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  #1  
Old 05-11-2013
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Question Cardiology Step 3 Patient!

A 65 year old man with HTN presents to your office for evaluation of right leg pain that increases on walking about one block. The pain seems to disappear when he sits and takes rest for about 10 minutes. He is concerned because it is interfering with his exercise activity that his cardiologist has recommended him. His medications include hydrochlorthiazide and enalapril. The patient has a history of heavy smoking but he quit 2 years ago. Physical exam was normal except for diminished dorsalis pedis pulses bilaterally. An arterial doppler is performed and ankle brachial index obtained which is 0.70.
The next best step in the management of his leg pain?
A) Start Cilostozol
B) Start Pentoxyfilline
C) Supervised exercise therapy
D) Recommend unsupervised exercise for 30 minutes everyday.
E) Add clopidogrel.
F) Obtain Magnetic Resonance Angiography.
G) Arterial bypass surgery

For the patient in Q437, which of the following is most effective in reducing the combined risk of ischemic stroke, myocardial infarction, or vascular death ?

A) Aspirin
B) Clopidogrel
C) Cilostozol
D) Pentoxifilline
E) Abciximab

The patient was appropriately treated and a follow up visit was scheduled one month later. The patients symptoms have moderately improved. During this visit, his fasting lipid panel revealed an LDL of 126mg%, HgbA1c of 5.5 and a blood pressure of 128/82. Next important step:
A) Advise dietary modification to treat his high LDL cholesterol
B) Start Atorvastatin and Dietary changes
C) Start Metformin
D) Start Metoprolol

Three months after he was diagnosed with Peripheral arterial disease, the patient suffered a massive myocardial infarction and hospitalized. He underwent Coronary artery bypass grafting and his symptoms are now well controlled. While in the hospital, the patient was started on Aspirin and Clopidogrel. He was continued on Hydrochlorthiazide and Enalapril. His Ejection fraction after the MI was 35%. One month after discharge, during a regular follow up with his cardiologist, he was started on metoprolol. Two weeks after this the patient comes back to your office with worsening leg pain on walking. On physical examination, the legs are normal in color with diminished dorsalis pedis pulses bilaterally.
Next best step in management:

A) Stop metoprolol
B) Change metoprolol to carvedilol
C) Start Cilostozol
D) Obtain angiogram and schedule arterial bypass surgery
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  #2  
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A
b
b
d
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  #3  
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Quote:
Originally Posted by firstaid150 View Post
A
b
b
d
why did you pick clopidogrel over aspirin for the second question?
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  #4  
Old 05-11-2013
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Cuz i read in uw that clopidogrill has more benifit over asprin. Wat are the rite answers?
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Plus clopidogril is superior for stroke prevention
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Old 05-12-2013
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A) Cilostazol is a good way to start therapy along with exercise.
B) Clopidrogel is better than ASA in reducing mortality and stroke risk (CAPRIE study, Uworld, MTB 3, emedicine)
B) This patient has CAD equivalent and an LDL above 100, so we should start atorvastatin + dietary changes + exercise whenever he can tolerate it.

D) this patient has refractive PAD + other cardiac risks that put him a risk for a lot of complications... better to operate.
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  #7  
Old 05-12-2013
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Yup Right On!
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Old 05-12-2013
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good explanations XPEAZX.

the answers i found online said
C
B
B
D

so unsure about the first one.

thanks for the point about aspirin vs clopidogrel being in MTB 3 - will hv to read again. clearly skipped that!
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You're welcome.

I dont agree with the first one being C tho, it would be correct if the pt could clearly at least somewhat exercise, in the question they are saying his pain is so bad he cant even exercise.. on these cases you start cilostazol so that he can actually exercise! there is no point on recommending exercise on a pt that already has that recommendation per his/her cardiologist and he/she clearly says he cant follow that recommendation because of the pain.

You can look for that study in PUBMED, there they discover a greater risk reduction with clopidrogel ccompared with ASA, but ASA also lowers mortality and risk of stroke, if both are in the options then pick clopidrogel
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  #10  
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Quote:
Originally Posted by XpaezX View Post
You're welcome.

I dont agree with the first one being C tho, it would be correct if the pt could clearly at least somewhat exercise, in the question they are saying his pain is so bad he cant even exercise.. on these cases you start cilostazol so that he can actually exercise! there is no point on recommending exercise on a pt that already has that recommendation per his/her cardiologist and he/she clearly says he cant follow that recommendation because of the pain.

You can look for that study in PUBMED, there they discover a greater risk reduction with clopidrogel ccompared with ASA, but ASA also lowers mortality and risk of stroke, if both are in the options then pick clopidrogel
thanks again!
these are archers questions. will wait for them to post up the explanations and then update the post.
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Quote:
Originally Posted by mbbs2010 View Post
thanks again!
these are archers questions. will wait for them to post up the explanations and then update the post.
Ok man, thank you!
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  #12  
Old 05-15-2013
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Quote:
Originally Posted by mbbs2010 View Post
good explanations XPEAZX.

the answers i found online said
C
B
B
D

so unsure about the first one.

thanks for the point about aspirin vs clopidogrel being in MTB 3 - will hv to read again. clearly skipped that!
FYI- I found it in another forum: correct answers are: CBBB
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  #13  
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Quote:
Originally Posted by stepdoc1 View Post
FYI- I found it in another forum: correct answers are: CBBB
Nope why would B be correct in the last one? What would be the point in changing metoprolol to carvelidol? This patient has refractory PAD....
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Quote:
Originally Posted by XpaezX View Post
Nope why would B be correct in the last one? What would be the point in changing metoprolol to carvelidol? This patient has refractory PAD....
This is the link: http://www.usmleforum.com/files/forum/2013/5/732698.php
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Quote:
Originally Posted by stepdoc1 View Post

If I have learned something, is that never trust that forum, its full with trolls and people that dont know what they are talking about most of the time.. look at what he says..


supandi - 05/12/13 15:08 it is CBBB

Last question - non selective beta blockers worsen the claudication pain. If we use alpha+beta blocker such as carvedilol results are much better

This guy thinks Metoprolol is a non selective Beta Blocker... eventho Carvedilol has alpha activity there is no point of giving it to the present patient..

The patient has had an MI, has a low Ejection fraction and you cant give cilostazol because of acute CHF secondary to water retention.. that is why your only option is surgery
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archers hasnt published the answers yet - on their blog or any other pages associated with them
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Yup is is better to wait.. I was just trying to show how that guy stated that metoprolol is a non-selective beta blocker when clearly is a selective beta blocker....

From my point of view he lost the entire argument just by that statement..
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Old 05-16-2013
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Quote:
Originally Posted by mbbs2010 View Post
archers hasnt published the answers yet - on their blog or any other pages associated with them
As far as I know this is what I saw on their facebook page (usmle galaxy):

Answers are : 1.C
2.B
3.B
4.B

1. The question asks what is the best therapy to ameliorate his leg pain , so the best answer is supervised exercise. Clopidogrel is an essential drug in managing cardiovascular complications of PAD but it does not improve the leg pain. Cilostozol is a good drug in treating leg pain in PAD but it is a second choice after failing exercise therapy

2. Clopidogrel was found to be better than Aspirin in reducing vascular complications in PAD. CAPRIE trial which studies these options found that Clopidogrel reduced vascular events more than Aspirin.

3. PAD is a coronary artery disease equivalent. In all CAD equivalents, LDL goal is less than 100. If it is more than 100, patient must be started on a statin and dietary measures as soon as possible.

4. It is normally believed that beta blockers are relatively contraindicated in peripheral vascular disease as they block beta-2 also and cause peripheral vaso-constriction. Because of unopposed beta-2 blockade, worsening of claudication leg pain can occur. Considering the timing of worsened pain in this question, it certainly worsened after starting a beta blocker. So, discontinuing the current beta blocker and switching to a vasodilatory beta blocker is very helpful in these situations. Carvedilol and Labetalol block both alpha and beta receptors so, they do not cause peripheral vasoconstriction.
This patient is status- post myocardial infarction and needs a beta blocker as it has been shown to reduce mortality. So, complete cessation of beta-blockade is not appropriate.
Cilostozol is a useful option if exercise therapy failed in PAD but in the q.4 above, worsened pain is clearly followed beginning of beta-blocker therapy.
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  #19  
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Quote:
Originally Posted by stepdoc1 View Post
As far as I know this is what I saw on their facebook page (usmle galaxy):

Answers are : 1.C
2.B
3.B
4.B

1. The question asks what is the best therapy to ameliorate his leg pain , so the best answer is supervised exercise. Clopidogrel is an essential drug in managing cardiovascular complications of PAD but it does not improve the leg pain. Cilostozol is a good drug in treating leg pain in PAD but it is a second choice after failing exercise therapy

2. Clopidogrel was found to be better than Aspirin in reducing vascular complications in PAD. CAPRIE trial which studies these options found that Clopidogrel reduced vascular events more than Aspirin.

3. PAD is a coronary artery disease equivalent. In all CAD equivalents, LDL goal is less than 100. If it is more than 100, patient must be started on a statin and dietary measures as soon as possible.

4. It is normally believed that beta blockers are relatively contraindicated in peripheral vascular disease as they block beta-2 also and cause peripheral vaso-constriction. Because of unopposed beta-2 blockade, worsening of claudication leg pain can occur. Considering the timing of worsened pain in this question, it certainly worsened after starting a beta blocker. So, discontinuing the current beta blocker and switching to a vasodilatory beta blocker is very helpful in these situations. Carvedilol and Labetalol block both alpha and beta receptors so, they do not cause peripheral vasoconstriction.
This patient is status- post myocardial infarction and needs a beta blocker as it has been shown to reduce mortality. So, complete cessation of beta-blockade is not appropriate.
Cilostozol is a useful option if exercise therapy failed in PAD but in the q.4 above, worsened pain is clearly followed beginning of beta-blocker therapy.
All right with that explanation there is no way I can refute that.. thank you for posting the answers + explanations
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