A patient with a history of angina arrives for treatment. All of the following are appropriate stress-reduction measures EXCEPT:

Correct answer: A. Challenging or contradicting the patient to redirect their focus

• A. CORRECT as the EXCEPTION. Confronting, contradicting or provoking a patient raises SYMPATHETIC OUTFLOW — heart rate, blood pressure and myocardial oxygen demand all climb. In a patient with coronary artery disease, that is precisely the physiology that precipitates an anginal attack. Every element of a stress-reduction protocol works in the opposite direction.
• B. Having the patient's NITROGLYCERIN accessible — and confirming it has not expired — is a required preparation for any patient with angina.
• C. SHORT MORNING appointments are standard: the patient is rested, and brief visits limit the duration of physiological stress.
• D. PROFOUND ANESTHESIA is central to stress reduction. Pain is itself a potent sympathetic stimulus, so inadequate anesthesia directly raises cardiac risk.

Note: The stress-reduction protocol: recognize anxiety, premedicate if indicated, short morning appointments, minimize waiting, profound anesthesia, vital signs, nitrous oxide if appropriate, and postoperative follow-up. Limit epinephrine to about 0.04 mg in significant cardiac disease.