Practical Cardiovascular Medicine. Elias B. Hanna

her cardiovascular mortalityInitial PCI reduces anginaIf the patient is undergoing non-cardiac surgery, PCI of LAD reduces her risk of perioperative MISingle-vessel CABG may reduce her risk of death or MI

      16 Question 16. After undergoing coronary revascularization, which statement is incorrect?After one- or two-vessel PCI, the risk of repeat revascularization is ~20% at 5 yearsAfter multivessel revascularization, the risk of recurrent events is ~27% with CABG and ~37% with PCI at 5 yearsAfter high-risk PCI (e.g., complex proximal LAD PCI), stress testing is indicated routinely at 6–12 months

      17 Question 17. A 70-year-old man has undergone PCI of the mid-LAD with one DES 1 year ago. He presents with recurrent mild angina. Coronary angiography shows 90% in-stent restenosis of the LAD. What is the next step?Medical therapyPCICABGPCI or CABG

      18 Question 18. A 51-year-old woman presents with exertional angina. She undergoes a standard treadmill ECG testing, where she exercises for 7 minutes and exhibits her typical angina without any ST change. What is the next step?Risk factor modification, aspirin, statin, and antianginal therapyCoronary angiographyCTA

      19 Question 19. A coronary angiography is performed for the patient in Question 18 and does not reveal any significant CAD. What is the next step?Reassure the patient that her pain is not of a cardiac origin. Consider gastroesophageal reflux therapyThe patient likely has coronary vasospasm. Prescribe amlodipinePerform adenosine PET imaging. If the diagnosis is confirmed, add metoprolol and L-ArgininePerform adenosine PET imaging. If the diagnosis is confirmed, add nitrates

      20 Question 20. A 50-year-old diabetic man has exertional angina (2 flights of stairs, 4 blocks). On stress echo, he walks 7 minutes on Bruce protocol, develops mild pain, 2 mm of ST depression in leads V4–V6, and inferior hypokinesis. Coronary angiography shows 80% proximal RCA stenosis, with no disease in the LAD or LCx. What is the next step?Optimize medical therapyPerform RCA PCIPerform RCA FFR, then PCI if appropriate

      21 Question 21. In a diabetic patient with stable angina, which of the following is incorrect:β-Blockers reduce mortality in patients with stable CAD and without prior MIMetoprolol worsens HbA1c, while carvedilol does not affect HbA1c and improves insulin resistanceThe higher the HbA1c, the more effective ranolazine is in reducing angina of diabetic patientsRanolazine improves HbA1c by up to 1%

      22 Question 22. A 60-year-old diabetic man has dyspnea on exertion and occasional episodes of rest chest discomfort. A resting ECG shows borderline inferior Q waves. On stress echo, he walked 8 minutes and had 1 mm of ST-segment depression in V4–V6, with dyspnea and no chest pain. His inferior wall is akinetic with EF 35–40% at rest and without worsening during exercise. Coronary angiography shows a totally occluded RCA in its mid-segment, and moderate, 50% disease in the proximal LAD. What is the next step?Aggressive statin and antianginal therapy. No revascularization of RCA CTORevascularization of RCA CTOPerform FFR of LAD. If significant, refer to CABG (LAD and RCA). If insignificant, perform PCI of RCAPerform FFR of LAD. If significant, refer to CABG. If insignificant, perform medical therapy onlyPerform FFR of LAD. If significant, perform LAD PCI (not RCA). If insignificant, perform medical therapy only

      23 Question 23. In stable CAD, which two features guide the decision to revascularize?

      24 Answer 1. A (Section II.C). According to Hubbard et al., the patient has >40% risk of severe CAD (age, sex, diabetes, typical angina).¹³ Also, PAD predicts severe CAD. He has not only a high probability of CAD, but a high probability of severe CAD. The severity of his angina is another indicator of the need for invasive angiography with possible revascularization.

      25 Answer 2. D. This is a typical COURAGE patient with mild angina, good functional capacity, and low-risk stress test. For this patient, medi- cal therapy is as good as PCI + medical therapy. If angina is severe despite medical therapy, COURAGE functional substudies would support PCI (PCI would be superior to medical therapy for reduction of angina and reduction of ischemic burden). FFR is not necessary, since ischemia of the LCx territory has already been proven by nuclear imaging.

      26 Answer 3. A. Except in left main disease, a patient with mild stable angina is appropriately treated with medical therapy only, regardless of ischemia severity. The MASS trial showed that for isolated LAD disease >80%, there was no difference in mortality between CABG vs. angioplasty vs. medical therapy, although angina was reduced with angioplasty and more so with CABG. The LAD disease addressed in the MASS trial was proximal LAD disease.

      27 Answer 4. A .Again, a patient with mild angina and no severe functional limitation is appropriately treated with medical therapy only (typical COURAGE or ISCHEMIA patient). In the stable CAD setting, the value of revascularization is purely symptomatic and is questionable in a patient with no severe or refractory angina, even if proximal LAD (ISCHEMIA, COURAGE, MASS trial), severe ischemia (ISCHEMIA), or multivessel disease is present (ISCHEMIA, COURAGE, BARI 2D).

      28 Answer 5. D. As opposed to Questions 3 and 4, the patient has three-vessel CAD (>70%). Similarly to the previous questions, he does not necessarily need revascularization per ISCHEMIA and BARI2 D trials. CABG revascularization remains reasonable based on old CABG vs medical therapy trials. Of note, the stress test may underestimate the true severity of ischemia. Nuclear defects being comparative to the best segment, the LCx and RCA may appear to be normally perfused when, in fact, they are ischemic but less ischemic than the LAD. If revascularization is chosen, FFR may be warranted since stress test is not high risk and will allow adequate assessment of RCA and LCx.

      29 Answer 6. D. Asymptomatic patients qualify for revascularization only if left main disease is present (according to ISCHEMIA trial). Possibly, they may qualify for revascularization if 3-vessel CAD or 2-vessel CAD with proximal LAD is present (according to old CABG vs medical therapy trials). CTA is an appropriate alternative to coronary angiography even after high-risk stress test, as per ISCHEMIA trial. While one may question the indication of stress test in this asymptomatic patient, it is reasonable to exclude left main disease once ischemia is found.

      30 Answer 7. True. PCI of CTO is more technically challenging than standard PCI (2-3 times complication rates). Even more strictly than standard PCI, it is only indicated in patients who have severe and refractory angina, particularly with favorable PCI features (short <2 cm, not heavily calcified, good stump).

      31 Answer 8. B. The patient has low-risk DTS of +5. A low-risk stress ECG/low risk DTS does not necessarily rule out high-risk CAD. In fact, 10% of patients with low-risk DTS have left main or three-vessel CAD. A high-risk stress imaging result overrules a low or intermediate DTS. This patient has a high-risk stress imaging result, but based on ISCHEMIA trial, this does not mandate an invasive strategy (coronary angiography +/- revascularization). A conservative strategy, preferably after left main rule-out by CTA, is appropriate.

      32 Answer 9. A. The patient does not have a clear angina. Revascularization is only indicated if symptoms are severe or refractory. The patient has an increased surgical risk, including a risk of functional ischemia/infarction of the RCA territory during surgery. However, except for left main disease or extensive three-vessel CAD, preoperative revascularization does not change postoperative cardiac complications. If surgery is necessary, medical therapy with a statin and a β-blocker, initiated more than a week before surgery, and careful perioperative monitoring are the strategies that improve outcomes.

      33 Answer 10. A. Even in the absence of CAD, vasospastic angina is associated with a significant risk of cardiac events (~20% within a few years), especially when extensive or severe ST changes or arrhythmias have been demonstrated. With CCB, this risk is reduced to <1% (unstable angina may occur at a higher rate). Statin has additional benefit on top of CCB. IVUS is reasonable if the lesion is ≥50% obstruc- tive on angiography or has worrisome angiographic features (overhanging borders, eccentric, hazy).

      34 Answer 11. D. Even if coronary angiography does not show any obstruction, a convincing chest pain history along with a perfusion abnor- mality suggest that the chest discomfort is a true angina. Half of women whose symptoms are worrisome enough to warrant coronary angiography but who are not found to have CAD have, in fact, microvascular dysfunction or, less so, macrovascular spasm. This is particularly the case of patients with typical angina features and abnormal stress testing. Myocardial bridging is usually incidental, even when severe; however, it may be considered the culprit in a patient with typical angina and anterior