style="font-size:15px;"> 48 Answer 23. C. OCT helps show features of plaque erosion and SCAD. Plaque erosion is characterized by thrombus with an intact intimal cap or a fibrointimal plaque. However, when SCAD is suspected, it is best to avoid any coronary manipulation, including OCT, as each manipulation increases the risk of intramural hematoma propagation. When the flow is preserved and the disease is not critical, SCAD is best treated conservatively with no PCI. The majority of SCADs (70-97%) will heal by 1-2 months.49 Answer 24. B. Patients with true ACS/type 1 MI may have HTN secondary to the distress of angina. However, in the case presented here, the persistence of HTN and its requirement for multiple agents implies that malignant HTN is the primary process responsible for the patient’s pain and troponin rise. The severe LVH, seen on echo, accentuates ischemic demands and is a marker of uncontrolled HTN. The degree of troponin rise (< 1 ng/ml) is consistent with ischemic imbalance. Ischemic workup, possibly stress testing, may be performed once HTN is controlled and chest pain resolves.
50 Answer 25. A. Compare this case to Question 24. The quick resolution of HTN with NTG implies that HTN was secondary to myocardial ischemia (catecholamine surge), rather than a cause of ischemia. Even the milder troponin rise, in context, is worrisome for true ACS and plaque rupture.
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