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  #1  
Old 10-20-2011
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Default Cardiology

A 58-year-old man with longstanding diabetes is evaluated for chest pressure. He has a past history of a non-Q-wave myocardial infarction 5 years prior and a below the knee amputation caused by diabetic complications. In addition to his diabetic and antihypertensive medications, he takes sublingual nitroglycerin on an as-needed basis, a daily baby aspirin, a lipid-lowering agent, and a beta-blocker. Vital signs are: blood pressure 130/85 mm Hg, resting pulse 53/min, and respirations 16/min. Recent laboratory work includes a hemoglobin A1c level of 7.2% and a low density lipoprotein level of 89 mg/dL. A dipyridamole (Persantine) thallium myocardial scan reveals mild global hypokinesis with a reversible anterior defect. Coronary arteriography reveals an ejection fraction estimated at 40-45%, diffuse irregularities of the left anterior descending artery, and a 90% stenosis of the left circumflex artery. Which of the following would be the most beneficial treatment for this patient?
A. Coronary artery bypass grafting
B. Heparin therapy
C. Increased beta blockade
D. Long-acting nitrate therapy
E. Percutaneous transluminal coronary angioplasty with stent placement
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  #2  
Old 10-20-2011
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is it E...PTCA???
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  #3  
Old 10-20-2011
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Non diabetic pt 2 artery occoluded stent 3 artery bypass

EXCEPT if Left main coronary block do a bypass

In diabetic 2 vessel block means bypass needed.

This case am not sure about the left anterrion decending you say diffuse irregularities so i suspect its not a significant stenosis ( meaning 70% or more stenosis as anything less not really treated with surgery) so im going to have to choose choice E with reservations
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Old 10-20-2011
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this diabetic patient might have sufferd 2nd MI with atypical symptoms(chest tigtness without pain ,vomitings etc.) ,so i prefer bypass ??????
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Old 10-20-2011
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A. Coronary artery bypass grafting
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Old 10-20-2011
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Default Answer

The correct answer is A. Coronary artery bypass grafting (CABG), compared with medical management, has been proven to prolong life in three subsets of patients with documented coronary artery disease on arteriography: 1) patients with extensive left main disease, 2) patients with three-vessel disease and a reduced ejection fraction, and 3) patients with two-vessel disease that includes proximal left anterior descending disease and a reduced ejection fraction or evidence of ischemia. Patients with diabetes also benefit from revascularization as compared with medical management plus PTCA. This patient is diabetic and has two-vessel disease with a reduced ejection fraction and evidence of reversible ischemia on thallium scintigraphy.

Heparin (choice B) is used in unstable angina when a thrombus has formed on a ruptured plaque. It is not indicated for stable coronary artery disease.

Beta-blockers (choice C) are excellent first-line medical therapy for coronary artery disease. They have been shown to reduce morbidity and mortality among patients with coronary heart disease after myocardial infarction (MI) and have been shown to reduce rates of stroke and nonfatal MIs. Additionally, patients at high risk for perioperative coronary events have improved outcomes with beta-blockade. This patient is already well treated. It is unlikely his pulse, already in the low 50s, could tolerate a significant increase in beta blockade. Further, this subpopulation benefits from CABG compared with medical therapy.

Long-acting nitrate therapy (choice D) can help control anginal symptoms, but have not been proven to reduce mortality. This patient will derive far greater benefit from a CABG.

Percutaneous transluminal coronary angioplasty with stent placement (choice E) is useful for discrete blockages. Given this patientís multivessel disease and diabetes, CABG is the preferred procedure.
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