Heart Disease And Chronic Stable Angina: Quiz!

Chronic stable angina is the correct answer in this case because it is the only one of the options which may be relieved by rest.

The pathophysiology of IHD is due to a disruption in the balance of myocardial oxygen supply and demand. The supply side consists of coronary blood flow, oxygen availability, and oxygen extraction. The demand side consists of heart rate, contractility, and wall tension.

Beta-blockers are titrated in order to achieve a heart rate of 55-60 bpm. However, the caveat here is that in some cases, adverse effects may cause the target to be changed for individual patients. An example of this could be symptomatic hypotension. Remember from A&P that cardiac output (CO)= Heart rate (HR) x Stroke volume (SV). Furthermore, Blood pressure (BP)= CO x vascular resistance. Therefore, since CO affects BP and HR affects CO...by lowering HR we are essentially lowering BP and this may become problematic for some patients.

Clopidogrel is indicated for monotherapy in patients who cannot take aspirin. In addition to this, dual therapy with ASA and clopidogrel may be used in patients who are at "high risk" (previous MI, previous ischemic stroke, or symptomatic PAD).

Tachyphylaxis is the correct answer. Remember that this means there is an acute decrease in response to the drug.

The bronchospastic disease is the only relative contraindication to beta-blockers listed here. All other options are examples of absolute contraindications to beta-blocker therapy.

Remember, metoprolol SUCCINATE (the extended-release form of the drug), NOT metoprolol TARTRATE (the immediate-release form of the drug) has been shown to prevent MI/mortality in studies.

CABG is generally recommended in preference to PCI to improve survival in patients with diabetes mellitus and multivessel CAD for which revascularization is likely to improve survival (3-vessel CAD or complex 2-vessel CAD involving the proximal LAD), particularly if a LIMA graft can be anastomosed to the LAD artery, provided the patient is a good candidate for surgery (Level of Evidence: B)

NSTEMI has a NON-occlusive thrombus. This, along with the ST-segment depression (vs. elevation) is the major difference between an NSTEMI and STEMI.

Ranolazine is used as a substitute for beta-blockers. This is used in the course of therapy if beta-blockers are contraindicated, ineffective, or cause too many adverse effects. Remember that in some cases if there is no contraindication or overwhelming adverse effects of beta-blockers, ranolazine may be used in addition to beta-blocker therapy if monotherapy is ineffective.

Due to the longer elimination half-life of tadalafil (15-35 hours), the recommended interval of separation of this drug is longer than that of sildenafil and vardenafil.

Beta-blockers, calcium channel blockers, and nitrates all decrease symptoms of angina. Ranolazine also decreases symptoms. Of note, beta-blockers are the only agents listed that decrease both mortality AND symptoms.

ACEI/ARBs, Aspirin, and beta-blockers have all been shown to decrease mortality in studies. Other agents that have been shown to have this same effect are clopidogrel and statins.

All of the above are correct except for a family history of diabetes. While diabetes itself is a risk factor for IHD, this is due to the pathophysiology of the disease. Therefore, someone with a family history of the disease would not be at an increased risk of IHD unless they had developed diabetes themselves.

As mentioned in question 6, beta-blockers provide both a decrease in mortality and symptoms and provides a rationale for use with HTN and IHD because it also helps to treat HTN. In patients with DM and HTN, ACEi is used to provide a nephroprotective effect. In addition to that, ACEi provides a decrease in mortality associated with IHD and help to treat HTN.

Concomitant use of simvastatin no greater than 20mg is recommended with amlodipine. Concomitant use of simvastatin no greater than 10mg is recommended with non-dihydropyridine calcium channel blockers. Using more than this amount can increase the risk of rhabdomyolysis and other muscle toxicities.