Free Examination Medicine: A Guide to Physician Training by Nicholas J. Talley, Simon O’connor Page B

coronary syndromes (ST elevation, troponin elevation).
    2. Prognosis is improved with aspirin, beta-blockers and, for large infarcts (ejection fraction <40%), ACE inhibitors and beta-blockers (e.g. carvedilol, bisoprolol and extended-release metoprolol).
    3. Patients with three-vessel disease and significant left ventricular damage or with left main coronary artery stenosis benefit prognostically from coronary artery bypass surgery even if their symptoms have settled on medical treatment. Those with tight proximal (before the first diagonal branch) left anterior descending lesions probably also benefit from surgery or angioplasty.
    4. Epleronone, an aldosterone antagonist, is indicated for patients with cardiac failure following an infarct.

    Secondary prevention

    1. Control of cardiac risk factors is even more important once the presence of coronary artery disease has been established. It should be a routine part of the management of these patients.
    2. Dietary advice for weight and lipid reduction may be indicated. Lipid-lowering drug treatment with a statin should be introduced for all patients who can tolerate it. Total cholesterol should be reduced to less than 4.0 mmol/L (aim for the LDL to be below 1.8 mmol/L).
    3. Patients should be encouraged to take part in a cardiac rehabilitation program, if this is available, where advice about safe exercise, weight reduction and changes to dietary and smoking habits can be encouraged.

Revascularisation
    For some long-case patients with ischaemic heart disease the emphasis will be on revascularisation (coronary surgery or angioplasty). These procedures are so common that many patients with other presenting problems will have had them.

    The history
    Similar information to that outlined in the ischaemic heart disease long case is required.

    1. Careful questioning about risk factor control, both before and after surgery or angioplasty, is very important. The patient should know whether he or she has ever had an infarct and may know whether there was significant left ventricular damage.
    2. Find out what procedure (or procedures) the patient has had and whether there has been complete relief of symptoms.
    3. If coronary artery surgery was performed, ask how many grafts were inserted and whether internal mammary or other arterial (e.g. radial artery) conduits were used. It may be possible from the history to work out whether surgery was performed to improve symptoms or prognosis (e.g. three-vessel or left main disease), or both.
    4. The patient may know how many vessels were dilated if angioplasty was performed and whether stents were inserted. The patient should know whether bare metal stents (BMS) or drug-eluting stents were used. Ask whether the angioplasty was performed in the setting of a myocardial infarction or acute coronary syndrome. Find out for how long dual anti-platelet treatment was prescribed.

    The examination
    Examine the patient as for the ischaemic heart disease long case.

    1. Note the presence of a median sternotomy scar. Patients who have had a left internal mammary artery (LIMA) graft often have a numb patch to the left of the sternum. This may be permanent.
    2. Look at the sternal wound for signs of infection; osteomyelitis of the sternum is a rare but disastrous complication of surgery. Look and feel for sternal instability. Sternal wires are often palpable.
    3. Examine the arms for the very large scar that results from radial artery harvesting.
    4. Examine the legs for saphenous vein harvesting wounds. Infection and breakdown of these wounds are more common than for the sternal wound.

    Management

    SURGERY
    Use of the left internal mammary artery to graft the left anterior descending (LAD) coronary artery has been routine for more than 20 years. Other arterial conduits are used less often, but ‘all arterial revascularisation’ is performed routinely in some centres or where saphenous vein grafts (SVGs) are not possible, e.g. previous