MKSAP 2: CAD

Question 1

Name the components of typical angina:

Answer 1

(1) substernal chest pain or discomfort (2) provoked by exertion or emotional stress (3) relieved by rest or nitro

Question 2

What group of patients is stress testing most useful for?

Answer 2

At intermediate pretest probability of CAD (10%-90%)

Question 3

What 2 categories of medicines are the regimen broken in to for guideline directed medical therapy?

Answer 3

Cardioprotective & antianginal meds

Question 4

What are the 5 medications included in GDMT for stable angina?

Answer 4

Aspirin
B-blocker
Long acting nitrate
Sublingual nitro
moderate to high intensity statin

Question 5

What are the recommendations for aspirin therapy in CAD?

Answer 5

All patients with established CAD should be on at least 81mg ASA daily unless contraindicated. In patient allergic to ASA, clopidogrel is recommended as alternative.
New antiplatelet agents as monotherapy (prasugrel, ticagrelor) has not been tested in stable angina.

Question 6

What is the indication for DAPT?

Answer 6

ASA + (clopidogrel, prasugrel or ticagrelor) is only recommended following PCI or ACS.

Question 7

What is the dose titration recommendation for BB in chronic stable angina?

Answer 7

Resting HR 55-60 bpm.

Question 8

What are the contraindications to BB therapy?

Answer 8

symptomatic bradycardia, high grade AV block, acute decompensated HF, severe reactive airway disease

Question 9

What are the indications for ACEi in chronic stable angina?

Answer 9

ACEi are indicated in the treatment of stable angina, especially in patients with DM and LV systolic dysfunction

Question 10

State the cholesterol management guidelines for moderate to high intensity statins.

Answer 10

Moderate to high intensity statins are recommended for all patients with

(1) LDL chol > 190
(2) DM or
(3) > 7.5% 10 year ASCVD score

Question 11

What are the antianginal medications of GDMT?

Answer 11

B-blockers, nitrates, CCB, ranolazine

Question 12

Describe the indications for CCB in GDMT?

Answer 12

Second line therapy in patients with chronic stable angina who are intolerant of BB or who have continued symptoms on BB and nitrates.

Question 13

Describe the mechanism of CCB and specifically nondihydropyridine CCB?

Answer 13

All CCBs vasodilate systemic and coronary arteries. Nondihydropyridine CCBs (diltiazem and verapamil) reduce HR

Question 14

What is the indication for ranolazine in GDMT?

Answer 14

Selective inhibitor of the late inward sodium channel in the myocardium, indicated for patients symptomatic still on BB, nitrates and CCB.
Use with caution in patients with advanced liver disease or kidney disease.

Question 15

what are the indications for PCI in chronic, stable angina?

Answer 15

For patients with refractory symptoms while on optimal medical therapy, those who are unable to tolerate optimal medical therapy or those with high risk features on noninvasive exercise and imaging tests.

Question 16

What is the indication for CABG in chronic, stable angina?

Answer 16

Generally indicated for those who remain symptomatic with optimal medical therapy and have specific angiographic findings (either LM disease or multivessel disease with involvement of the proximal LAD artery), concomitant reduced systolic function or DM.

Question 17

Describe the guidelines for DAPT and duration for the following conditions:

• stable angina who undergo PCI or CABG
• PCI with BMS
• PCI with DES

Answer 17

• stable angina who undergo PCI or CABG: ASA indefinitely
• BMS: DAPT for at least one month
• DES: DAPT for at least one year; extended therapy can be considered

Question 18

Define STEMI, NSTEMI and UA.

Answer 18

STEMI: presence of ischemic chest pain (or an equivalent) and the presence of greater than 1mm ST segment elevation in 2 or more consecutive leads or new LBBB on ECG
NSTEMI: abnormal cardiac biomarkers with ischemic chest pain but the notable absence of ST segment elevation on ECG, although has ST segment depression or TWI
UA: ischemic chest pain, ECG changes but no abnormal biomarkers

Question 19

What is the initial medical therapy indicated for STEMI?

Answer 19

ASA, BB, nitrates, heparin

Question 20

What is the treatment algorithm for patients that present to a non-PCI capable facility?

Answer 20

If <120 min to facility -> urgent transfer

If >120 min to facility -> thrombolytics and still transfer in case of thrombolytic failure

Question 21

Name the absolute contraindications to thrombolytics for STEMI

Answer 21

Any previous ICH
Known cerebrovascular lesion
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed head or facial trauma within 3 months

Question 22

Name the thrombolytic agents used in treatment of STEMI in order of less effective to most effective

Answer 22

(1) streptokinase
(2) alteplase
(3) reteplase
(4) tenecteplase

Question 23

What reperfusion arrythmia are thrombolytic patients prone to? And when should a repeat ECG be obtained after thrombolysis?

Answer 23

Accelerated idioventricular rhythm - considered benign when it occurs within 24 hrs of reperfusion
ECG at 60 min after

Question 24

What patients do you want to avoid nitrates and analgesics? Why?

Answer 24

Inferior STEMI patients with evidence of RV infarction bc can lead to reduced preload and hypotension

Question 25

What patients do you avoid BB in in STEMI?

Answer 25

Evidence of heart failure, hypotension, bradycardia, advanced AV block Dosed with IV metoprolol, 5mg increments q5 min up to 15mg then oral therapy

Question 26

What is the recommendation for DAPT after STEMI?

Answer 26

Should be continued in STEMI patients for a full year regardless of intervention or stent used

Question 27

Name the platelet P2Y12 agents and their indication in STEMI treatment?

Answer 27

clopidogrel (Plavix) ticagrelor (Brilinta) prasugrel (Effient) Plavix the most widely studied and its use with concomitant PCI and thrombolytic therapy is associated with improved outcomes

Question 28

Name the platelet glycoprotein IIb/IIIa inhibitors and their role in STEMI?

Answer 28

abciximab (Reopro) tirofiban (Aggrastat) eptifibatide (Integrilin) reserved for administration in the cath lab in patients who undergo primary PCI Use in patients who get thrombolytics without PCI is not recommended

Question 29

What are the blood glucose goals for patients with STEMI and DM?

Answer 29

<180

Question 30

What is the long term medical therapy recommended after STEMI?

Answer 30

ASA, BB, ACEi, nitrates, statin, P2Y12 inhibitor

Question 31

What are the most common complications of STEMI?

Answer 31

arrhythmias, heart failure, vascular access issues

Question 32

What additional therapy is indicated in patients with heart failure following STEMI?

Answer 32

Diuretics for preload reduction and nitrates or ACEi for afterload reduction

Question 33

What triad of findings would lead you to diagnose R ventricular infarction after STEMI? Treatment?

Answer 33

hypotension, clear lung exam, elevated JVP | referfusion, aggressive volume resuscitation, and use of inotropes until RV function improves

Question 34

What is the diagnosis? 3-7 days after STEMI: hemodynamic compromise, new loud holosystolic murmur, and palpable thrill

Answer 34

ventricular septal defect

Question 35

How does papillary muscle rupture present after STEMI?

Answer 35

3-7 days after; hemodynamic compromise, pulmonary edema, loud systolic murmur

Question 36

What are the risk factors for left ventricular free wall rupture and how does it present after STEMI?

Answer 36

Advanced age, female sex, anterior MI, incomplete reperfusion Most commonly present with pericardial tamponade, PEA, and death

Question 37

what is the treatment for LV thrombus after STEMI?

Answer 37

Therapeutic warfarin for 3-6 months

Question 38

What risk calculator is used in patients with NSTEMI to guide early invasive vs medical management therapy?

Answer 38

``` TIMI risk score: (1) Age > 65 years (2) 3 or more traditional CAD RFs (3) Documented CAD with greater than 50% stenosis (4) ST segment deviation (5) 2 or more anginal episodes in the last 24 hrs (6) ASA use in the past week (7) Elevated cardiac biomarkers 0-2 low risk 3-4 intermediate risk 5-7 high risk ```

Question 39

What is the recommended initial management and workup for someone with NSTEMI or UA?

Answer 39

ASA, BB, nitrates, statin and Plavix (P2Y12 inhib) Calculate risk stratification Intermediate or high risk consider anticoagulant agents or GP IIb/IIIa inhibitor

Question 40

What is the recommended dosing of ASA for ischemic chest pain?

Answer 40

325mg at presentation and 81mg QD after especially if in combo with Plavix

Question 41

What is the recommendation for DAPT in NSTEMI?

Answer 41

All patients with NSTEMI should receive DAPT regardless of TIMI score unless increased risk of bleeding

Question 42

What is the dosing for Plavix?

Answer 42

300 or 600mg loading dose at admission and 75mg QD after

Question 43

What are the advantages to prasugrel and ticagrelor over clopidogrel

Answer 43

Found to be superior to Plavix in NSTEMI and UA patients; do not require hepatic metabolism, are more potent, faster onset of action; but not as thoroughly studied and need to be stopped 5-7 days prior to CABG

Question 44

What is the indication for use of GP IIb/IIIa inhibitors in NSTEMI/UA?

Answer 44

Only in high risk features: ongoing angina, evidence of ischemia after initiation of standard antiplatelet and antianginal meds, reinfarction or heart failure. Indicated along with UFH at the time of PCI because of potent antiplatelet activity.

Question 45

What is the first step in the NSTEMI algorithm?

Answer 45

Initiate ASA, BB, nitrate, statin

Question 46

What are the meds and doses for high intensity statin therapy?

Answer 46

atorvastatin 40-80mg/d | rosuvastatin 20-40mg/d

Question 47

What are other non-cardiac causes of ischemic type chest pain presentation?

Answer 47

Coronary vasospasm due to illicit drugs | Takotsubo cardiomyopathy

Question 48

How is coronary vasospasm treated long term?

Answer 48

Long term nitrates, CCB and avoidance of triggers

Question 49

Review the guidelines for DAPT for the following patients: - ACS patient treated medically - ACS with PCI DES - ACS with PCI BMS

Answer 49

- ACS treated medically: ASA indefinitely and DAPT one year - ACS with PCI DES: ASA indefinitely and DAPT one year - ACS with PCI BMS: ASA indefinitely and DAPT at least 4 weeks, up to one year as tolerated

Question 50

What other meds should ACS patients be on?

Answer 50

ACEi and statins indefinitely as tolerated; BB at least 3 years, but usually indefinitely as tolerated

Question 51

What guideline differences exist in managing CAD in women compared to men?

Answer 51

Women are more likely to present with atypical symptoms such as fatigue, dyspnea, nausea and abd complaints. In women with CAD, GDMT is recommended first prior to consideration for revascularization.

Question 52

What are the special treatment guidelines recommended for DM and CAD?

Answer 52

High intensity statin therapy and antihypertensive treatment with goal <140/90 with ACEi or ARBs Avoidance of rosiglitazone for risk of increased CV events