Cardiology II Patient Cases(Completely solved)
1. J.D. is a 66-year-old, 70-kg woman with a history of MI, HTN, hyperlipidemia, and diabetes
mellitus who
presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike
upper chest
pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her
typical angina
was occurring with less exertion. Electrocardiography showed ST depressions in leads II and III,
and aVF
and hyperdynamic T waves and positive cardiac enzymes. Home medications are ASA 81
mg/day, simvastatin
40 mg every night, metoprolol 50 mg 2 times/day, and metformin 1 g 2 times/day. Which one of
the
following is the best antiplatelet/anticoagulant strategy for this patient?
A. ASA 325 mg and clopidogrel 600 mg × 1 and then 75 mg/day, UFH titrated to 50-70 seconds
immediately
plus eptifibatide 180-mcg/kg bolus × 2 and then 2 mcg/kg/minute at time of PCI if indicated.
B. ASA 325 mg and e correct answers1. Answer: a
In this patient, the presence of ST depression on EKG,
positive biomarkers for myocardial necrosis, at least
three risk factors for CAD, and history of CAD (prior
MI), as well as other factors, suggests a high risk of future
events. In such high-risk patients, cardiac catheterization
(invasive strategy) is used to determine whether
occluded or partially occluded epicardial arteries exist,
which can be intervened on, and whether to make an intervention
(stent or percutaneous transluminal coronary
angioplasty). Aspirin and clopidogrel or prasugrel is indicated
for an early invasive strategy in the management
of an NSTEMI. The GP IIb/IIIa inhibitors abciximab or
eptifibatide should be initiated at the time of PCI. Unfractionated
heparin, enoxaparin, or fondaparinux should be
initiated on presentation and would be appropriate to pair
with abciximab or eptifibatide. Abciximab was beneficial
only in clinical trials of primary PCI or PCI during the
abciximab infusion (early invasive strategy). Abciximab
was not superior to placebo when used in a conservative
medical management strategy without PCI. Unfractionated
heparin, together with clopidogrel, has been studied
in medically managed patients not pursuing catheterization
(CURE trial) but was studied in a low-risk patient
population. Metformin should be held for 24 hours either
before or after the catheterization (especially in those
with renal dysfunction) to prevent lactic acidosis.
, 2. J.D. received a percutaneous transluminal coronary angioplasty and paclitaxel-eluting stent in
her right coronary
artery. Which one of the following best represents how long clopidogrel therapy should be
continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. At least 12 months. correct answers2. Answer: D
Clopidogrel has been studied most commonly for a 30-
day poststenting procedure to prevent acute reocclusion
of coronary vessels. Because the stent is not endothelialized
for a longer period after drug-eluting stent placement
compared with traditional stents, a clopidogrel duration
of at least 3 months was initially recommended
for sirolimus-eluting stent and at least 6 months after
paclitaxel drug-eluting stent placement to prevent risk of
acute stent thrombosis. However, this recommendation
was recently extended to at least 1 year for both of these
drug-eluting stents. Although the duration of clopidogrel
has changed, that of ASA 162-325 mg/day has remained
the same. This dose of ASA should be continued for at
least 3 months for sirolimus and 6 months for paclitaxel
drug-eluting stent. After these timeframes, the ASA dose
may be reduced to 75-162 mg/day indefinitely.
3. Which one of the following is the optimal lifelong ASA dose once dual therapy with
clopidogrel after PCI
with stent implantation is completed?
A. 25 mg.
B. 81 mg.
C. 325 mg.
D. 650 mg correct answers3. Answer: B
Doses of ASA lower than 75 mg/day (e.g., 25 mg) have
not proved as efficacious as higher doses of ASA after
combination therapy with clopidogrel and a PCI procedure.
Aspirin 325 mg should be given to all patients after
a PCI procedure with stent implantation throughout the
recommended duration of clopidogrel therapy (1 month for bare metal stents, 3 months for
sirolimus-eluting
stents, and 6 months for paclitaxel-eluting stents). Once
the recommended duration of dual therapy is completed,
patients should receive a reduced dose of 75-162 mg/day
to prevent GI and bleeding complications, and 81 mg is
within this range of doses (Class I, LOE B). There is no
evidence that a higher dose of ASA (650 mg) has any
benefit over lower doses of ASA, and it has a higher risk
1. J.D. is a 66-year-old, 70-kg woman with a history of MI, HTN, hyperlipidemia, and diabetes
mellitus who
presents with sudden-onset diaphoresis, nausea, vomiting, and dyspnea, followed by a bandlike
upper chest
pain (8/10) radiating to her left arm. She had felt well until 1 month ago, when she noticed her
typical angina
was occurring with less exertion. Electrocardiography showed ST depressions in leads II and III,
and aVF
and hyperdynamic T waves and positive cardiac enzymes. Home medications are ASA 81
mg/day, simvastatin
40 mg every night, metoprolol 50 mg 2 times/day, and metformin 1 g 2 times/day. Which one of
the
following is the best antiplatelet/anticoagulant strategy for this patient?
A. ASA 325 mg and clopidogrel 600 mg × 1 and then 75 mg/day, UFH titrated to 50-70 seconds
immediately
plus eptifibatide 180-mcg/kg bolus × 2 and then 2 mcg/kg/minute at time of PCI if indicated.
B. ASA 325 mg and e correct answers1. Answer: a
In this patient, the presence of ST depression on EKG,
positive biomarkers for myocardial necrosis, at least
three risk factors for CAD, and history of CAD (prior
MI), as well as other factors, suggests a high risk of future
events. In such high-risk patients, cardiac catheterization
(invasive strategy) is used to determine whether
occluded or partially occluded epicardial arteries exist,
which can be intervened on, and whether to make an intervention
(stent or percutaneous transluminal coronary
angioplasty). Aspirin and clopidogrel or prasugrel is indicated
for an early invasive strategy in the management
of an NSTEMI. The GP IIb/IIIa inhibitors abciximab or
eptifibatide should be initiated at the time of PCI. Unfractionated
heparin, enoxaparin, or fondaparinux should be
initiated on presentation and would be appropriate to pair
with abciximab or eptifibatide. Abciximab was beneficial
only in clinical trials of primary PCI or PCI during the
abciximab infusion (early invasive strategy). Abciximab
was not superior to placebo when used in a conservative
medical management strategy without PCI. Unfractionated
heparin, together with clopidogrel, has been studied
in medically managed patients not pursuing catheterization
(CURE trial) but was studied in a low-risk patient
population. Metformin should be held for 24 hours either
before or after the catheterization (especially in those
with renal dysfunction) to prevent lactic acidosis.
, 2. J.D. received a percutaneous transluminal coronary angioplasty and paclitaxel-eluting stent in
her right coronary
artery. Which one of the following best represents how long clopidogrel therapy should be
continued?
A. 1 month.
B. 3 months.
C. 6 months.
D. At least 12 months. correct answers2. Answer: D
Clopidogrel has been studied most commonly for a 30-
day poststenting procedure to prevent acute reocclusion
of coronary vessels. Because the stent is not endothelialized
for a longer period after drug-eluting stent placement
compared with traditional stents, a clopidogrel duration
of at least 3 months was initially recommended
for sirolimus-eluting stent and at least 6 months after
paclitaxel drug-eluting stent placement to prevent risk of
acute stent thrombosis. However, this recommendation
was recently extended to at least 1 year for both of these
drug-eluting stents. Although the duration of clopidogrel
has changed, that of ASA 162-325 mg/day has remained
the same. This dose of ASA should be continued for at
least 3 months for sirolimus and 6 months for paclitaxel
drug-eluting stent. After these timeframes, the ASA dose
may be reduced to 75-162 mg/day indefinitely.
3. Which one of the following is the optimal lifelong ASA dose once dual therapy with
clopidogrel after PCI
with stent implantation is completed?
A. 25 mg.
B. 81 mg.
C. 325 mg.
D. 650 mg correct answers3. Answer: B
Doses of ASA lower than 75 mg/day (e.g., 25 mg) have
not proved as efficacious as higher doses of ASA after
combination therapy with clopidogrel and a PCI procedure.
Aspirin 325 mg should be given to all patients after
a PCI procedure with stent implantation throughout the
recommended duration of clopidogrel therapy (1 month for bare metal stents, 3 months for
sirolimus-eluting
stents, and 6 months for paclitaxel-eluting stents). Once
the recommended duration of dual therapy is completed,
patients should receive a reduced dose of 75-162 mg/day
to prevent GI and bleeding complications, and 81 mg is
within this range of doses (Class I, LOE B). There is no
evidence that a higher dose of ASA (650 mg) has any
benefit over lower doses of ASA, and it has a higher risk
