patient has no symptoms or signs suggesting deep venous thrombosis
or pulmonary embolism (eg, pleuritic pain, dyspnea, tachycardia). Lower-extremity
venous ultrasonography Is therefore not indicated.

(Choice E) A transthoracic echocardiogram can assess for segmental wall motion


abnormalities during an episode of chest pain, or after exercise in a diagnostic stress
test. It can also be used to look for valvular pathology (eg, aortic stenosis) in patients
with exertional chest pain and a suspicious murmur or other signs of valve disease.

Educational objective:
Diagnostic testing for coronary artery disease (CAD) should not be performed routinely in
low-risk patients as they frequently can have false-positive test results. Patients with
intermediate probability of CAD should receive appropriate stress testing based on
electrocardiogram (ECG) findings and their ability to exercise. High-risk patients should
be started on appropriate medical therapy, with expert evaluation to consider coronary
angiography.

References:
1. The chest pai n choice decision aid: a randomized trial.

Time Spent: 2 seconds


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Media Exhibit

probability of coronary artery disease I

Pretest probability of coronary artery disease

Low Asymptomatic people of all ages


(<10%) Atypical chest pain in women age <50

Atypical angina in men of all ages


Intermediate
Atypical angina in women age >50
(20%-80%)
Typical angina in women age 30-50

High Typical angina in men age >40


(>90%) Typical angina in women age >60
~UWortd

- 0
I__I __
~

C__
ard__
io__
vas__
cu__
lar__ ste__
sy__ m_e ______________________________________________________________________________Fe_e_d_b_ac_k___________E_n_d_B_Io_c_k____
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Media Exhibit

:ation of angina

Classification of angina

Typical location (eg, substernal), quality (eg, pressure)


& duration (eg, >20 min)
Classic
Provoked by exercise/emotional upheaval
Relieved with nitroglycerin or rest

Atypical 2 of 3 classic angina characteristics

Non-anginal 0 or 1 of 3 classic angina characteristics


UWorld

- 0
I__I __
~

C__
ard__
io__
vas__
cu__
lar__ ste__
sy__ m_e ______________________________________________________________________________Fe_e_d_b_ac_k___________E_n_d_B_Io_c_k____
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A 63-year-old man comes to the emergency department with substernal chest pain and
diaphoresis. The pain started one hour ago and was not relieved with antacids. His
medical problems include asthma, for which he uses inhaled fluticasone, and peptic ulcer
disease, for which he takes omeprazole. Blood pressure is 160/1 00 mm Hg and pulse is
90/min. A bruit is heard over the right carotid artery, and a mild systolic murmur is
present at the cardiac apex. Sublingual nitroglycerin and aspirin are administered and
within minutes the patient reports resolution of pain. Which of the following most likely
accounts for the improvement in his symptoms?

o A Alteration in heart rate


0 B. Decreased left ventricular ejection fraction
0 C. Decreased left ventricular volume
o D. Increased cardiac preload
o E. Increased left ventricular compliance
0 F. Increased systemic afterload

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A 63-year-old man comes to the emergency department with substernal chest pain and
diaphoresis. The pain started one hour ago and was not relieved with antacids. His
medical problems include asthma, for which he uses inhaled fluticasone, and peptic ulcer
disease, for which he takes omeprazole. Blood pressure is 160/100 mm Hg and pulse is
90/min. A bruit is heard over the right carotid artery, and a mild systolic murmur is
present at the cardiac apex. Sublingual nitroglycerin and aspirin are administered and
within minutes the patient reports resolution of pain. Which of the following most likely
accounts for the improvement in his symptoms?

A Alteration in heart rate [2%]

B. Decreased left ventricular ejection fraction [3%]

C. Decreased left ventricular volume [73%]

D. Increased cardiac preload [1 3%]


E. Increased left ventricular compliance [6%]
F. Increased systemic afterload [3%]

Proceed to Next Item

Explanation: User ld

Nitrates are excellent antianginal drugs and are used frequently to relieve chest pain in
patients with stable angina pectoris and acute coronary syndrome. Nitrates are primarily
vasodilators and dilate veins, arterioles, and coronary arteries by relaxing vascular
smooth muscle cells. Although nitrates act as venodilators and coronary vasodilators,
their primary anti-ischemic effects are due to systemic vasodilation rather than coronary
vasodilation. Systemic venodilation lowers preload and left ventricular end-diastolic
volume and reduces myocardial oxygen demand by reducing wall stress. Nitrates also
cause arterial and arteriolar vasodilation, although to a lesser degree, and can decrease

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E. Increased left ventricular compliance [6%]


F. Increased systemic afterload [3%]

Proceed to Next Item

Explanation: User ld
Nitrates are excellent antianginal drugs and are used frequently to relieve chest pain in
patients with stable angina pectoris and acute coronary syndrome. Nitrates are primarily
vasodilators and dilate veins, arterioles, and coronary arteries by relaxing vascular
smooth muscle cells. Although nitrates act as venodilators and coronary vasodilators,
their primary anti-ischemic effects are due to systemic vasodilation rather than coronary
vasodilation. Systemic venodilation lowers preload and left ventricular end-diastolic
volume and reduces myocardial oxygen demand by reducing wall stress. Nitrates also
cause arterial and arteriolar vasodilation, although to a lesser degree, and can decrease
systemic vascular resistance and blood pressure. The fall in systemic blood pressure
reduces wall stress, which leads to further decrease in myocardial oxygen demand.
(Choice A) Nitrates do not have a direct effect on heart rate. However, a fall in blood
pressure with nitrates can induce reflex tachycardia with an increase in myocardial
oxygen demand and worsening angina. This can best be prevented by concomitant use
of beta blockers.
(Choice B) Nitrates have no direct effect on cardiac chronotropy or inotropy
(contractility) and left ventricular ejection fraction. They can indirectly cause reflex
tachycardia in patients with a significant fall in blood pressure.
(Choices 0 and F) Systemic venodilation caused by nitrates leads to a decrease, not
an increase, in preload. Systemic arterial dilation also causes a decrease in afterload,
which occurs to a much lesser degree than a decrease in preload. In contrast, an
increase in preload and/or afterload will cause an increase in wall stress with increased
myocardial oxygen demand and worsening angina.

(Choice E) Nitrates have no direct effect on left ventricular compliance.


Educational objective:
The primary anti-ischemic and antianginal effects of nitrates are due to systemic
vasodilation rather than coronary vasodilation. Systemic venodilation lowers preload and
left ventricular end-diastolic volume, reducing wall stress and myocardial oxygen demand.

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A 47 -year-old female smoker with type 2 diabetes mellitus, mild normocytic anemia, and
stage 3 chronic renal disease is being evaluated for exertional dyspnea. Her family
history is insignificant. Blood pressure is 142/88 mm Hg and pulse is 76/min. Her body
mass index is 32 kg/m2 Single photon emission CT images are obtained at rest and after
5 minutes of treadmill exercise by using separate intravenous injections of
technetium-99-labeled perfusion agent, as shown in the images below.

This patient would benefit most from which of the following medications?

0 A Albuterol
0 B. Antiplatelet agent
0 C. Appetite suppressant
0 D. Erythropoietin
0 E. Metformin

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A 47-year-old female smoker with type 2 diabetes mellitus, mild normocytic anemia, and
stage 3 chronic renal disease is being evaluated for exertional dyspnea. Her family
history is insignificant. Blood pressure is 142/88 mm Hg and pulse is 76/min. Her body
mass index is 32 kg/m2 Single photon emission CT images are obtained at rest and after
5 minutes of treadmill exercise by using separate intravenous injections of
technetium-99-labeled perfusion agent, as shown in the images below.

This patient would benefit most from which of the following medications?

A. .Aibuterol [ 14%)
B. Antiplatelet agent (68%)
C. Appetite suppressant (2%)
D. Erythropoietin [1 2%)
E. Metformin (3%)

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Technetium-99-labeled (Tc-99m) perfusion agents (sestamibi or tetrofosmin) have a


half-life of 6 hours, passively diffuse into perfused myocardial cells, have minimal
redistribution afterward, and can provide an assessment of both myocardial function and
perfusion. Tc-99m is injected at rest and images are obtained during the gated single
photon emission CT (SPECT) scan (bottom panel above}. The patient then undergoes
stress testing (physiologic or pharmacologic) and has repeat gated SPECT images (top
panel above). Patients with normal tracer uptake at both rest and exercise have an
excellent prognosis with <1% annual risk of coronary artery disease (CAD).

A decreased tracer uptake both at rest and with exercise (fixed defect) indicates likely
scar tissue with decreased perfusion and CAD. A decreased tracer uptake with stress
but normal uptake at rest (reversible defect) indicates inducible ischemia and likely CAD,
as seen in this patient's apical images. Current guidelines recommend antiplatelet
therapy (eg, aspirin) for prevention of myocardial infarction, beta blockers, and
modification of the patient's risk factors (eg, smoking cessation, lipids, diabetes).

(Choice A) Albuterol is a beta agonist that may cause tachycardia, elevated blood
pressure, and possible arrhythmias in a patient with suspected CAD. Current guidelines
recommend beta blockers to reduce the potential for future coronary events.

(Choice C) Appetite suppressants are sympathomimetics that can cause significant


elevations in heart rate and blood pressure and are contraindicated in patients with CAD.
Item ~\='Mark <? [> at ~ ~ , GJIIA)
0. ld: 9648 PreVIous Next Lab Values Notes Calculator Reverse Color Text Zoom

half-life of 6 hours, passively diffuse into perfused myocardial cells, have minimal
redistribution afterward, and can provide an assessment of both myocardial function and
perfusion. Tc-99m is injected at rest and images are obtained during the gated single
photon emission CT (SPECT) scan (bottom panel above). The patient then undergoes
stress testing (physiologic or pharmacologic) and has repeat gated SPECT images (top
panel above). Patients with normal tracer uptake at both rest and exercise have an
excellent prognosis with <1 % annual risk of coronary artery disease (CAD).

A decreased tracer uptake both at rest and with exercise (fixed defect) indicates likely
scar tissue with decreased perfusion and CAD. A decreased tracer uptake with stress
but normal uptake at rest (reversible defect) indicates inducible ischemia and likely CAD,
as seen in this patient's apical images. Current guidelines recommend antiplatelet
therapy (eg, aspirin) for prevention of myocardial infarction, beta blockers, and
modification of the patient's risk factors (eg, smoking cessation, lipids, diabetes).

(Choice A) Albuterol is a beta agonist that may cause tachycardia, elevated blood
pressure, and possible arrhythmias in a patient with suspected CAD. Current guidelines
recommend beta blockers to reduce the potential for future coronary events.

(Choice C) Appetite suppressants are sympathomimetics that can cause significant


elevations in heart rate and blood pressure and are contraindicated in patients with CAD.

(Choice 0 ) Erythropoietin stimulates erythropoiesis for this patient's anemia but can
cause serious cardiovascular events, thromboembolic events, stroke, and increased
mortality in patients with cardiovascular disease.

(Choice E) Metformin may cause lactic acidosis when given to patients with conditions
predisposing to hypoxia (eg, cardiovascular disease, chronic kidney disease) and should
be avoided in this patient.

Educat io nal objective:


Single photon emission CT scan is a useful tool to evaluate for coronary artery disease
and indicates inducible ischemia when a reversible defect is noted on stress and rest
images. Antiplatelet therapy is the preferred treatment to prevent coronary artery disease
in these patients.

References:
1. SPECT imaging for detecting coronary artery disease and determ ining
prognosis by noninvasive assessment of m yocardial perfusion and
myocardial viability.

Time Spent: 8 seconds Copyright UWorld Last updated: [11 /24/2016]

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