Ischemic Heart DiseaseIschemic Heart DiseaseCase 1Case 1

A 44 year old woman comes to the office complaining of A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. The intermittent substernal chest pain for the last several weeks. The pain sometimes happens with exertion, sometimes at rest and pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. She has there is no fixed pattern. She also complains of nausea. She has no past medical history.no past medical history.

1.1. What is the most common risk for coronary artery disease?What is the most common risk for coronary artery disease?

2.2. What three features of chest pain on history or physical on the What three features of chest pain on history or physical on the boards tell you for sure the pain is boards tell you for sure the pain is not not ischemic in nature?ischemic in nature?

3.3. Her initial EKG is normal. What is the next best step in Her initial EKG is normal. What is the next best step in management?management?

4.4. What in the question will make you answer a thallium stress What in the question will make you answer a thallium stress test?  test?  

5.5. When is the answer a dipyridamole, adenosine or dobutamine When is the answer a dipyridamole, adenosine or dobutamine stress test? stress test?

A 44 year old woman comes to the office complaining of A 44 year old woman comes to the office complaining of intermittent substernal chest pain for the last several weeks. intermittent substernal chest pain for the last several weeks.

The pain sometimes happens with exertion, sometimes at rest The pain sometimes happens with exertion, sometimes at rest and there is no fixed pattern. She also complains of nausea. and there is no fixed pattern. She also complains of nausea.

Her stress test is Her stress test is AbAbnormal.normal.  

1. What is the next step in management?1. What is the next step in management?

2. What is the GOAL of therapy for her LDL?2. What is the GOAL of therapy for her LDL?    

3. What are the coronary artery disease equivalents?3. What are the coronary artery disease equivalents?

4. What is the most common adverse effect of statins?4. What is the most common adverse effect of statins?

Case 3Case 3A 68 year old man comes to the emergency department of a A 68 year old man comes to the emergency department of a small rural hospital in Wyoming with one hour of crushing small rural hospital in Wyoming with one hour of crushing

substernal chest pain after shoveling snow. The pain radiates substernal chest pain after shoveling snow. The pain radiates to his arm and jaw. He is sweating, nauseated and has to his arm and jaw. He is sweating, nauseated and has

Levine’s sign when describing the pain. He has a history of Levine’s sign when describing the pain. He has a history of hypertension and smokes one pack a day of cigarettes. His hypertension and smokes one pack a day of cigarettes. His

initial EKG shows 2 mm of ST elevation in V2-V4.initial EKG shows 2 mm of ST elevation in V2-V4.

1. What is the best initial step?1. What is the best initial step?

  

2. When are calcium blockers the answer?2. When are calcium blockers the answer?

    

3. When is lidocaine or amiodarone the answer?3. When is lidocaine or amiodarone the answer?

4. What is the most accurate diagnostic step at this time?4. What is the most accurate diagnostic step at this time?

Question Case 3Question Case 3A 65 year old man comes to the emergency department with A 65 year old man comes to the emergency department with

30 minutes of substernal chest pain and ST segment elevation 30 minutes of substernal chest pain and ST segment elevation in II, III, aVF. He has received aspirin, metoprolol and in II, III, aVF. He has received aspirin, metoprolol and

undergone angioplasty. Which of the following is most likely undergone angioplasty. Which of the following is most likely to lower his mortality?to lower his mortality?

a.a. Oxygen Oxygen

b.b. Nitrates Nitrates

c.c. ACE inhibitors ACE inhibitors

d.d. Statins Statins

e.e. Morphine Morphine

f.f. LidocaineLidocaine  

Question Question A 64 year old man comes to the emergency department 1 hour A 64 year old man comes to the emergency department 1 hour after he had 40 minutes of substernal chest pain. He had a non-after he had 40 minutes of substernal chest pain. He had a non-

hemorhagic stroke six weeks ago and currently has a blood hemorhagic stroke six weeks ago and currently has a blood pressure of 182/108. The EKG shows ST elevation in V2-V4. pressure of 182/108. The EKG shows ST elevation in V2-V4. He has received aspirin and oxygen. Which of the following is He has received aspirin and oxygen. Which of the following is

most appropriate in his management?most appropriate in his management?

a. Thrombolytics now a. Thrombolytics now b. Transfer for Angioplasty b. Transfer for Angioplasty c. Nitrates c. Nitrates d. Coronary bypass surgeryd. Coronary bypass surgerye. Add metoprolol and ACE inhibitors onlye. Add metoprolol and ACE inhibitors onlyf. Add metoprolol and ACE inhibitors then give f. Add metoprolol and ACE inhibitors then give thrombolyticsthrombolytics

Case 6Case 6A 68 year old man comes to the Emergency Department with A 68 year old man comes to the Emergency Department with one hour of crushing substernal chest pain radiating to his arm one hour of crushing substernal chest pain radiating to his arm and jaw. He has never had chest pain before. The initial EKG and jaw. He has never had chest pain before. The initial EKG

has 1 mm of ST depression (or normal) in V2-V4. has 1 mm of ST depression (or normal) in V2-V4.

1. What is the next best step in management?1. What is the next best step in management?

    

2. His pain persists despite this. What will you do next?2. His pain persists despite this. What will you do next?

  

  3. When are calcium blockers the answer?3. When are calcium blockers the answer?

When you cannot give beta blockers.When you cannot give beta blockers.

  

  4. What should be done in all patients on the following day?4. What should be done in all patients on the following day?

Question Question A 24 year old man comes to the emergency department with A 24 year old man comes to the emergency department with

30 minutes of chest pain that developed after injecting 30 minutes of chest pain that developed after injecting cocaine. His EKG is normal. What would you order first for cocaine. His EKG is normal. What would you order first for

him?him?

a. Diltiazem a. Diltiazem

b. Metoprolol b. Metoprolol

c. Thrombolytics c. Thrombolytics

d. Angioplasty d. Angioplasty

e. Angiographye. Angiography

Case 8Case 8A 68 year old man who was transferred from the CCU five days A 68 year old man who was transferred from the CCU five days ago after having a myocardial infarction becomes part of your ago after having a myocardial infarction becomes part of your service. He has had no further chest pain or discomfort for the 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 last several days and he feels quite well. He is now ready for

discharge.discharge.1. What will you do prior to discharge?1. What will you do prior to discharge?--Stress testingStress testing

  2. Is angiography necessary?2. Is angiography necessary?Only if the stress test shows significant ischemiaOnly if the stress test shows significant ischemia

  3. When will you answer coronary artery bypass grafting (CABG)?3. When will you answer coronary artery bypass grafting (CABG)?

4. What will you discharge him on?4. What will you discharge him on?

5. What advice will you give him?5. What advice will you give him?

6. His wife asks you if the patient will have sex with her. What do 6. His wife asks you if the patient will have sex with her. What do you tell her?you tell her?

  

a. Aspirin, beta blockers, ACE inhibitors, Statinsa. Aspirin, beta blockers, ACE inhibitors, Statinsb. Beta blockers, ACE inhibitors, warfarinb. Beta blockers, ACE inhibitors, warfarinc. Aspirin alonec. Aspirin aloned. Aspirin, beta blockers, warfarind. Aspirin, beta blockers, warfarin

Question Case 8

A patient is being discharged after a myocardial infarction.

What will you discharge him on?

Congestive Heart FailureCongestive Heart Failure Case 1Case 1A 64 year old woman with a history of a myocardial infarction comes to 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 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 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 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, 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 an S3 gallop, pedal edema which extends to her areola, ascites and jugulovenous distension. jugulovenous distension.

1. What will you do first for her?1. What will you do first for her?

2. What is the MOST accurate means of assessing her ejection fraction?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 3. What will you do differently if the labs in the case state his baseline creatinine is 2.3?creatinine is 2.3?

4. When are angiotensin II receptor blockers the answer?4. When are angiotensin II receptor blockers the answer?

Case 2Case 2Two days later the same patient Two days later the same patient has completely improved. She is has completely improved. She is ten pounds lighter and she has no ten pounds lighter and she has no

dyspnea.dyspnea.What will you discharge her on?What will you discharge her on?

Valvular Heart DiseaseValvular Heart DiseaseA 27 year old woman comes to the office for evaluation of mild A 27 year old woman comes to the office for evaluation of mild

dyspnea. She emigrated from South America several years ago. On dyspnea. She emigrated from South America several years ago. On physical examination she has a respiratory rate of 22, jugulovenous physical examination she has a respiratory rate of 22, jugulovenous distention and bilateral basilar rales. Cardiac exam reveals a loud S1 distention and bilateral basilar rales. Cardiac exam reveals a loud S1

and a high pitched sound in diastole immediately followed by a and a high pitched sound in diastole immediately followed by a diastolic murmur.diastolic murmur.

1. What is the most likely diagnosis?1. What is the most likely diagnosis?    

2. What is the ‘best initial’ and ‘most accurate’ diagnostic tests?2. What is the ‘best initial’ and ‘most accurate’ diagnostic tests?Echo is always first. Cardiac angiography is more accurate and can give direct Echo is always first. Cardiac angiography is more accurate and can give direct

pressure measurements.pressure measurements.  

3. What is the best initial therapy?3. What is the best initial therapy?

Diuretics and sodium restrictionDiuretics and sodium restriction  

Several months later she returns because of worsening dyspnea despite Several months later she returns because of worsening dyspnea despite therapy. She is now six months pregnant.therapy. She is now six months pregnant.

4. What is the best therapy for her now?4. What is the best therapy for her now?

  

Atrial ArrhythmiasAtrial ArrhythmiasCase 1 Supraventricular tachycardiaCase 1 Supraventricular tachycardia

A 29 year old senior medical resident comes to the emergency room 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 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 cups of coffee, 4 beers, 3 cheeseburgers, 2 ‘power drinks’ and 1 viagra. An EKG shows supraventricular tachycardia at a rate of 160. viagra. An EKG shows supraventricular tachycardia at a rate of 160.

His blood pressure is 124/80.His blood pressure is 124/80.

1. What would you do first?1. What would you do first?

2. What is next if this is unsuccessful?2. What is next if this is unsuccessful?

    

3. What other medications are acceptable to control the rate?3. What other medications are acceptable to control the rate?

    

4. If the SVT continues to be recurrent what is the best long term 4. If the SVT continues to be recurrent what is the best long term therapy?  therapy?  

5. If the case were changed to atrial flutter how would the above answers 5. If the case were changed to atrial flutter how would the above answers differ?differ?

Case 3Case 3A 64 year old woman with a history of hypertension comes to the 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 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 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 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. her rate was elevated or that her rhythm was irregular or for how long.

A EKG shows atrial fibrillation at a rate of 118.A EKG shows atrial fibrillation at a rate of 118.

1. What is the best initial step in management?1. What is the best initial step in management?

  

2. After this is accomplished what would you do next?2. After this is accomplished what would you do next?

  

3. What is the best method of converting her to sinus 3. What is the best method of converting her to sinus rhythm?rhythm?

A 41 year old gastroenterologist has been having A 41 year old gastroenterologist has been having palpitations. His EKG shows atrial fibrillation with a palpitations. His EKG shows atrial fibrillation with a rate of 80. He has no past medical history, no diabetes rate of 80. He has no past medical history, no diabetes and no hypertension. His echo is normal. When you and no hypertension. His echo is normal. When you

discuss cardioversion by electricity or medications he discuss cardioversion by electricity or medications he refuses and instructs you to do something to yourself refuses and instructs you to do something to yourself

that is anatomically impossible. that is anatomically impossible.

  

What is the best therapy for this patient?What is the best therapy for this patient?

A 47 year old man comes to see you for advice about smoking cessation. 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 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 medications and has no allergies. He is not black, white, Asian or Hispanic. On physical examination he has a blood pressure of 155/92. Hispanic. On physical examination he has a blood pressure of 155/92. He comes back the following week to have his blood pressure checked He comes back the following week to have his blood pressure checked again because his managed care plan will not pay for ambulatory home again because his managed care plan will not pay for ambulatory home

blood pressure monitoring. His blood pressure is now 152/94. The blood pressure monitoring. His blood pressure is now 152/94. The following week it is the same.following week it is the same.

1. What is the next best step in the management of this patient?1. What is the next best step in the management of this patient?  

  

2. Which of these will be the most effective?2. Which of these will be the most effective?

  

3. Which of them has the weakest data to suggest efficacy?3. Which of them has the weakest data to suggest efficacy?

  

After four months of attempts he comes back After four months of attempts he comes back and says he would rather just be fat and lazy, and says he would rather just be fat and lazy, keep smoking and take some pills. keep smoking and take some pills.

What is the best initial medical therapy?What is the best initial medical therapy?   

  

What will you do in the 30% of patients who What will you do in the 30% of patients who are not adequately controlled with this are not adequately controlled with this regimen?regimen?

When you see THIS in the history

Use THIS as the ‘best initial therapy’

Diabetes  

Myocardial infarction  

CHF  

Isolated systolic hypertension  

Migraine headaches  

BPH  

Asthma  

Depression  

Peripheral arterial disease  

Osteoporosis  

Pregnancy  

Case 2Case 2A man has hypertension, a history of myocardial A man has hypertension, a history of myocardial

infarction and infarction and hyperlipidemiahyperlipidemia..

  

What will you answer as the first drug to use to control his What will you answer as the first drug to use to control his blood pressure?blood pressure?

Case 3Case 3A woman has hypertension, a history of myocardial A woman has hypertension, a history of myocardial

infarction and infarction and diabetesdiabetes..

1. What will you answer as the first drug to use 1. What will you answer as the first drug to use to control his blood pressure?to control his blood pressure?

  

2. What is the blood pressure goal of therapy?2. What is the blood pressure goal of therapy?

Case 4Case 4A man has a history of a mild myocardial A man has a history of a mild myocardial

infarction, hypertension and infarction, hypertension and asthma.asthma.

What will you answer as the first drug to use to What will you answer as the first drug to use to control his blood pressure?control his blood pressure?

Case 5Case 5A 54 year old man comes to the emergency A 54 year old man comes to the emergency

department with several hours of headache, blurry department with several hours of headache, blurry vision, mild confusion, and dyspnea. His blood vision, mild confusion, and dyspnea. His blood

pressure is 210/130.pressure is 210/130.

What is the best therapy for this patient?What is the best therapy for this patient?

  

  

When is sublingual nifedipine the correct answer?When is sublingual nifedipine the correct answer?

Case 7Case 7A 24 year old woman comes to see you because of headaches. A 24 year old woman comes to see you because of headaches.

On physical examination you find a blood pressure of On physical examination you find a blood pressure of 160/105. On physical examination you find a bruit on one 160/105. On physical examination you find a bruit on one

side. A renal ultrasound shows both kidneys are small but one side. A renal ultrasound shows both kidneys are small but one of the kidneys is slightly smaller than the other. of the kidneys is slightly smaller than the other.

What is the next best diagnostic step?What is the next best diagnostic step?

  

What is the most accurate diagnostic test?What is the most accurate diagnostic test?

  

  

What is the best initial therapy?What is the best initial therapy?