A 63-year-old male smoker with no history of CVD and a treatment for hypertension complains of typical chest pain on exertion the preceding 2 months without any aggravation. He is scheduled for coronary angiography in 7 days.
In the meantime, you should start the following antiplatelet treatment(s):
Low-dose aspirin daily. The patient will have coronary angiography for a high suspicion of SIHD. Until the angiogram is performed, he should be treated with optimal medical treatment including aspirin, statins, control of blood pressure (β-blockers/angiotensin converting), and additional medical therapy for the relief of symptoms (β-blockers, calcium channel blockers, long-acting nitrates, or sublingual nitroglycerin). The efficacy of clopidogrel pretreatment compared with the administration in the catheterization laboratory is controversial. 62 There is no evidence to give prasugrel or ticagrelor in patients with SIHD.
A 66-year-old man with intermediate probability of ischemic heart disease is scheduled for stress testing.
Which of the following strategies is not recommended?
Pharmacologic stress with nuclear myocardial perfusion imaging if able to exercise and interpretable ECG. Patients with intermediate pretest probability of CAD are those who most benefit from stress testing to improved diagnostic accuracy. The choice of stress test depends on two questions: Is the patient able to exercise? Is the resting ECG interpretable? The ACC/AHA SIHD guidelines recommend standard exercise ECG testing for interpretable ECG and at least moderate physical functioning or no disabling comorbidity (level of evidence A, class I). Exercise with nuclear myocardial perfusion imaging or echocardiography is recommended for patients with an intermediate to high pretest probability of ischemic heart disease who have an uninterpretable ECG and at least moderate physical activity functioning or no disabling comorbidity. Pharmacologic stress with cardiac MR can be useful for patients with an intermediate to high pretest probability who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity. Pharmacologic stress with nuclear myocardial perfusion imaging, echocardiography, or cardiac MR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidities.
A 65-year-old man with hypercholesterolemia, diabetes, and hypertension presents new, worsening, typical angina symptoms. The angiogram (Fig. below)
shows:
Severe ostial and moderate distal left main trunk stenosis. The coronary angiography shows severe ostial and moderate distal left main trunk stenosis.
A 64-year-old man with stable ischemic heart disease (SIHD) wants to know whether he is at high risk for mortality.
Which of the following clinical and exercise testing data are useful to predict the risk?
All of the above. The 2012 AHA/ACC guidelines on SIHD recommend using a nomogram to predict the risk of death in patients with SIHD. This score is based on following clinical and exercise testing variables: age, male gender, typical angina, diabetes, cigarette smoking, hypertension, proportion of predicted METs achieved, ST-segment depression, test-induced angina, abnormal heart rate recovery, and frequent ventricular ectopy during recovery.
A 48-year-old woman presents with congestive heart failure. The etiology of her heart failure based on the coronary angiogram (Fig. below)
is:
Arteriovenous fistula. The coronary angiography reveals large coronary AV fistula involving the RCA. Patient underwent surgical ligation of the fistula with resolution of her symptoms.
Click to expand