Master the board step 3

Cardiology
Treatment
Aspirin and metoprolol are the 2 main routinely indicated medications
because of their benefit on mortality. Nitrates should be used for those with
angina pain but they do not lower mortality.
ACE inhibitors and ARBs should only be used in further management for
stable cases if the question describes any of the following:
··
Congestive failure
··
Systolic dysfunction
··
Low ejection fraction
Coronary angiography is predominantly used to determine who is a candidate
for coronary artery bypass grafting (CABG). You do not need to do
angiography to diagnose CAD. Stress testing can show “reversible ischemia.”
However, you must do angiography to see who needs CABG.
ARBs are used
interchangeably with ACE
inhibitors, especially if
the patient has a cough
with ACE inhibitors. Both
ACE and ARBs cause
hyperkalemia.
You do not need to do angiography to initiate the following:
··
Aspirin + metoprolol (mortality benefit)
··
Nitrates (pain)
··
ACE/ARB (low ejection fraction)
··
Clopidogrel, prasugrel, or ticagrelor (acute MI or cannot tolerate aspirin)
··
Statins (LDL > 70–100)
··
If pain persists, add ranolazine
Which of the following is the main difference between saphenous vein grafts and
internal mammary artery grafts?
a. There is less need for aspirin and metoprolol with internal mammary artery
grafts.
b. Warfarin is necessary with saphenous vein grafts.
c. Internal mammary artery grafts remain open for 10 years.
d. Heparin is necessary for vein grafts.
Answer: C. The main difference between saphenous vein grafts and internal mammary
artery grafts is that vein grafts start to become occluded after 5 years but internal
mammary artery grafts are often patent at 10 years. There is no difference in the need
for medications.
Indications for CABG:
··
Three coronary vessels with > 70 percent stenosis
··
Left main coronary artery stenosis > 50–70 percent
··
2 vessels in a diabetic
··
2 or 3 vessels with low ejection fraction
Ranolazine:
••
Anti-angina med
• • Added if other meds do
not control pain
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