A 65-year-old hypertensive man was hospitalized for non-ST-segmentelevation myocardial infarction (NSTEMI). The clinical examination shows a fourth heart sound (S4 ).
What is expected to be found at the echocardiography?
Reduction in left ventricular compliance. An S4 is frequently present in patients with acute MI and is related to auricular contraction and ventricular compliance reduction during ventricular filling. Rapid deceleration of transmitral flow during protodiastolic filling of the left ventricle and increased inflow into the left ventricle are responsible for the third heart sound (S3 ). A systolic ejection murmur is suggesting for aortic sclerosis.
A 66-year-old man known for diabetes mellitus treated with oral glucose lowering medications presents with UA. Coronary angiography reveals a three-vessel disease: 70% mid-LAD lesion, complex, long, and calcified; 70% focal proximal left circumflex artery (LCX) stenosis; and 70% focal mid-RCA lesion. A hybrid coronary revascularization was proposed. All the following statements are correct regarding hybrid coronary revascularization, with the exception of one.
Hybrid revascularization mandates surgical and percutaneous revascularization during the same procedure. According to the ACC/AHA PCI guidelines, hybrid coronary revascularization is defined as the planned combination of LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries and intended to combine the advantages of CABG (i.e., durability of the LIMA graft) and PCI. Hybrid revascularization is particularly suitable in patients with limitations to traditional CABG (e.g., heavily calcified proximal aorta, lack of graft conduits, or a non-LAD coronary artery unsuitable for bypass but amenable to PCI) and situations in which PCI of the LAD artery is not feasible (e.g., excessive tortuosity or calcification, complex bifurcation lesion, and very long lesion). The procedure may be performed in one operative setting or as a staged procedure. CABG before PCI is preferred. 5 Preliminary reports suggest that this approach is feasible and safe, but randomized data are lacking.
A 57-year-old female smoker presents to the emergency department for an ongoing new typical chest pain lasting 30 minutes. The physical examination is unremarkable and she is hemodynamically stable. The ECG reveals T inversion in II, III, and aVF leads.
Which of the following biomarker elevation has been associated with an improved benefit of ticagrelor therapy over clopidogrel in patients hospitalized with ACS?
High-sensitive troponin T (Hs-TnT). In the PLATO (Platelet Inhibition and Patient Outcomes) trial, 9,946 patients presented with non-ST-elevation ACS: 5,357 were revascularized and 4,589 managed conservatively. Highsensitive elevated Hs-TnT (>14.0 ng/L) have been described to predict substantial benefit (reduction rate of CV death, MI, and stroke) of ticagrelor over clopidogrel in patients who were revascularized or treated conservatively, while no apparent was observed in those who had normal Hs-TnT.
A 58-year-old man known for a metabolic syndrome shows increasing frequency of chest pain on exertion in the preceding 2 weeks. Resting ECG did not show significant abnormalities.
Which of the exercise parameters are associated with adverse prognosis?
All of the above. Patients with extensive and severe CAD are more likely to present abnormal exercise ECG results. Early onset of angina, ischemic ST depression ≥2 mm, downsloping ST segment starting at <5 METs, involving ≥5 leads and persisting ≥5 minutes into recovery, and fall in blood pressure at low exercise are all associated with adverse prognosis.
A 58-year-old man presented stable chest pain on moderate effort exertion in the preceding 12 months. The medical history is relevant for hypertension and hyperlipidemia. His current treatment includes lisinopril, atorvastatin, metoprolol, and aspirin. He is addressed for coronary angiography that showed a 70% to 90% lesion of the LCX successfully treated with PCI with a placement of a DES. The LVEF was normal.
What was the expected benefit of a PCI over a medical therapy?
No improvement of any of the mentioned endpoints. The COURAGE trial enrolled 2,287 patients with significant CAD to an initial strategy: (1) PCI and OMT or (2) OMT only. There were no significant differences between the PCI group and the medical therapy group in the composite of death, MI, and stroke (HR: 1.05; 95% CI: 0.87 to 1.27), and hospitalization for ACS (HR: 1.07; 95% CI: 0.84 to 1.37) or MI (HR: 1.13; 95% CI: 0.89 to 1.43). The authors concluded that as initial management strategy in patients with stable CAD, PCI did not reduce the risk of death, MI, or other MACE when added to OMT. According to the 2011 ACC/AHA PCI guidelines, revascularization should not be performed to improve survival in patients with SIHD with one or more coronary artery stenoses that are not anatomically significant, or involve only the LCX or RCA, or subtend only a small area of viable myocardium.
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