Step 3 Ch 3 Cardiology 1-1

Front 1

21. CK-MB vs. troponin?

Back 1

a. Both rise at 3-6 hrs after the start of chest pain.
b. They have nearly the same specificity.
c. The main difference between CK-MB and troponin is that CK-MB stays elevated for 1-2 days while troponin stays elevated for 1-2 weeks. Therefore, CK-MB testing is the best test to detect reinfarction a few days after the initial infarction.

Front 2

22. When is Myoglobin the right answer for chest pain?

Back 2

a. When the question asks “which of the following will rise first?” when the choices are all cardiac enzymes.
b. Myoglobin elevates as early as 1-4 hrs after the start of chest pain.

Front 3

23. Note: Do not answer “consultation” for single best answer questions. However, “consultation” is ok to answer as a part of CCS management. In single best answer questions, a consultant should not be necessary when ordering an ekg, checking enzymes, and giving aspirin to a pt w/acute coronary syndrome.

Back 3

23. Note: Do not answer “consultation” for single best answer questions. However, “consultation” is ok to answer as a part of CCS management. In single best answer questions, a consultant should not be necessary when ordering an ekg, checking enzymes, and giving aspirin to a pt w/acute coronary syndrome.

Front 4

24. A 56 yo man comes to the office a few days after an episode of chest pain. This was his first episode of pain, and he has no risk factors. IN the ED, he had a normal EKG and normal CK-MB, and was released the next day. Which of the following is most appropriate in his further management?

Back 4

a. Stress (exercise tolerance) testing.
b. Stress test when the case is equivocal or uncertain for the presence of CAD. Do not do an angiography unless the stress test is abnormal. Exercise tolerance testing detects CAD when the heart rate is raised and ST segment depression is detected. This case is asking you to know that a stress test is way of increasing sensitivity of detection of CAD beyond an EKG and enzymes.

Front 5

25. CCS tip: Step 3 loves the phrase further management.

Back 5

25. CCS tip: Step 3 loves the phrase further management.

Front 6

26. When do I answer dipyridamole or adenosine thallium stress test or dobutamine echo?

Back 6

a. Pts who cannot exercise to a target heart rate of >85% of maximum.
b. COPD
c. Amputation
d. Deconditioning
e. Weakness/Previous stroke
f. Lower-extremity ulcer
g. Dementia
h. Obesity

Front 7

27. When do I answer exercise thallium testing or stress echo?

Back 7

a. EKG is unreadable for ischaemia:
1. Left bundle branch block
2. Digoxin use
3. Pacemaker in Place
4. Left ventricular hypertrophy
5. Any baseline abnormality of the ST segment of the EKG.

Front 8

28. When is the Sestamibi nuclear stress testing appropriate?

Back 8

a. Obese pts and those w/large breasts because of the greater ability of this radioisotope to penetrate tissue.

Front 9

29. A 63 yo fm is in your office for evaluation of an abnormal stress test that shows an area of reversible ischaemia. She has no risk factors for CAD. What is the most accurate diagnostic test, or what is the best next step in further management?

Back 9

a. Angiography.
b. Angiogrpahy is the next diagnostic step to evaluate an abnormal stress test that shows “reversible” ischaemia. Reversible ischaemia is the most dangerous thing that a stress test can show.
c. If the stress test shows “fixed” defects-that is, a defect unchanged between exercise and rest- this is a scar from a previous infarction.
d. Fixed defects do not need angiography.

Front 10

30. With the above situation, what is the answer only if the angiogram has already been done?

Back 10

a. Coronary bypass.

Front 11

31. Best initial test to evaluate valve function of ventricular wall motion?

Back 11

a. Echocardiography.

Front 12

32. Most accurate method to evaluate ejection fraction?

Back 12

a. Nuclear ventriculogram.

Front 13

33. A pt admitted 5 days ago for an MI has a new episode of chest pain. Which of the following is the most specific method of establishing the diagnosis of new infarction?

Back 13

a. CK-MB.
b. CK-MB should return to normal 2-3 days after MI.
c. If a reinfarction has occurred, the level will go back up again 5 days later, while the troponin level will still be up from the original infarction.

Front 14

34. Utility of angiography?

Back 14

a. Can detect obstructive, stenotic lesions but cannot detect myocardial necrosis.

Front 15

35. In whom should stress testing NEVER be performed?

Back 15

a. If the pt is having current chest pain.
b. Chest pain is a reason to stop the stress test.

Front 16

36. Definition of Acute Coronary Syndrome (ACS)?

Back 16

a. Causes acute chest pain
b. Can be w/exercise or at rest
c. Can have ST segment elevation, depression, or even a normal EKG.
d. Not based on enzyme levels, angiography, or stress test results.
e. Based on a hx of chest pain w/features suggestive of ischaemic disease.

Front 17

37. Best initial therapy for all cases of Acute Coronary Syndrome (ACS)?

Back 17

a. Aspirin

Front 18

38. Utility of Aspirin?

Back 18

a. It has an INSTANT effect on inhibiting platelets.
b. Aspirin alone reduces mortality by 25% for acute MI and by 50% for “unstable angina,” which may become a non-ST segment elevation MI (NSTEMI).

Front 19

39. Other drugs that should be administered in Acute Coronary Syndrome (ACS)?

Back 19

a. Nitrates and morphine should also be administered in acute coronary syndromes, but they do NOT lower mortality.
b. Oxygen has no benefit if the patient is not hypoxic.

Front 20

40. What 1 of 2 possible drugs is added to aspirin for all patients w/an acute MI?

Back 20

a. Prasugrel or Clopidogrel.
b. One of these is also added to everyone getting angioplasty and a stent.