ssrpk
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well pt. is diabetic, so metoprolol is out! maybe not in real life setting, but for all practical purposes on the exam...its out!
its a difficult question star1
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| star1
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 we r here to deal with difficult one!!!!!!!!!!!!!!!!!!!!!!!
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| Aashi
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Forget abt metaprolol masking hypoglycemic effects in a diabetic pt/or even causing hyperglycemia,when he can die with an ischemic heart....>infarction,,we still give metaprolol in these life threatening situations simply coz it decreases mortailty.....period...but this is not the answer to the q posted..the q is which decreases mortality THE MOST? its angioplasty,u can save him from gettin an infarct,if u intervene earlier by doing an angioplasty..and if this fails, only then u go for an bypass...so I pick B as my answer 
Edited by Aashi on 11/23/06 - 11:15 AM
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| smartestdoc
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U r right Aashi, the most beneficial wud be an emergency angioplasty as it wud revascularize and prevent much of the muscle mass from dying.
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| ssrpk
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perfecto
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| AAAAA
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The correct answer is A.
beta-blocker.
Less than 20% of all American hospitals have 24 hours angioplasty. Besides the patient is a diabetics. In pt with multi-vessel diseases, with reduced left ventricular function, CABG is preferred over angioplasty.
Beta-blockers should be initiated early in the absence of any contraindications. In high-risk patients, they should be given initially IV then followed by the oral route with a goal target resting heart rate of 50 to 60 beats per minute (bpm). Patients with low to intermediate risk may start out with oral therapy. The duration of benefit is uncertain. A meta-analysis of double blinded randomized trials in patients with evolving MI showed a 13% reduction in risk progression to AMI. Other multiple randomized trails in coronary artery disease (CAD) patients have shown a decrease in mortality and/or morbidity rates.
In NBME, they ask you in Step 2, the treatment as a 4th year medical student what you should do.
To give metoprolol IV is the correct answer !
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| AAAAA
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Less than 20 % of all hospitals have emergency angiopalsty and very few have 24 hours angioplasty.
Diabetic patients should undergo CABG than angioplasty if have multiple vessel diseases and decreased left ventricular function.
beta-blocker is still the right answer.
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| Aashi
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A doubt AAAA,How did u know this guy has got single/double/triple vessel disease just from the given history...ohh is it from ECG? st depression from V2 - V4,what does that imply?the anterior dec is ishemic?are u cent percent sure that this guy has triple vessel disease,and out of suspicion from a simple ECG,u fix him a bypass?where r the echo reports,to show a dilated LV and low EF?one more thing...noone said that betablockers doesnt decrease mortality...read the q carefully,they said whichone of the following decreases mortality the greatest?its better we dont asume,that the hospital that the pt is currently doesnt do a PCI,so we shldnt be selecting angioplasty..the best treatment is angioplasty,coz its decreases mortailty more than any drugs! if u still think u can revasularize a pt with betablocker,well good 4 u...but i stand firm on my first answer and that is angioplasty,coz i belive he will survive better if i open up his arteries,and see first wether how many of his arteries are blocked and then schedule a bypass,if i fail to open it up or if its more than 3 vessels blocked.....................GL
Edited by Aashi on 11/23/06 - 04:10 PM
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| AAAAA
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I may agree with you.
but NBME wants you to choose the non-invasive intervention.
Never in any examination would ask you to go ahead with angioplasty for revascularixation.
For diabetics, even angioplasty is futile because the patient will have plaques re-acculmulated within 5 years.
currently we are using special stents with anti-epithelial cell growth factors to coat the stents in most angioplasty cases. But Medicare are not paying for those stents with anti-epithelial cell.
Angioplasty is a "bandage approach" to a diabetics with Non-ST-T wave chest pain !
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| mazinger
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what made not to choose angioplasty was that many drugs used in that procedure can make the pt rebleed abciximab, aspirin, clopidogrel... but I guess the risk of bleed is outweighed by the benefit... Star1 where did u get this question from?
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| ssrpk
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one important thing tht no one seem to consider is tht this is not just ischemia, its a infarction, atually posterior wall infarction![pain for 2 hrs,and ST depression in V2-4,ST elevation in case of posterior wall infarcts occurs only when the infarct is apical in location in which case ST elevation will be detected by leads II and III]
so its either thrombolytics, or angioplasty, as thrombolytics are clearly contraindicated, so angioplasty is the correct answer!
And AAAAA, don't assume too much from the question, as its not mentioned anywhere tht the patient has three vessel disease or tht the hospital is actually a remote one where angioplasty is not available! This is an emergent situation and the main goal should be to revascularize! stay focused to wht the question says!
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| Aashi
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I agree with ssprk...one shldnt assume,things which arent given the q,and be cent percent sure that NBME/any q bank is EXPECTING us to think the invisble contents that is not visible in the q..that q is very straight forward,and a little thinking more than enough to know what is beneficial for the pt..regarding mazingers opinion abt the risk outweighing the benefits,by using heparin/or/tirofiban/ PLAVIX/even ASA in this pt with a bleeding PUD,even i wont go that far mazinger,hez got a frank bleed,and the history clearly mentions a melena,which clearly knocks out the above 3 drugs from the whole list of choices...metaprolol is v.good and it decreases mortality...but which would be the interventions that will decrease the mortality the most in this pt will defintely be angioplasty with the given set of details in the q,without any assumptions ofcourse!...okay star1 i had enough discussion regrading this q...if u know the answer,pls paste that down...its ur turn to roll the dice.
GL
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| ssrpk
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hey aashi, when are u taking ur step2,i've read ur posts, yu are too good!
good luck
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| AAAAA
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Actually this is a very complex question !
The issue is about conservative management vs aggressive invasive angioplasty.
Which one will reduce the mortality of the patient?
The way to think is not just revascularization but the risks of the patient.
The patient is a diabetics and is now considered a major coronary risk factor.
I do agree angioplasty is beneficial for this patient in this case.
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| Data297
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Star1 can you post the correct and explination?
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| robin082006
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I go with B too.
Metoprolol may increase the quality of life in patients with IHD but here the question asks about greatest decrease in mortality.
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