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Cardiovascular Medicine Follow-up Arrange for cardiac rehabilitation. Medications at hospital discharge should include aspirin indefinitely, ap2yrrinhibitor for at least 1year, a B-blocker, a statin, and an ACE inhibitor or ARB (in patients with LV systolic dysfunction, hypertension, diabetes, or kidney disease). Chronic Stable Angina Diagnosis Stable angina pectoris is defined as reproducible, stable anginal symptoms of at least 2 months' duration precipitated by exertion or stress and relieved by rest. Testing Stress testing is most useful in patients with an intermediate pretest probabili[z of CAD (>tO% to <90%). Pretest probability is based on a patient's age, sex, and symptoms; risk factors for CAD; and ECG findings. Cardiovascular symptoms Calculate pretest probability (likelihood) of CAD Low lntermediate" Highb No additional testing ECG normal and Medicaltherapy able to exercise? for CAD Yes No

No additional testing ECG normal and Medicaltherapy able to exercise? for CAD Yes No Exercise ECG ECG abnormal and able to exercise? . No response to Markedly Yes No therapy positive test . Lifestyle-limiting symptoms . Progression to Exercise MPl, exercise Pharmacologic MPl, unstable angina echocardiography, or pharmacologic coronary CT angiography echocardiography, or coronary CT angiography

Exercise ECG ECG abnormal and able to exercise? . No response to Markedly Yes No therapy positive test . Lifestyle-limiting symptoms . Progression to Exercise MPl, exercise Pharmacologic MPl, unstable angina echocardiography, or pharmacologic coronary CT angiography echocardiography, or coronary CT angiography Markedly Markedly posifive test positive test Coronary angiography

Markedly Markedly posifive test positive test Coronary angiography Stress lest Criteria for Markedly Positive Test Resuh Exercise ECG Significant ST-segment J at low workload, ST-segment 1, hyPotension Exercise/pharmacologic MPI TID or lung intake of thallium, ischemia in >2 vascular distributions, EF <35% Exercise/pharmacologic echocardiography EF <35% at rest, ischemia in >2 vascular distributions, fall in EF with stress Coronary CT angiography Significant stenosis (>70% in a major epicardial coronary artery) Diagnosis of Coronary Artery Disease: Algorithm for diagnosis of patients with CAD. MPI : myocardial perfusion imaging; TID : transient ischemic dilation. 'lntermediate pretest probability (likelih00d) is variably defined as between 1 0% and 90% 0r between 250/oand75o/o. 5

Cardiovascular Medicine Follow-up Most thoracic aortic aneurysms are asymptomatic. Surveillance and treatment depend on aneurysm size and subsequent rup- ture risk. Surveillance intervals for asymptomatic thoracic aortic aneurysm of the aortic root and ascending aorta are: . 3.5 to 4.4 cm -+ annual imaging . 4.5 to 5.4 cm + every 6 months Surveillance intervals for Marfan sl,ndrome related aneurysm: o 3.5 to 4.4 cm -+ annual imaging . 4.5 to 5 cm -+ every 6 months DON'T BE TRICKED . Do not use hydralazine for acute aortic dissection because it increases shear stress. . Schedule surgery for type B dissection ifmajor aortic vessels, such as renal arteries, are involved. TEST YOURSEIF A 73 year old man has a t hour history of severe, tearing substernal chest pain. BP is 90/60 mm Hg in the right arm and 130/70 mm Hg in the left arm. A chest x ray shows a widened mediastinum. ANSWER: For diagnosis, choose dissection of the aortic arch. For acute management, select p blockers, sodium nitroprusside, and emergent imaging studies. Abdominal Aortic Aneurysm Screening One-time ultrasonographic screening is indicated to detect an asymptomatic AAA in any man between the ages of 65 and 75 years who has ever smoked and in selected men ages 65 to 75 years who have never smoked (e.g., family history ofAAA). DOil'T BE TRICKED o Do not screen women for AAA. Diagnosis Most chronic AAAs are asymptomatic. Signs and symptoms of a ruptured AAA include new abdominal, flank, or back pain: hypotension; syncopei and sudden collapse and shock. The diagnosis is conflrmed by MRA or CT. DOil'T BE TRICKED . Ultrasonography is not accurate for diagnosing a ruptured abdominal aorta. Treatment Therapy includes treatment of cardiovascular risk factors. Schedule surgical or endovascular repair of AAAs >5.5 cm in diameter, those growing >0.5 cm per year, or symptomatic AAAs. Ruptured AAA requires emergent surgery or endovascular repair. 43

Endocrinology and Metabolism DOil'T BE TRICKED . Do not use estrogen replacement therapy for osteoporosis in postmenopausal women. . IV bisphosphonates are contraindicated in patients with severe hypocalcemia and CKD Follow-up Although no consensus exists, follow-up DEXA 24 months after beginning therapy for osteoporosis is reasonable. TEST YOURSELF An 82-year old woman has been taking thyroid hormone since age 31 years. She has lost about 7.6 cm (3.0 in) in height. Serum TSH Ievel is <0.01 pU/mL (normal 0.5 to 5.0 pU/mL). ANSWER: For diagnosis, choose thyroid hormone-induced osteoporosis. For management, reduce the thyroid hormone dose and schedule DEXA. Osteomalacia Diagnosis Osteomalacia results from failure of the organic matrix of bone to mineralize because of lack of available calcium orphosphorus. Most cases of osteomalacia are related to abnormalities in vitamin D. Symptoms and signs include . fatigability, malaise, and bone pain . proximal muscle weakness . Iooser zones (bands perpendicular to the bone surface visible on x rays) . hypocalcemiaandhypophosphatemia . elevated serum alkaline phosphatase level Testing Evaluate for underlying conditions that may lead to intestinal malabsorption of vitamin D, such as celiac disease, or abnormali- ties in vitamin D metabolism, such as liver and kidney disease. Diagnosis is confirmed with bone biopsy when necessary. Treatment If osteomalacia is secondary to vitamin D deficiency, treat with oral ergocalciferol 1000 to 2000 U/d and elemental calcium I gld. DO]I'T BE TRICKED . Not all fractures in older adult patients are caused by osteoporosis. Look for osteomalacia, particularly in nursing- home residents. 79