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A 60-year-old man comes to the emergency department due to substernal chest

discomfort over the past 3 hours. He has had no shortness of breath, lightheadedness,
or palpitations, but he had an episode of profuse sweating when the discomfort started.
The patient has a history of diet-controlled type 2 diabetes mellitus. ECG shows normal
sinus rhythm with ST-segment depression in leads V4-V6. His initial troponin I level is
0.5 ng/ml (normal, <0.01 ng/ml), and a second level 6 hours later is 1.1 ng/ml. He is
taken to the cardiac catheterization laboratory. Coronary angiogram shows near-total
occlusion of th e left circumflex artery, which is treated with an everolimus-eluting stent.
The rest of th e coronary vessels show mild, non obstructive atherosclerosis. In addition
to aspirin, beta blocker, statin, and an angiotensin-converting enzyme inhibitor, which of
the following should be part of this patient's medical reg imen?

0 A Dihydropyridine calcium channel blocker

0 B. Factor Xa inhibitor
0 C. Long-acting nitrate
0 D. Microtubule inhibitor
0 E. P2y12 receptor blocker
0 F. Phosphodiesterase-S Inhibitor

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A 60-year-old man comes to the emergency department due to substernal chest

discomfort over the past 3 hours. He has had no shortness of breath, lightheadedness,
or palpitations, but he had an episode of profuse sweating when the discomfort started.
The patient has a history of diet-controlled type 2 diabetes mellitus. ECG shows normal
sinus rhythm with ST-segment depression in leads V4-V6. His initial troponin I level is
0 .5 ng/mL (normal, <0.01 ng/mL), and a second level 6 hours later is 1.1 nglmL. He is
taken to the cardiac catheterization laboratory. Coronary angiogram shows near-total
occlusion of the left circumflex artery, which is treated with an everolimus-eluting stent.
The rest of the coronary vessels show mild, non obstructive atherosclerosis. In addition
to aspirin, beta blocker, statin, and an angiotensin-converting enzyme inhibitor, which of
the following should be part of this patient's medical regimen?

A Dihydropyridine calcium channel blocker [5%)

B. Factor Xa inhibitor [26%)
C. Long-acting nitrate [1 0%)
D. Microtubule inhibitor [1%)
E. P2y12 receptor blocker [53%)
F. Phosphodiesterase-S inhibitor [4%)

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Explanation: User

This patient had a non-ST elevation myocardial infarction (NSTEMI) (chest pain, ST
depression, troponin elevation) and underwent revascularization ofthe culprit coronary
artery with a drug-eluting stent. Long-term medical therapy in such patients is aimed at
prevention of recurrent coronary events (secondary prevention) and reduction of overall
cardiovascular events. Medical therapy shown to improve morbidity and mortality in
patients with known coronary heart disease includes:
1. Dual antiplatelet therapy (DAPT) with aspirin and P2y12 receptor blockers (eg,
clopidogrel, prasugrel, ticagrelor)
2. Beta blockers
3. Angiotensin-converting enzyme inhibitors or angiotensin II recepto r
blockers
4. HMG-CoA reductase inhibitors (statins)
5. Aldosterone antagonists (eg, spironolactone, eplerenone) in patients with left
ventricular ejection fraction <40% who have heart failure symptoms or diabetes

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Explanation: User ld

This patient had a non-ST elevation myocardial infarction (NSTEMI) (chest pain, ST
depression, troponin elevation) and underwent revascularization of the culprit coronary
artery with a drug-eluting stent. Long-term medical therapy in such patients is aimed at
prevention of recurrent coronary events (secondary prevention) and reduction of overall
cardiovascular events. Medical therapy shown to improve morbidity and mortality in
patients with known coronary heart disease includes:
1. Dual antiplatelet therapy (DAPT) with aspirin and P2y12 receptor blockers (eg,
clopidogrel, prasugrel, ticagrelor)
2. Beta blockers
3. Angiotensin-converting enzyme inhibitors or angiotensin II receptor
blockers
4. HMG-CoA reductase inhibitors (statins)
5. Aldosterone antagonists (eg, spironolactone, eplerenone) in patients with left
ventricular ejection fraction !:40% who have heart failure symptoms or diabetes
mellitus

DAPT with aspirin and a P2y12 receptor b locker leads to a significant reduction in
recurrent Ml and cardiovascular death compared to aspirin alone in patients with
NSTEMI. Long-term DAPT also reduces the risk of stent thrombosis and is currently
recommended for at least 12 months in all patients following drug-eluting stent placement.

(Choice A) Dihydropyridine calcium channel blockers (eg, amlodlpine) are occasionally

used as adjunctive therapy (in addition to nitrates and beta blockers) in patients with
angina. They have not been shown to provide any mortality benefit in patients with
NSTEMI.

(Choice B) Apixaban, a direct factor Xa inhibitor, is used for anticoagulation in

nonvalvular atrial fibrillation and for management of deep venous thrombosis and
pulmonary embolism.

(Choice C) lsosorbide mononitrate, a long-acting nitrate providing rapid, symptomatic

relief in patients with recurrent angina, has no mortality benefit in patients with coronary
heart disease. Routine use in asymptomatic patients is not indicated.

(Choice 0) Postinfarction pericarditis (pericardia! rub, chest pain) sometimes develops

after an Ml and can be treated with the tubulin inhibitor colchicine. Colchicine Is not
routinely prescribed to asymptomatic patients.

(Choice F) Phosphodiesterase-S inhibitors are vasodilators used for erectile dysfunction

and are contraindicated in patients on nitrates (risk of hypotension). Milrinone is a

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recurrent Ml and cardiovascular death compared to aspirin alone in patients with
NSTEMI. Long-term DAPT also reduces the risk of stent thrombosis and is currently
recommended for at least 12 months in all patients following drug-eluting stent placement.

(Choice A) Dihydropyridine calcium channel blockers (eg, amlodipine) are occasionally

used as adjunctive therapy (in addition to nitrates and beta blockers) in patients with
angina. They have not been shown to provide any mortality benefit in patients with
NSTEMI.

(Choice B) Apixaban, a direct factor Xa inhibitor, is used for anticoagulation in

nonvalvular atrial fibrillation and for management of deep venous thrombosis and
pulmonary embolism.

(Choice C) lsosorbide mononitrate, a long-acting nitrate providing rapid, symptomatic

relief in patients with recurrent angina, has no mortality benefit in patients with coronary
heart disease. Routine use in asymptomatic patients is not indicated.

(Choice D) Postinfa rction pericarditis (pericardia! rub, chest pain) sometimes develops
after an Ml and can be treated with the tubulin inhibitor colchicine. Colchicine is not
routinely prescribed to asymptomatic patients.

(Choice F) Phosphodiesterase-S inhibitors are vasodilators used for erectile dysfunction

and are contraindicated in patients on nitrates (risk of hypotension). Milrinone is a
selective phosphodiesterase inhibitor that increases contractility (by increasing cyclic
AMP concentrations): oral milrinone therapy is associated with increased mortality in
patients with heart failure.

Educational obj ective:

Dual antiplatelet therapy (aspirin and a P2y12 receptor blocker) leads to a reduction in
recurrent myocardial infarction (MI) and cardiovascular death compared to aspirin alone
in patients with non-ST elevation MI. It also reduces the risk of stent thrombosis and is
recommended in all patients for at least 12 months following drug-eluting stent placement.

References:
1. 2014 AHA/ACC guideline for the management of patients with non-ST-
elevation acute coronary syndromes: executive summary: a report of
the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines.
2. Effects of clopidogrel in addition to aspirin in patients with acute
coronary syndromes without ST-segment elevation.

Time Spent: 2 seconds Copyright© UWorld Last updated: [10/17/2016)

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