1. Stable Coronary Artery Disease

2. Case Presentations

3. Case 1 Initial Presentation Chief Complaint: The patient is a 59-year-old male with a history of “heartburn” after taking sildenafil. History of Present Illness: He reports receiving a free trial of sildenafil and on several occasions, he reported "heartburn" before, during, and after sexual activity. Onset: Two months ago Duration: Two months

4. Case 1 Past Medical History: Coronary artery disease (CAD) status/post PCI 10 years ago Hypertension Hypercholesterolemia Diabetes mellitus Family History: Both parents died in their 80s from cancer. No family history of premature CAD exists. Social/Occupational History: He smokes a pipe once a day; drinks three beers per week; works as a grocery clerk at the local market.

5. Case 1 Physical Findings Age: 59 Gender: Male Race: Caucasian Height: 178 cm (70 inches) Weight: 93 kg (204 lbs) Blood Pressure: 130/90 mm Hg Pulse: 83 bpm Respiration: 16 breaths/minute General Appearance: Comfortable, alert, orientated Head and Neck: No jugular venous distention, no carotid bruit, carotid pulses normal Chest and Lungs: Clear to auscultation bilaterally Cardiac Exam: Regular rate and rhythm, S1, S2, no murmur Abdomen: Soft, nontender, nondistended, normal active bowel sounds

6. Case 1 Which of the following is an incorrect statement regarding sildenafil citrate (Viagra)? A.Sildenafil is a selective inhibitor of cyclic GMP-specific phosphodiesterase type 5. B.Sildenafil results in smooth muscle relaxation, vasodilatation, and enhanced penile erection. C.Sildenafil increases systolic and diastolic blood pressure. D.Nitrates are contraindicated within 24 hours of using sildenafil because of the potential for a precipitous fall in blood pressure. E.Sildenafil has no significant effect on heart rate. F.The peak blood pressure effects of sildenafil typically occur one hour after the dose.

7. Case 1 Which of the following is an incorrect statement regarding sildenafil citrate (Viagra)? A.Sildenafil is a selective inhibitor of cyclic GMP-specific phosphodiesterase type 5. B.Sildenafil results in smooth muscle relaxation, vasodilatation, and enhanced penile erection. C.Sildenafil increases systolic and diastolic blood pressure. D.Nitrates are contraindicated within 24 hours of using sildenafil because of the potential for a precipitous fall in blood pressure. E.Sildenafil has no significant effect on heart rate. F.The peak blood pressure effects of sildenafil typically occur one hour after the dose.

8. Case 1 You choose first … A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

9. Case 1 You choose first … A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

10. Echocardiogram: Left ventricular ejection fraction was moderately reduced at 41% with global hypokinesis present

11. Case 1 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

12. Case 1 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

13. Case 1 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

14. Case 1 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

18. How would you treat this patient? A. Medically (drugs) B. Surgically (CABG or PCI)

19. Given the history of diabetes, the low ejection fraction, the severity of disease, and number of lesions and occluded LAD, the patient underwent revascularization with coronary artery bypass grafting. The patient did well, and on postoperative day five, he was discharged home.

20. Case 2 Initial Presentation Chief Complaint: A 57-year-old man presented with a complaint of chest pressure on exertion. History of Present Illness: He reported chest pressure on exertion while mowing the lawn or walking, that radiates to his shoulders bilaterally, also accompanied by dyspnea on exertion, lasting about five minutes and relieved by rest. He denied any nausea, vomiting, or diaphoresis, and denied chest pain at rest. Onset: Four months ago Duration: Four months

21. Case 2 Past Medical History: Hypertension Hypercholesterolemia Family History: Mother had MI at young age. Social/Occupational History: No cigarette or tobacco use; works as carpenter.

22. Case 2 Physical Findings Age: 59 Gender: Male Race: Caucasian Height: 167cm (66 inches) Weight: 91 kg (200 lbs) Blood Pressure: 120/70 mm Hg Pulse: 56 bpm Respiration: 16 breaths/minute General Appearance: Well appearing, in no obvious distress Head and Neck: No jugular venous distention, no carotid bruit, carotid pulses normal Chest and Lungs: Clear to auscultation bilaterally Cardiac Exam: Regular rate and rhythm, S1, S2, no murmur Abdomen: Soft, nontender, nondistended, normal active bowel sounds

23. Case 2 Laboratory Findings Normal hematology Normal chemistry Lipid profile: Total cholesterol 5.38 mmol/l (208 mg/dL) LDL-cholesterol 2.80 mmol/l (108 mg/dL) Triglycerides 3.19 mmol/l (283 mg/dL)

24. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

25. Case 2 You choose first … A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

26. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

27. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

28. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

29. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

30. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

31. Case 2 What do you do next? A. ECG B. Holter ECG monitoring C. Stress Echo D. Exercise testing E. Electrophysiological study F. Coronary angiography G. Other H. I don ’ t know

32. How would you treat this patient? A. Medically (drugs) B. Surgically (CABG or PCI)

33. Coronary angiography revealed a proximal 100% occlusion and an 80% mid occlusion of the left anterior descending (LAD) coronary artery; the left circumflex and right coronary artery were free of significant disease Following the stent procedure, the patient reported no angina with ambulation, and telemetry monitoring revealed no further premature ventricular complexes with or after activity. He was discharged on aspirin, atenolol, atorvastatin and clopidogrel for at least six months.

34. Thank you for attention!