Internal Medicine Handout for PLE October 2023
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Questions and Answers

Which of the following cases should a cardiac stress test be obtained for Angina Pectoris?

  • Both cases mentioned above
  • A 60-year-old female hypertensive and smoker with retrosternal chest pain precipitated by exertion and relieved by rest (correct)
  • A 20-year-old female with chest pain not triggered by exertion or relieved by rest or nitroglycerin

    • What is the most likely diagnosis for the second case mentioned (60-year-old female with retrosternal chest pain precipitated by exertion and relieved by rest)?

    Angina Pectoris

    What should be considered when determining the next best step in patient management?

    Diagnostic information, staging, or therapy

    What is the recommended dose of Aspirin for event prevention?

    <p>81-162mg/day</p> Signup and view all the answers

    What is the mechanism of action of Clopidogrel? Clopidogrel is a P2Y12 inhibitor that decreases ______ aggregation.

    <p>platelet</p> Signup and view all the answers

    Which class of drugs reduces heart rate, contractility, atrioventricular conduction, and ectopic activity?

    <p>Beta blockers</p> Signup and view all the answers

    What is one of the anginal equivalents commonly seen in women and older adults?

    <p>Dyspnea</p> Signup and view all the answers

    To increase the sensitivity of detection of CAD beyond ECG, the choice is a ______________ test.

    <p>Stress</p> Signup and view all the answers

    What is an indicator of severe coronary artery disease (CAD) based on the redistribution of coronary blood flow?

    <p>Postprandial angina</p> Signup and view all the answers

    Exercise as a form of stress test can provide physiologic data such as exercise time and workload.

    <p>True</p> Signup and view all the answers

    What is the next best step for a patient with traumatic tension pneumothorax?

    <p>Immediate decompression by doing needling thoracentesis</p> Signup and view all the answers

    For a patient considered to have an acute coronary syndrome, what is the next best step?

    <p>Treat with Aspirin</p> Signup and view all the answers

    How to distinguish anginal chest pain from other causes: _ chest pain vs. _ chest pain

    Signup and view all the answers

    Which of the following chest pain descriptions would MOST likely point to a possible acute coronary syndrome?

    <p>Pain lasting more than 10 minutes</p> Signup and view all the answers

    Which among the following laboratory parameters/procedures will dictate the management for ACS?

    <p>Trop I</p> Signup and view all the answers

    Given the clinical picture of anginal chest pain, which of the following features will lead you to proceed with urgent coronary angiogram possible angioplasty?

    <p>New abnormal wall motion and contractility on 2D Echo</p> Signup and view all the answers

    A 68-year-old male came in for sudden onset substernal chest pain. ECG revealed inferior wall STEMI, without Right Ventricle involvement. What is the next step in management?

    <p>Immediate PCI</p> Signup and view all the answers

    Which of the following medications is CONTRAINDICATED in this case?

    <p>Aspirin</p> Signup and view all the answers

    What is the most common cause of in-hospital death among patients suffering from ACS?

    <p>Ventricular Fibrillation</p> Signup and view all the answers

    Which of the following will you NOT CONSIDER first in the case mentioned? (Patient brought to the emergency room for chest heaviness)

    <p>Acute coronary syndrome</p> Signup and view all the answers

    For patients with STE-ACS (Infarct), what is the diagnostic procedure of choice to determine the direction of management?

    <p>2D echocardiogram</p> Signup and view all the answers

    Which of the following medications is contraindicated for a 68-year-old male with inferior wall STEMI without Right Ventricle involvement?

    <p>Metoprolol</p> Signup and view all the answers

    What is the most common cause of in-hospital death among patients suffering from ACS?

    <p>Pump Failure</p> Signup and view all the answers

    In which phase of the cardiac cycle is the Left Ventricle emptied?

    <p>Systole</p> Signup and view all the answers

    The most common cause of out-of-hospital death from STEMI is Ventricular Fibrillation, while the most common cause of in-hospital death is ___________.

    <p>Pump Failure</p> Signup and view all the answers

    What makes up the second heart sound (S2)?

    <p>Aortic (A2) and pulmonic (P2) valve closure</p> Signup and view all the answers

    Where are the individual components of the second heart sound BEST heard?

    <p>Second left interspace</p> Signup and view all the answers

    The A2-P2 interval narrows with expiration. True or False?

    <p>True</p> Signup and view all the answers

    A widened A2-P2 interval is associated with severe _?

    <p>MR</p> Signup and view all the answers

    Match the following diastolic sounds with their associated conditions:

    <p>Opening Snap = Mitral Stenosis Tumor Plop = Atrial Myxoma Pericardial Knock = Constrictive Pericarditis</p> Signup and view all the answers

    What is the next best step for a patient with traumatic tension pneumothorax?

    <p>Immediate decompression by doing needling thoracentesis</p> Signup and view all the answers

    For a patient being considered for acute coronary syndrome, what is the next best step?

    <p>Treat with Aspirin to save myocardium</p> Signup and view all the answers

    What is the best initial test for a male patient presenting with sudden severe headache and focal neurologic deficit?

    <p>Non-contrast head CT scan</p> Signup and view all the answers

    What type of murmurs generally INCREASE with inspiration?

    <p>Right-sided murmurs (TS, TR, PS, PR)</p> Signup and view all the answers

    What is the most likely diagnosis for the 69-year-old man with severe chest pain, bibasal crackles, and ST elevation in V3 and V4 leads?

    <p>Acute ST-elevation MI, anterior wall, Killip II</p> Signup and view all the answers

    Which type of murmurs are usually LOUDER during expiration?

    <p>Left-sided murmurs (AS, AR, MS, MR)</p> Signup and view all the answers

    What happens to most murmurs in terms of length and intensity?

    <p>MOST murmurs DECREASE in length and intensity</p> Signup and view all the answers

    What is the underlying pathophysiology in the case of the 69-year-old man?

    <p>Acute plaque rupture</p> Signup and view all the answers

    What is considered a pivotal diagnostic test for management of ST-elevation MI?

    <p>ECG</p> Signup and view all the answers

    Give two exceptions to the general trend of murmurs decreasing in intensity.

    <ol> <li>HOCM: becomes much louder</li> <li>MVP: becomes longer and often louder</li> </ol> Signup and view all the answers

    What happens to right-sided murmurs after the release of the Valsalva maneuver?

    <p>Return to baseline intensity earlier than left-sided murmurs</p> Signup and view all the answers

    What is the primary goal in the management of ST-elevation MI?

    <p>Reperfusion therapy</p> Signup and view all the answers

    Which of the following chest pain descriptions would MOST likely point to a possible acute coronary syndrome?

    <p>Pain lasting more than 10 minutes</p> Signup and view all the answers

    What typically happens to most murmurs with standing?

    <p>DIMINISH</p> Signup and view all the answers

    What is the average rate of hemodynamic progression involving aortic valve area?

    <p>Decrease in aortic valve area of 0.12 cm2/year</p> Signup and view all the answers

    Which laboratory parameter/procedure will dictate the management for Acute Coronary Syndrome?

    <p>Troponin I</p> Signup and view all the answers

    In the context of anginal chest pain, what feature would lead to the decision to proceed with urgent coronary angiogram or possible angioplasty?

    <p>Elevated Troponin</p> Signup and view all the answers

    Which two factors are associated with more rapid hemodynamic progression?

    <ol> <li>Older age</li> <li>Other factors not specified</li> </ol> Signup and view all the answers

    Study Notes

    Approach to Clinical Problem Solving

    • A cardiac stress test is not necessary for a 20-year-old female with chest pain that is not triggered by exertion and not relieved by rest or nitroglycerin.
    • A 60-year-old female with hypertension and smoking history, presenting with retrosternal chest pain precipitated by exertion and relieved by rest, should not undergo a treadmill stress test.
    • The clinician must establish whether the pain satisfies the three criteria for typical anginal pain: retrosternal or substernal in location, precipitated by exertion, and relieved within minutes by rest or nitroglycerin.
    • Consider other factors, such as age and risk factors, to determine the pretest probability for angina pectoris.

    Diagnostic Reasoning

    • There are two ways to make a diagnosis: pattern recognition and several steps in diagnostic reasoning.
    • Gather information with a differential diagnosis in mind, and undertake several steps in diagnostic reasoning.
    • Conceptualize the patient's objective problem with the greatest specificity one can achieve.
    • Look for discriminating features to support or refute each potential diagnosis.

    Cardiovascular Medicine

    • The most likely diagnosis for a 60-year-old female with hypertension and smoking history, presenting with retrosternal chest pain precipitated by exertion and relieved by rest, is angina pectoris.
    • In making the diagnosis of angina pectoris, the clinician must establish whether the pain satisfies the three criteria for typical anginal pain.

    Critical Care Medicine

    • The next best step depends on the clinical state of the patient, the potential severity of the disease, and the uncertainty of the diagnosis.
    • If the patient is unstable, the next best step is almost always therapy.

    Trauma and Tension Pneumothorax

    • The most urgent next step for a patient with severe dyspnea and absent breath sounds on the left lung after a traumatic chest injury is immediate decompression by doing needling thoracentesis.

    Acute Coronary Syndrome

    • For a patient being considered to have an acute coronary syndrome, the next best step is to treat with Aspirin, as it decreases mortality in the face of an acute coronary event.

    Ischemic Chest Pain

    • Ischemic chest pain has a sudden onset, increasing intensity, and is provoked by an activity (e.g., exercise, extreme emotion).
    • It may or may not respond to sublingual nitroglycerin.
    • Non-ischemic chest pain is usually predictable, precipitated by meal intake (GI causes), and changes in position.

    Subarachnoid Hemorrhage

    • The best initial test for a patient with sudden severe headache and focal neurologic deficit is a non-contrast head CT scan.

    • If the CT scan is negative, a lumbar puncture may be necessary.

    • The hallmark of aneurysmal rupture is blood in the CSF, and xanthochromia is the gold standard for the diagnosis of SAH.### Colicky Meningitis

    • Presents with radiation of pain to upper abdomen, shoulders, arms, and back

    • Can also radiate to wrist, fingers, neck, and throat, but not upper jaw

    • Empiric antibiotics should be loaded

    Cardiovascular Medicine

    • Ischemic Heart Disease (IHD) types:
      • Acute Coronary Syndrome
      • Chronic Coronary Syndrome
    • Risk factors:
      • Hypertension
      • Diabetes
      • Dyslipidemia
      • Obesity
      • Physical inactivity
      • Family history of premature CAD

    Anginal Equivalents

    • Dyspnea
    • Faintness
    • Fatigue
    • Exertional dyspnea (may be an indicator of IHD even when angina is absent or no evidence of CAD on ECG)
    • Postprandial angina (caused by redistribution of coronary blood flow, a marker of severe CAD)

    Stress Test

    • Used to increase sensitivity of CAD detection beyond ECG
    • Exercise stress test is the choice because it provides physiologic data such as exercise time and workload
    • Pharmacologic stress test forms: Dobutamine, Adenosine, and Dipyridamole

    Coronary Angiogram

    • Visualizes vessels up to small arteries
    • Lesions that can be treated by angioplasty are up to 200μm only

    Indications for Coronary Angiogram

    • Patients >45 years and females >55 years who are to undergo a cardiac operation
    • Patients after myocardial infarction
    • Patients with angina pectoris, regardless of severity, in whom noninvasive testing indicates a high risk of coronary events
    • Patients in whom coronary spasm or another nonatherosclerotic cause of myocardial ischemia is suspected

    Chronic Coronary Syndrome

    • Clinical presentation: inducible chest pain relieved by rest
    • Diagnosis: ECG / Stress Test
    • Management:
      • Medical
      • High risk features: send for coronary angiogram
      • Definitive Management: Revascularization (PCI or CABG)

    Medications

    • Aspirin: 81-162mg/day, cyclooxygenase-1 inhibitor, IA level of evidence
    • Clopidogrel: 75mg/day, P2Y12 inhibitor, IB level of evidence
    • Statins: 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, IA level of evidence
    • ACEi/ARB: RAAS blockers, IA level of evidence
    • Beta blockers: reduce heart rate, contractility, atrioventricular conduction, and ectopic activity, IA level of evidence### Class of Medications for Acute Coronary Syndrome (ACS)
    • Calcium Channel Blockers (CCBs):
      • Verapamil: 80-160mg 3x daily (immediate release), 120-480mg daily (slow release)
      • Diltiazem: 30-80mg 4x daily (immediate release), 120-320mg daily (slow release)
      • Contraindications: low heart rate, conduction disorder, sick sinus syndrome, CHF/low blood pressure, cardiogenic shock, severe aortic stenosis
    • Dihydropyridine CCBs:
      • Amlodipine: 5-10mg OD
      • Felodipine: 5-10mg OD
      • Nifedipine: 30-90mg OD (immediate release), 30-180mg OD (slow release)
      • Contraindications: severe aortic stenosis, obstructive cardiomyopathy, cardiogenic shock
    • Nitrates:
      • ISMN: 30-120mg OD
      • ISDN: 5mg SL prn
      • Contraindications: hypertrophic obstructive cardiomyopathy, low heart rate, heart rhythm disorder, allergy
    • Ivabradine:
      • 5mg-7.5mg BID
      • Contraindications: allergy, severe hepatic disease, cardiogenic shock
    • Nicorandil:
      • 10-40mg BID
      • Contraindications: allergy, severe hepatic disease
    • Trimetazidine:
      • 35mg BID
      • Contraindications: Parkinson's disease, tremor and movement disorders

    Indications for Coronary Artery Bypass Graft Surgery (CABG)

    • Left main coronary artery disease
    • 3 vessel disease + LVEF < 50% or diabetes
    • 2 vessel disease that includes proximal left descending coronary artery

    Management of Acute Coronary Syndrome (ACS)

    • Patients with unacceptable level of angina despite optimal medical management should be considered for coronary revascularization
    • Patients with single- or two-vessel disease with normal LV function and anatomically suitable lesions are advised to undergo PCI
    • Heart Team decision-making process involving cardiologist, surgeon, patient, and relative

    Classification of Myocardial Infarction

    • Type 1: Spontaneous myocardial infarction
    • Type 2: Myocardial infarction secondary to an ischemic imbalance
    • Type 3: Myocardial infarction resulting in death
    • Type 4a: Myocardial infarction related to percutaneous coronary intervention (PCI)
    • Type 4b: Myocardial infarction related to stent thrombosis
    • Type 5: Myocardial infarction related to coronary artery bypass grafting (CABG)

    Diagnostic Procedure for ACS

    • ECG: diagnostic procedure of choice to determine the direction of management
    • Troponin: laboratory parameter to dictate the management of ACS

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    Description

    Topnotch Medical Board Prep's handout for Internal Medicine review, specifically designed for the October 2023 PLE batch. This handout is only valid for this batch and will be updated regularly.

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