Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 232

1 Question 1. A 67-year-old man with a history of HTN and diabetes presents with exertional chest pain CCS III for 3–4 months. Chest pain is relieved with rest and with his wife’s NTG. He has left lower extremity claudication. On exam, distal left lower extremity pulses are not palpable. ECG shows LVH with 0.5 mm ST-segment depression. What is the most appropriate next step?Coronary angiographyExercise stress ECGExercise stress SPECTAdenosine SPECT

2 Question 2. A 67-year-old man with a history of LAD stent placed 2 years ago presents with mild angina on heavy exertion (CCS I). He is on atenolol, amlodipine, aspirin, and atorvastatin. BP 110/65, pulse 58 bpm. Exercise stress test result: 8 min on a Bruce protocol, mild angina occurred, DTS score +4. Nuclear perfusion shows a small area of apical–lateral ischemia, with a summed stress score of +3. Coronary angiography shows 60% proximal LCx stenosis, 30% mid-LAD, 40% mid-RCA. What is the next step?PCI of LCx. No need for FFR since the lesion is angiographically significantPCI of LCx. No need for FFR since the stress test is positiveFFR of LCx. Stent if FFR <0.80Continue medical therapy, no PCI

3 Question 3. A 76-year-old man presents with chest pain on heavy activity. His home medications consist of aspirin and a statin. A nuclear stress test shows mild/moderate anterior ischemia, and coronary angiography shows 80% mid-LAD stenosis. What is the next step?Medical therapy. There is no mortality difference between CABG, PCI, and medical therapy for this lesionPCICABG, since it provides mortality benefit compared to PCI or medical therapy

4 Question 4. Same scenario as Question 3, except the patient has severe anterior ischemia and 80% proximal LAD stenosis.Medical therapy.PCICABG, since it provides mortality benefit compared to PCI or medical therapy

5 Question 5. A 76-year-old man presents with chest pain on heavy activity (walking >2 blocks). He receives aspirin and a statin. A nuclear stress test shows moderate anterior ischemia, and coronary angiography shows 80% proximal LAD stenosis and 75% mid-RCA and mid- LCx stenoses. What is the next step?Medical therapyPCICABGA or CB or C

6 Question 6. A 47-year-old executive man, asymptomatic, is starting an exercise program at the gym. He is asymptomatic during daily activities. A stress test is ordered by his family physician. He exercises for 5 minutes and develops 1.5 mm ST depression without chest pain. Nuclear images show a large anterior and anterolateral reversible defect, with a normal EF and no TID. What is the next step?Just initiate medical therapyPerform coronary angiography, but only revascularize if left main or three-vessel CAD is presentCTAB or C

7 Question 7. A 56-year-old man presents with angina walking up one flight of stairs or less (= CCS III). He is not receiving any antianginal therapy. His nuclear stress test shows severe inferior ischemia. His angiogram shows CTO of the RCA with features that make it favorable for PCI (non-calcified, ~2 cm long)True or false: PCI is not appropriate, as the patient is not receiving maximal antianginal therapy

8 Question 8. A 50-year-old female, smoker, presents with chest pain that occurs with exertion, but not consistently, and sometimes occurs at rest. Each episode lasts ~45 minutes. BP = 160/95, HR = 78. She undergoes a treadmill nuclear stress testing. She exercises for 5 minutes, does not report any chest pain, and no ST abnormality is seen. Her nuclear images show a large reversible anterior defect with a summed stress score of +10. The patient prefers to try medical therapy first if deemed appropriate by the physician. What is her Duke Treadmill Score? What is the most appropriate next step?Start aspirin, statin, β-blockers and amlodipine. Coronary angiography is indicated, as her risk of cardiac events is >5% per yearStart aspirin, statin, β-blockers and amlodipine. CTA is indicated, as her risk of cardiac events is >5% per yearNo further test is indicated, as her risk of cardiac events is <1% per yearStart amlodipine, since the likely diagnosis is vasospasm

9 Question 9. A 65-year-old diabetic patient is planning to undergo elective cholecystectomy. He has mild dyspnea on exertion (>4 METs) but no angina. He undergoes preoperative testing with a nuclear SPECT, which shows severe inferior ischemia and preserved EF. Coronary angiography shows 80% mid-RCA stenosis. What is the next step?Aggressive medical regimen. Revascularization is not indicated. His surgical risk is intermediate but revascularization will not improve itAggressive medical regimen. Revascularization is not indicated. His surgical risk is low and revascularization will not improve itAggressive medical regimen and PCI of the RCA with BMSAggressive medical regimen and PCI of the RCA with DES

10 Question 10. A 58-year-old woman has exertional chest pain (and some episodes of pain with mental stress). While undergoing treadmill stress ECG, she develops severe chest pain, inferior ST-segment elevation, and multiple runs of non-sustained VT. The pain and ST elevation resolve at 5 minutes of recovery. Coronary angiography is performed and shows a smooth 80% stenosis of the mid-RCA, which improves to a mild, 25% stenosis with NTG. What is the prognosis and what is the treatment?Even in the absence of obstructive CAD, her risk of unstable angina/MI/VT is ~20% at several years of follow-up. She must be placed on amlodipine and statinIn the absence of obstructive CAD, her risk of unstable angina/MI/VT is low (<5%) at several years of follow-up. Provide CCB for symp- tomatic reliefVasospasm frequently occurs on top of obstructive CAD. Perform IVUS to ensure that the residual stenosis is not a more severe stenosis or a ruptured plaque.

11 Question 11. A 55-year-old woman, smoker, presents with exertional chest pain. A nuclear stress test shows a reversible anterior defect. Coronary angiography is performed and does not show any obstructive CAD. Moderate bridging of the mid-LAD (50% obstructive) is seen. What is the diagnosis?Myocardial bridgingCoronary epicardial vasospasmMicrovascular dysfunctionAny of the above

12 Question 12. What diagnostic testing could help establish the diagnosis in the patient of Question 11?Stress echoStress MRIIntracoronary acetylcholine testingIntracoronary or intravenous adenosine testingAdminister NTG during coronary angiography, even if no spasm is seenB, C, D, and EAll of the above

13 Question 13. A 50-year-old man presents with resting chest pain and ST-segment elevation in the inferior leads. His coronary angiography shows a smooth 90% mid-RCA stenosis that is relieved with NTG. Which statement is incorrect?Prinzmetal angina is twice more common in women than menMicrovascular dysfunction is more common than macrovascular spasmWithout CCB therapy, recurrent MI occurs in a substantial proportion of patients with Prinzmetal angina (~20%)The definite diagnosis requires a concomitant documentation of the following three features: vasospasm on angiography, chest pain, and ST-segment changesAmong patients with exertional chest pain, abnormal stress testing, yet unobstructed coronary arteries, the incidence of coronary vasomotion abnormalities is 50-70% (macrovascular or microvascular)

14 Question 14. A 69-year-old man has chronic exertional angina, CCS III. He undergoes coronary angiography and is found to have 90% proximal RCA stenosis. Which statement is correct?Initial PCI, as opposed to initial medical therapy only, reduces his risk of MIInitial PCI reduces his cardiovascular mortalityInitial PCI reduces anginaSingle-vessel CABG reduces his risk of death or MI

15 Question 15. A 59-year-old woman has occasional, atypical, non-exertional chest pain. She undergoes stress testing, which shows a large anterior defect. Coronary angiography shows 80% proximal LAD stenosis with FFR of 0.67. Which statement is correct (multiple possible answers)?Initial PCI reduces her risk of MIInitial PCI reduces her cardiovascular mortalityInitial PCI reduces anginaIf the patient is undergoing non-cardiac surgery, PCI of LAD reduces her risk of perioperative MISingle-vessel CABG may reduce her risk of death or MI

16 Question 16. After undergoing coronary revascularization, which statement is incorrect?After one- or two-vessel PCI, the risk of repeat revascularization is ~20% at 5 yearsAfter multivessel revascularization, the risk of recurrent events is ~27% with CABG and ~37% with PCI at 5 yearsAfter high-risk PCI (e.g., complex proximal LAD PCI), stress testing is indicated routinely at 6–12 months

17 Question 17. A 70-year-old man has undergone PCI of the mid-LAD with one DES 1 year ago. He presents with recurrent mild angina. Coronary angiography shows 90% in-stent restenosis of the LAD. What is the next step?Medical therapyPCICABGPCI or CABG

18 Question 18. A 51-year-old woman presents with exertional angina. She undergoes a standard treadmill ECG testing, where she exercises for 7 minutes and exhibits her typical angina without any ST change. What is the next step?Risk factor modification, aspirin, statin, and antianginal therapyCoronary angiographyCTA

19 Question 19. A coronary angiography is performed for the patient in Question 18 and does not reveal any significant CAD. What is the next step?Reassure the patient that her pain is not of a cardiac origin. Consider gastroesophageal reflux therapyThe patient likely has coronary vasospasm. Prescribe amlodipinePerform adenosine PET imaging. If the diagnosis is confirmed, add metoprolol and L-ArgininePerform adenosine PET imaging. If the diagnosis is confirmed, add nitrates

20 Question 20. A 50-year-old diabetic man has exertional angina (2 flights of stairs, 4 blocks). On stress echo, he walks 7 minutes on Bruce protocol, develops mild pain, 2 mm of ST depression in leads V4–V6, and inferior hypokinesis. Coronary angiography shows 80% proximal RCA stenosis, with no disease in the LAD or LCx. What is the next step?Optimize medical therapyPerform RCA PCIPerform RCA FFR, then PCI if appropriate

21 Question 21. In a diabetic patient with stable angina, which of the following is incorrect:β-Blockers reduce mortality in patients with stable CAD and without prior MIMetoprolol worsens HbA1c, while carvedilol does not affect HbA1c and improves insulin resistanceThe higher the HbA1c, the more effective ranolazine is in reducing angina of diabetic patientsRanolazine improves HbA1c by up to 1%

22 Question 22. A 60-year-old diabetic man has dyspnea on exertion and occasional episodes of rest chest discomfort. A resting ECG shows borderline inferior Q waves. On stress echo, he walked 8 minutes and had 1 mm of ST-segment depression in V4–V6, with dyspnea and no chest pain. His inferior wall is akinetic with EF 35–40% at rest and without worsening during exercise. Coronary angiography shows a totally occluded RCA in its mid-segment, and moderate, 50% disease in the proximal LAD. What is the next step?Aggressive statin and antianginal therapy. No revascularization of RCA CTORevascularization of RCA CTOPerform FFR of LAD. If significant, refer to CABG (LAD and RCA). If insignificant, perform PCI of RCAPerform FFR of LAD. If significant, refer to CABG. If insignificant, perform medical therapy onlyPerform FFR of LAD. If significant, perform LAD PCI (not RCA). If insignificant, perform medical therapy only

23 Question 23. In stable CAD, which two features guide the decision to revascularize?

24 Answer 1. A (Section II.C). According to Hubbard et al., the patient has >40% risk of severe CAD (age, sex, diabetes, typical angina).¹³ Also, PAD predicts severe CAD. He has not only a high probability of CAD, but a high probability of severe CAD. The severity of his angina is another indicator of the need for invasive angiography with possible revascularization.

25 Answer 2. D. This is a typical COURAGE patient with mild angina, good functional capacity, and low-risk stress test. For this patient, medi- cal therapy is as good as PCI + medical therapy. If angina is severe despite medical therapy, COURAGE functional substudies would support PCI (PCI would be superior to medical therapy for reduction of angina and reduction of ischemic burden). FFR is not necessary, since ischemia of the LCx territory has already been proven by nuclear imaging.

26 Answer 3. A. Except in left main disease, a patient with mild stable angina is appropriately treated with medical therapy only, regardless of ischemia severity. The MASS trial showed that for isolated LAD disease >80%, there was no difference in mortality between CABG vs. angioplasty vs. medical therapy, although angina was reduced with angioplasty and more so with CABG. The LAD disease addressed in the MASS trial was proximal LAD disease.

27 Answer 4. A .Again, a patient with mild angina and no severe functional limitation is appropriately treated with medical therapy only (typical COURAGE or ISCHEMIA patient). In the stable CAD setting, the value of revascularization is purely symptomatic and is questionable in a patient with no severe or refractory angina, even if proximal LAD (ISCHEMIA, COURAGE, MASS trial), severe ischemia (ISCHEMIA), or multivessel disease is present (ISCHEMIA, COURAGE, BARI 2D).

28 Answer 5. D. As opposed to Questions 3 and 4, the patient has three-vessel CAD (>70%). Similarly to the previous questions, he does not necessarily need revascularization per ISCHEMIA and BARI2 D trials. CABG revascularization remains reasonable based on old CABG vs medical therapy trials. Of note, the stress test may underestimate the true severity of ischemia. Nuclear defects being comparative to the best segment, the LCx and RCA may appear to be normally perfused when, in fact, they are ischemic but less ischemic than the LAD. If revascularization is chosen, FFR may be warranted since stress test is not high risk and will allow adequate assessment of RCA and LCx.

29 Answer 6. D. Asymptomatic patients qualify for revascularization only if left main disease is present (according to ISCHEMIA trial). Possibly, they may qualify for revascularization if 3-vessel CAD or 2-vessel CAD with proximal LAD is present (according to old CABG vs medical therapy trials). CTA is an appropriate alternative to coronary angiography even after high-risk stress test, as per ISCHEMIA trial. While one may question the indication of stress test in this asymptomatic patient, it is reasonable to exclude left main disease once ischemia is found.

30 Answer 7. True. PCI of CTO is more technically challenging than standard PCI (2-3 times complication rates). Even more strictly than standard PCI, it is only indicated in patients who have severe and refractory angina, particularly with favorable PCI features (short <2 cm, not heavily calcified, good stump).

31 Answer 8. B. The patient has low-risk DTS of +5. A low-risk stress ECG/low risk DTS does not necessarily rule out high-risk CAD. In fact, 10% of patients with low-risk DTS have left main or three-vessel CAD. A high-risk stress imaging result overrules a low or intermediate DTS. This patient has a high-risk stress imaging result, but based on ISCHEMIA trial, this does not mandate an invasive strategy (coronary angiography +/- revascularization). A conservative strategy, preferably after left main rule-out by CTA, is appropriate.

32 Answer 9. A. The patient does not have a clear angina. Revascularization is only indicated if symptoms are severe or refractory. The patient has an increased surgical risk, including a risk of functional ischemia/infarction of the RCA territory during surgery. However, except for left main disease or extensive three-vessel CAD, preoperative revascularization does not change postoperative cardiac complications. If surgery is necessary, medical therapy with a statin and a β-blocker, initiated more than a week before surgery, and careful perioperative monitoring are the strategies that improve outcomes.

33 Answer 10. A. Even in the absence of CAD, vasospastic angina is associated with a significant risk of cardiac events (~20% within a few years), especially when extensive or severe ST changes or arrhythmias have been demonstrated. With CCB, this risk is reduced to <1% (unstable angina may occur at a higher rate). Statin has additional benefit on top of CCB. IVUS is reasonable if the lesion is ≥50% obstruc- tive on angiography or has worrisome angiographic features (overhanging borders, eccentric, hazy).

34 Answer 11. D. Even if coronary angiography does not show any obstruction, a convincing chest pain history along with a perfusion abnor- mality suggest that the chest discomfort is a true angina. Half of women whose symptoms are worrisome enough to warrant coronary angiography but who are not found to have CAD have, in fact, microvascular dysfunction or, less so, macrovascular spasm. This is particularly the case of patients with typical angina features and abnormal stress testing. Myocardial bridging is usually incidental, even when severe; however, it may be considered the culprit in a patient with typical angina and anterior ischemia.

35 Answer 12. F. Stress MRI and stress PET are the best non-invasive modality for the diagnosis of microvascular dysfunction, followed by stress SPECT (which has the pitfall of a high false-positive rate in women). Stress echo and stress ECG have a lower yield. Invasively, there are two aspects of microvascular dysfunction: (i) microvascular spasm, unveiled by acetylcholine, (ii) inability to vasodilate and increase coronary flow, unveiled by adenosine infusion. Concerning myocardial bridging, NTG administration may worsen it and further suggest it as a culprit.

36 Answer 13. A. Macrovascular spasm is only slightly more common in women than men. Microvascular dysfunction is 4 times more common in women than men.

37 Answer 14. C. In stable CAD, PCI only improves angina control. There is no demonstrated effect on MI or mortality, even if the lesion appears angiographically critical. It may improve unstable angina presentations (FAME 2 trial), but not MI. PCI is appropriate in a patient with severe angina, especially if it persists despite antianginal therapy. In the stable CAD setting, revascularization with CABG improves mortality of patients with left main disease and likely that of patients with three-vessel disease or two-vessel disease with proximal LAD (in multivessel disease without left main involvement, CABG may only reduce MI risk, not mortality, as per BARI 2D trial).

38 Answer 15. C. In stable CAD, PCI has not demonstrated a reduction of mortality or MI in comparison with medical therapy, even when the proximal LAD is treated (COURAGE, ISCHEMIA, MASS, MASS II trials). CABG may reduce mortality in single-vessel proximal LAD according to a meta-analysis of old CABG vs. medical therapy trials, but not according to more recent trials (MASS, BARI 2D, ISCHEMIA). Preoperative revascularization has not demonstrated an improvement of postoperative outcomes, except, possibly, in the case of left main or three-vessel CAD.

39 Answer 16. C. Asymptomatic restenosis is not clearly associated with adverse prognosis. Also, there is no evidence that PCI for recurrent, asymptomatic ischemia improves outcomes, and thus routine testing is not indicated. Concerning choice B, note that, after CABG, ~27% of patients have recurrent events at 5 years, yet each SVG has ~30% risk of occlusion at 5 years (most SVG occlusions are asymptomatic).

40 Answer 17. D. ISCHEMIA trial, wherein revascularization did not prove superior to conservative management in stable, high-risk CAD, excluded patients with PCI or CABG in the last year. COURAGE trial excluded patients with isolated in-stent restenosis. Symptomatic DES restenosis is often treated with repeat PCI: intracoronary imaging is performed to check for stent expansion, as stent underexpansion accounts for at least 50% of DES restenosis and is treated with high-pressure balloon inflation. If restenosis is mainly due to neointimal hyperplasia or if it is diffuse or extending outside the stent, repeated DES stenting is performed (stent inside a stent). CABG is an alternative therapy for LAD in-stent restenosis.

41 Answer 18. A. The stress test does not reveal high-risk findings and proves a good functional capacity. Thus, medical therapy for low-risk CAD vs. microvascular disease may be initiated. CTA or stress imaging may be performed for further risk stratification, but is not necessary.

42 Answer 19. C. Half of women with typical angina have no significant CAD. The most likely cause of angina in this case is endothelial dysfunction, with inability of the microvasculature to dilate during stress. Macrovascular spasm is a second possibility, but it is less likely and more commonly presents as rest pain (vs. exertional pain in microvascular dysfunction). The diagnosis is made non-invasively by comparing the rest and post-adenosine myocardial perfusion using PET or MRI. Unlike macrovascular spasm, metoprolol is a first-line treatment for microvascular dysfunction (CorMica trial).

43 Answer 20. A. The patient has mild angina (CCS I) and mild functional limitation. This is a typical ISCHEMIA trial patient, where PCI does not improve survival or MI rates. To qualify for revascularization, his angina needs to be severe and persistent despite two antianginal drugs, or he needs to have left main disease (+/- 3-vessel CAD or 2-vessel with proximal LAD)

44 Answer 21. A.

45 Answer 22. The patient does not clearly have angina, although dyspnea may be an angina equivalent (exertional dyspnea is commonly multifactorial and is not as specific as chest pain for CAD). Revascularization would only be appropriate for severe angina, or clinical HF caused by LV dysfunction. If dyspnea and LV dysfunction persist after medical therapy, PCI of RCA may be justified. If performed immediately, FFR of the LAD may be low but exaggerated as it supplies collaterals to the RCA (for the same lesion: larger territory→> lower FFR). It is best to perform FFR of such a moderate LAD stenosis only after RCA recanalization, when such recanalization becomes indicated.Answer 23.

46 Answer 23. Decision to revascularize is guided by: (1) severity of angina, and (2) presence of left main disease (+/- other high-risk anatomical features, such as 3-vessel CAD or 2-vessel with proximal LAD). ISCHEMIA trial questioned the role of severe ischemia which was previously used to guide revascularization.