Transcript Ischemic Heart Disease - Saint Francis Hospital and Medical Center

Ischemic Heart Disease
Case 1
A 44 year old woman comes to the office complaining of
intermittent substernal chest pain for the last several weeks. The
pain sometimes happens with exertion, sometimes at rest and
there is no fixed pattern. She also complains of nausea. She has
no past medical history.
1.
What is the most common risk for coronary artery disease?
2.
What three features of chest pain on history or physical on the
boards tell you for sure the pain is not ischemic in nature?
3.
Her initial EKG is normal. What is the next best step in
management?
4.
What in the question will make you answer a thallium stress
test?
5.
When is the answer a dipyridamole, adenosine or dobutamine
stress test?
A 44 year old woman comes to the office complaining of
intermittent substernal chest pain for the last several weeks.
The pain sometimes happens with exertion, sometimes at rest
and there is no fixed pattern. She also complains of nausea.
Her stress test is Abnormal.
1. What is the next step in management?
2. What is the GOAL of therapy for her LDL?
3. What are the coronary artery disease equivalents?
4. What is the most common adverse effect of statins?
Case 3
A 68 year old man comes to the emergency department of a
small rural hospital in Wyoming with one hour of crushing
substernal chest pain after shoveling snow. The pain radiates
to his arm and jaw. He is sweating, nauseated and has
Levine’s sign when describing the pain. He has a history of
hypertension and smokes one pack a day of cigarettes. His
initial EKG shows 2 mm of ST elevation in V2-V4.
1. What is the best initial step?
2. When are calcium blockers the answer?
3. When is lidocaine or amiodarone the answer?
4. What is the most accurate diagnostic step at this time?
Question Case 3
A 65 year old man comes to the emergency department with
30 minutes of substernal chest pain and ST segment elevation
in II, III, aVF. He has received aspirin, metoprolol and
undergone angioplasty. Which of the following is most likely
to lower his mortality?
a.
b.
c.
d.
e.
f.
Oxygen
Nitrates
ACE inhibitors
Statins
Morphine
Lidocaine
Question
A 64 year old man comes to the emergency department 1 hour
after he had 40 minutes of substernal chest pain. He had a nonhemorhagic stroke six weeks ago and currently has a blood
pressure of 182/108. The EKG shows ST elevation in V2-V4.
He has received aspirin and oxygen. Which of the following is
most appropriate in his management?
a. Thrombolytics now
b. Transfer for Angioplasty
c. Nitrates
d. Coronary bypass surgery
e. Add metoprolol and ACE inhibitors only
f. Add metoprolol and ACE inhibitors then give
thrombolytics
Case 6
A 68 year old man comes to the Emergency Department with
one hour of crushing substernal chest pain radiating to his arm
and jaw. He has never had chest pain before. The initial EKG
has 1 mm of ST depression (or normal) in V2-V4.
1. What is the next best step in management?
2. His pain persists despite this. What will you do next?
3. When are calcium blockers the answer?
When you cannot give beta blockers.
4. What should be done in all patients on the following day?
Question
A 24 year old man comes to the emergency department with
30 minutes of chest pain that developed after injecting
cocaine. His EKG is normal. What would you order first for
him?
a. Diltiazem
b. Metoprolol
c. Thrombolytics
d. Angioplasty
e. Angiography
Case 8
A 68 year old man who was transferred from the CCU five days
ago after having a myocardial infarction becomes part of your
service. He has had no further chest pain or discomfort for the
last several days and he feels quite well. He is now ready for
discharge.
1. What will you do prior to discharge?
-Stress testing
2. Is angiography necessary?
Only if the stress test shows significant ischemia
3. When will you answer coronary artery bypass grafting (CABG)?
4. What will you discharge him on?
5. What advice will you give him?
6. His wife asks you if the patient will have sex with her. What do
you tell her?
Question Case 8
A patient is being discharged after a myocardial
infarction.
What will you discharge him on?
a. Aspirin, beta blockers, ACE inhibitors, Statins
b. Beta blockers, ACE inhibitors, warfarin
c. Aspirin alone
d. Aspirin, beta blockers, warfarin
Congestive Heart Failure Case 1
A 64 year old woman with a history of a myocardial infarction comes to
the emergency room with the acute onset of shortness of breath over the
last several hours. She can’t remember what medications she is supposed
to be using. She has a bag of potato chips in one hand and a pepperoni
pizza in the other. On physical examination she has rales to her apices, an
S3 gallop, pedal edema which extends to her areola, ascites and
jugulovenous distension.
1. What will you do first for her?
2. What is the MOST accurate means of assessing her ejection fraction?
3. What will you do differently if the labs in the case state his baseline
creatinine is 2.3?
4. When are angiotensin II receptor blockers the answer?
Two days later the same patient
has completely improved. She is
ten pounds lighter and she has no
dyspnea.
What will you discharge her on?
Valvular Heart Disease
A 27 year old woman comes to the office for evaluation of mild
dyspnea. She emigrated from South America several years ago. On
physical examination she has a respiratory rate of 22, jugulovenous
distention and bilateral basilar rales. Cardiac exam reveals a loud S1
and a high pitched sound in diastole immediately followed by a
diastolic murmur.
1. What is the most likely diagnosis?
2. What is the ‘best initial’ and ‘most accurate’ diagnostic tests?
Echo is always first. Cardiac angiography is more accurate and can give direct
pressure measurements.
3. What is the best initial therapy?
Diuretics and sodium restriction
Several months later she returns because of worsening dyspnea despite
therapy. She is now six months pregnant.
4. What is the best therapy for her now?
Atrial Arrhythmias
Case 1 Supraventricular tachycardia
A 29 year old senior medical resident comes to the emergency room
with palpitations. He has been studying for the boards and has had 5
cups of coffee, 4 beers, 3 cheeseburgers, 2 ‘power drinks’ and 1
viagra. An EKG shows supraventricular tachycardia at a rate of 160.
His blood pressure is 124/80.
1. What would you do first?
2. What is next if this is unsuccessful?
3. What other medications are acceptable to control the rate?
4. If the SVT continues to be recurrent what is the best long term
therapy?
5. If the case were changed to atrial flutter how would the above answers
differ?
Case 3
A 64 year old woman with a history of hypertension comes to the
office for a routine visit. She is maintained on a diuretic with good
control of her blood pressure. You note that her heart rate is 118 and is
irregularly irregular. She firmly denies symptoms and had no idea that
her rate was elevated or that her rhythm was irregular or for how long.
A EKG shows atrial fibrillation at a rate of 118.
1. What is the best initial step in management?
2. After this is accomplished what would you do next?
3. What is the best method of converting her to sinus
rhythm?
A 41 year old gastroenterologist has been having
palpitations. His EKG shows atrial fibrillation with a
rate of 80. He has no past medical history, no diabetes
and no hypertension. His echo is normal. When you
discuss cardioversion by electricity or medications he
refuses and instructs you to do something to yourself
that is anatomically impossible.
What is the best therapy for this patient?
A 47 year old man comes to see you for advice about smoking cessation.
He has no current complaints and no past medical history. He is on no
medications and has no allergies. He is not black, white, Asian or
Hispanic. On physical examination he has a blood pressure of 155/92. He
comes back the following week to have his blood pressure checked again
because his managed care plan will not pay for ambulatory home blood
pressure monitoring. His blood pressure is now 152/94. The following
week it is the same.
1. What is the next best step in the management of this patient?
2. Which of these will be the most effective?
3. Which of them has the weakest data to suggest efficacy?
After four months of attempts he comes back
and says he would rather just be fat and lazy,
keep smoking and take some pills.
What is the best initial medical therapy?
What will you do in the 30% of patients who
are not adequately controlled with this
regimen?
When you see THIS
in the history
Diabetes
Myocardial infarction
CHF
Isolated systolic hypertension
Migraine headaches
BPH
Asthma
Depression
Peripheral arterial disease
Osteoporosis
Pregnancy
Use THIS as the ‘best initial
therapy’
Case 2
A man has hypertension, a history of myocardial
infarction and hyperlipidemia.
What will you answer as the first drug to use to control his
blood pressure?
Case 3
A woman has hypertension, a history of myocardial
infarction and diabetes.
1. What will you answer as the first drug to use
to control his blood pressure?
2. What is the blood pressure goal of therapy?
Case 4
A man has a history of a mild myocardial
infarction, hypertension and asthma.
What will you answer as the first drug to use to
control his blood pressure?
Case 5
A 54 year old man comes to the emergency
department with several hours of headache, blurry
vision, mild confusion, and dyspnea. His blood
pressure is 210/130.
What is the best therapy for this patient?
When is sublingual nifedipine the correct answer?
Case 7
A 24 year old woman comes to see you because of headaches.
On physical examination you find a blood pressure of
160/105. On physical examination you find a bruit on one
side. A renal ultrasound shows both kidneys are small but one
of the kidneys is slightly smaller than the other.
What is the next best diagnostic step?
What is the most accurate diagnostic test?
What is the best initial therapy?