You refer a patient for consideration of aortic valve replacement.
Which one of the following patients is least likely to need coronary angiography?
Guidelines recommend angiography for everyone considered for valve surgery except men <40 years of age and premenopausal woman with no cardiac risk factors.
A 75-year-old woman is admitted with an episode of unstable angina. She develops anterior T-wave inversion on her ECG and serum troponin is elevated. Initial treatment includes aspirin and clopidogrel. She undergoes coronary angiography which demonstrates a culprit lesion in the mid-course of the LAD. This is treated with a drug-eluting stent with good results. LV function is preserved.
Forty-eight hours post-procedure she has an episode of frank haematuria and then develops clot retention. The urology registrar reviews her and recommends stopping her antiplatelets.
What is your response?
The risks of acute stent thrombosis are high unless full antiplatelet therapy is given. Neither agent alone is suitable. Heparin is not a substitute.
A 74-year-old woman undergoes emergency laparotomy after presenting with sepsis and peritonism. In the postoperative period you are asked to review her since she has developed atrial fibrillation and blood tests reveal a raised serum troponin.
Which one of the following is most likely to be the appropriate decision?
Troponins T or I are constituents of the myocontractile apparatus and act as sensitive biomarkers for cardiac ischaemia. Levels can be elevated in several clinical scenarios, and this should be seen as indicating a higher risk of morbidity and mortality rather than a diagnostic tool. In the perioperative patient there may be many cardiac and non-cardiac mechanisms for troponin release. Management should be based upon clinical assessment.
A 54-year-old man is seen in the orthopaedic pre-assessment clinic. He has had stable angina and, in addition to medical therapy, has had disease in a dominant RCA treated with a zotarolimus-eluting stent 5 months previously. He is taking aspirin, clopidogrel, simvastatin, ramipril, and bisoprolol. He is free from angina, has a resting BP of 113/80 mmHg, and a heart rate of 48 bpm. His blood results are within normal limits, including a fasting total cholesterol of 3.2 mmol/L.
You are asked about changes to his medication.
Which one of the following would you agree with?
Drug-eluting stents carry a risk of stent thrombosis that continues out to 12 months, with reports of very late stent thrombosis beyond. Recommendations advise continuing dual-antiplatelet therapy for >12 months. The POISE trial investigated the effect of a non-titrated dose of long-acting metoprolol in the perioperative period. Compared with placebo, there was a higher incidence of stroke in this group. However, several other trials suggest a protective benefit of beta-blockers, and the recommendation is to continue treatment.
NB: Currently emerging data suggest that everolimus and biolimus (with biodegradable polymers) eluting stents are safe with shorter durations of dual antiplatelets (3–6 months), but the question is based on current guidance
You refer a patient for aortic valve replacement. Angiography demonstrates coronary disease.
In which one of the following situations would they also need CABG?
Guidelines recommend combined surgery where there is a primary indication for valve surgery and a coronary stenosis ≥70%.
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