Gyrus Daily Questions; Internal Medicine #6

[cingulate.gyrus]

A 54-year-old man presents to the emergency department with chest pain. He has had three episodes of chest pain in the past 24 h with exertion. Each has lasted 20–30 min and resolved with rest. His past medical history is significant for hypertension, hyperlipidemia, asthma, and chronic obstructive pulmonary disease. He currently smokes one pack/day of cigarettes. His family history is remarkable for early coronary artery disease in a sibling. Home medications include chlorthalidone, simvastatin, aspirin, albuterol, and home oxygen. In the emergency department, he becomes chest pain–free after receiving three sublingual nitroglycerin tablets and IV heparin. ECG shows 0.8 mm ST-segment depression in V5, V6, lead I and aVL. Cardiac biomarkers are negative. An exercise stress test shows inducible ischemia. Which aspects of this patient’s history add to the likelihood that he might have death, myocardial infarction (MI), or urgent revascularization in the next 14 days?

A. Age
B. Aspirin usage
C. Beta-agonist usage
D. Diuretic usage

[XpaezX]

D, probably the only one that doesnt decrease mortality and can probably worsen the O2 demand by decreasing Preload and inducing compensatory tachycardia.

[cingulate.gyrus]

The answer is B.



Patients with unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) exhibit a wide spectrum of risk of death, MI, or urgent revascularization. Risk stratification tools such as the TIMI risk score are useful for identifying patients who benefit from an early invasive strategy and those who are best suited for a more conservative approach. The TIMI risk score is composed of seven independent risk factors: Age ≥65, three or more cardiovascular risk factors, prior stenosis >50%, ST-segment deviation ≥0.5mm, two or more anginal events in <24 h, aspirin usage in the past 7 days, and elevated cardiac markers. Aspirin resistance can occur in 5–10% of
patients and is more common among those taking lower doses of aspirin. Having unstable angina despite aspirin usage suggests aspirin resistance. Use of a beta-agonist and a diuretic do not confer an independent risk for death, MI, or need for urgent revascularization.

Ref Harrison Chap. 238 17t edition