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NBME 24 Answers

nbme24/Block 4/Question#43 (50.1 difficulty score)
A 72-year-old woman with coronary artery ...
Neointima formation in the right coronary stent🔍
tags: vascular 

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submitted by xxabi(258),
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tSent rsootbsimh sv nsei.toress- tnSte brshoosmit is na autec losiuocnc fo a ncorayro ytrare ,stetn hcwih oeftn tssruel in uetca orrnayco modyesnr. Cna eb tednrpeev by ldua tnteeliaaltp ryteahp ro gergnulidt-u tiss-eensRo is teh aluagdr wngrnaroi fo teh ettns uelnm eud ot lnentimoai arftprle,ionio unelrtsgi in nlaanig t.ypommss

sunshinesweetheart  so just to clarify - it's the "symptom-free for 3 months" that rules out thrombosis? +6  
hpsbwz  It's moreso that at rest there's no changes, but during exercise there is. Like the pathophys of stable angina. +6  
suckitnbme  I think it's more because of the 2-month history of PROGRESSIVE angina sx with exertion. This points to a chronic process rather than an acute event. +  
alienfever  Drug-eluting stents prevent re-stenosis (rather than thrombosis) by releasing sirolimus which by blocking cell proliferation. +2  

submitted by sweetmed(144),
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ntetS nRsseeosti courcs rmfo crsa istues goswr eorv ntest isgnauc latnimoe“in rpyhel”apisa nda rragninw,o secimiah pmomysst nrrute :xT tvepren yb insgu rdig nelitug stsnte e.g iS.islormu Tsomobirsh Ptos eisntsso is u,teAc tnets vrssee as undsi orf bthsomur amrnofoti laluuys 22/ imgssin edmiat.ion :xT renepvt by usnig uald apnlaelittet marenttet od[algc.iterlrgac]/siplpiio+rorne Afetr 1 eary, hlizdienonateot of tnste ruccso nda heert is a eowlr srik of bou,trhsm Tx lwrdeoe to sujt pianisr.

submitted by hungrybox(1033),

Section on Endovascular Stenting from BIG ROBBINS (for people like me who need more context):

submitted by medschooler1(2),

I think the key here is that this patient already had a stent placed, was symptom free for a few months, and now has angina with exertion. Angina with exertion is describing "Stable angina", the angina is due to "demand ischemia". The most common cause of stable angina is atherosclerosis/atherosclerotic plaque build up and a very common adverse effect of stents is neointima formation/ forming a new plaque on the stent.... a thrombosis would cause angina at both rest and with exercise, due to "supply ischemia", and it would be more acute, not progressive like the question stem describes

submitted by an_improved_me(13),

Another thing to note: they could have made this question even trickier by asking whether or not you know which leads are associated with which arteries. This person had LAD and RCA stent placement. That means that they could have given you leads II, III, aVF (for RCA probs) or V1-V6, I, aVL (for LAD probs) and make you choose based on that.

This question was easier since all answers are regarding the RCA.