Coronary Artery Disease USMLE Step 1 Practice Question
A 61-year-old man with a history of anterior wall myocardial infarction 8 months ago presents with recurrent angina despite optimal medical therapy with aspirin 81 mg daily, atorvastatin 80 mg daily, and metoprolol. Vital signs are BP 128/82 mmHg, HR 92 bpm, RR 18/min, and SpO2 98% on room air. Physical examination reveals a displaced apical impulse. Laboratory studies show troponin I <0.04 ng/mL (normal). Transthoracic echocardiography demonstrates a left ventricular ejection fraction of 35% with anterior wall akinesis. Cardiac catheterization shows a patent left anterior descending (LAD) stent placed 8 months ago and a newly identified 90% stenosis in the right coronary artery (RCA) with TIMI 2 flow. Viability testing indicates viable myocardium in the RCA territory. Which of the following represents the most appropriate revascularization strategy?
Answer choices
- AInitiate inotropic support with milrinone and defer coronary intervention pending clinical stabilization over 4-6 weeks
- BPerform percutaneous intervention on the RCA stenosis to restore myocardial perfusion in the viable territoryCorrect answer
- CPursue re-intervention on the LAD stent to optimize anterior wall perfusion and prevent progression of systolic dysfunction
- DContinue maximal medical therapy alone without revascularization, given the patient's reduced ejection fraction and prior revascularization
- ERefer for urgent cardiac transplant evaluation given the presence of significant CAD and systolic dysfunction
- FPerform cardiac magnetic resonance imaging to quantify scar burden and defer any intervention pending the results
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