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Chapter 43: The Evaluation and Management of Stable Ischemic Heart Disease

Patrick R. Lawler

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    AMA Citation
    Lawler PR. Lawler P.R. Lawler, Patrick R.The Evaluation and Management of Stable Ischemic Heart Disease. In: Eisenberg MJ, Afilalo J, Joza JE, Karra R, Lawler PR. Eisenberg M.J., Afilalo J, Joza J.E., Karra R, Lawler P.R. Eds. Mark J. Eisenberg, et al.eds. Cardiology Board Review and Self-Assessment: A Companion Guide to Hurst's the Heart, 14e New York, NY: McGraw-Hill; . http://accesscardiology.mhmedical.com/content.aspx?bookid=2459&sectionid=193145879. Accessed April 25, 2019.
    MLA Citation
    Lawler PR. Lawler P.R. Lawler, Patrick R.. "The Evaluation and Management of Stable Ischemic Heart Disease." Cardiology Board Review and Self-Assessment: A Companion Guide to Hurst's the Heart, 14e Eisenberg MJ, Afilalo J, Joza JE, Karra R, Lawler PR. Eisenberg M.J., Afilalo J, Joza J.E., Karra R, Lawler P.R. Eds. Mark J. Eisenberg, et al. New York, NY: McGraw-Hill, , http://accesscardiology.mhmedical.com/content.aspx?bookid=2459&sectionid=193145879.

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Chapter 43: The Evaluation and Management of Stable Ischemic Heart Disease

A 65-year-old man with a history of obstructive coronary artery disease (CAD) is evaluated in your clinic. He complains that he develops chest pain walking approximately one city block and climbing one flight of stairs. Which of the following Canadian Cardiovascular Society (CCS) angina classes best describes the patient’s symptoms?

A. CCS I

B. CCS II

C. CCS III

D. CCS IV

E. None of the above are correct

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 43) Canadian Cardiovascular Society (CCS) angina classification is described in Table 43-1. This patient’s symptoms are most consistent with class III (option C).

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Table 43-1. The Canadian Cardiovascular Society Angina Scale
I II III IV

Ordinary physical activity does not cause angina including:

Walking and climbing stairs

Slight limitation of ordinary activity including:

Walking stairs rapidly

Walking uphill

Stair climbing after meals

 Marked limitation of ordinary physical activity. Inability to perform any physical activity without discomfort.

Angina occurs:

Only with strenuous, rapid, or prolonged exertion at work or recreation

Angina occurs:

A few hours after awakening

Walking > 2 city blocks (level ground)

Walking 1 flight of ordinary stairs at a normal pace

Angina occurs:

Walking ≤ 1 city block (level ground)

Climbing one flight of stairs under normal conditions and at a normal pace

Angina occurs:

With minimal activity

May be present at rest

Data from Campeau L. The Canadian Cardiovascular Society grading of stable angina pectoris after a quarter of a century of use, Can J Cardiol. 2002 Sep;18(9):941-944.

All of the following are criteria for defining vulnerable plaque except:

A. Active inflammation (eg, monocyte, macrophage, ± T-cell infiltration)

B. Thin cap with large lipid core

C. Endothelial denudation with superficial platelet aggregation

D. Fissured plaque

E. Luminal stenosis > 60%

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 43) Major criteria for the defining vulnerable plaque include options A through D.1 Additionally, luminal stenosis > 90% is also a major criterion. Minor criteria include: superficial calcified nodule, glistening yellow appearance (pathologic diagnosis), intraplaque hemorrhage, outward remodeling, and endothelial dysfunction.

A 64-year-old woman presents to your clinic with progressive exertional chest pressure over the past several months. All of the following are advantages ...

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