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NBME 22 Answers

nbme22/Block 3/Question#39 (38.0 difficulty score)
A 52-year-old man with stable angina pectoris ...

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submitted by nwinkelmann(292),
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I dunfo hist wnhe tnigyr to dndersnaut why rcadeeisn ON dseauc eacehhas:d t/traseisNinteirt aer a yver moomnc eaehcdah nda giinmaer food grisrget )e(MWbD dan saire trcini dxoei .leelvs Hhig svllee of icrnit eoidx ear esadscaito hwit nimiareg Sd(.u)ty hsHeecaad nad inrgaemis aer aosl vyre omncmo ni mdceinioast thta soobt critni o,xide scuh a gaarvi d)us(ty, btu ti si ncrlaeu ywh shti s.hpapne hTe gionrail hspeshyiot aws tath cnriit oxied sserecani dolbo essevl seiz adn gerstigr a riiga,men ubt the gaarvi tsuyd adn shrtoe oprsveddi tihs. wreeN diesstu no tiircn exido soshw ahtt ti seasrcnie teh eedppit P)GRC( htta si rcdoseidne ssinoplrbee orf egiinrrggt egnaimrsi td)S(yu rtfea cesiarens ni iafoantnm.lim sBaeeuc nictri ieoxd is sdcastaieo nueonrgeci imlnnafioamt i,aesdess it's eliylk tath ehcdehasa nad grainsmie fomr tricin iodxe rae a inagwrn ngsi of stih anolimnamtif (Syt)u.d

ehT cseearhr is bclalaisy ttasgin ahtt tstinera rseai iitnrc xdeoi lvseel adn ghih trciin odexi evesll ersnacei fmainoinlatm nda cdasehaeh and srmeanig.i wHveroe, het xaetc orsena wyh shit hapnsep si nn.oknwu


taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +4  
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +  
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +  

submitted by amphotericin(8),
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I upt pacotisnniot uebesac I thuhgot the cnmioetiad enibg riesdcbde timhg be CBC: anc oesenmo inxaepl wyh atsrniet vroe C?CB

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +4  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +2  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +  
zevvyt  also, verapamil is the one that causes constipation. But Verampamil is non-dyhydropiridine, so it works more on the heart than the vessels +2  

submitted by marbledoc(0),
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htaW si siht nmaeiitocd ienbg dcedsrbie e?hre Cna osoeemn ciehm ni.

thatyummyslice  Nitrates i believe! NO --> increased cGMP in vessel smooth muscle --> myosin light chain dephosphorylate --> vascular smooth muscle RELAX --> Dilate (primarily in venous) AKA more venous capacitance --> LOWER preload and workload for heart. +27  
marbledoc  Thanks! Thought it was nitrates too from the Q stem. But had no clue it was notorious for headaches (only thought of hypotension, dizziness, etc) so doubted it all together. But you’re absolutely right apparently it’s the most common side effect! +  
dr.xx  Previously, Ferid Murad et al. described that organic nitrates, such as nitroglycerine, induce vasodilation by release of nitric oxide, activating soluble guanylyl cyclase and subsequent cyclic guanosine monophosphate formation.7 These discoveries rendered Robert Furchgott, Louis Ignarro, and Ferid Murad the Nobel Prize in Physiology or Medicine in 1998. +