1 . The primary criterion for acute myocardial infarction is
| A) | | severe ischemic chest pain. |
| B) | | elevated cardiac biomarker levels. |
| C) | | pathologic Q waves on electrocardiography. |
| D) | | ST-segment changes on electrocardiography. |
OVERVIEW OF ACUTE CORONARY SYNDROME
An MI was once defined according to symptoms, ECG
abnormalities, and serum cardiac enzyme levels. The advent of more sensitive and specific
cardiac biomarkers and imaging studies has led to an ability to detect smaller amounts of
myocardial necrosis and, in turn, a need for a more precise definition of MI. While
myocardial injury, defined as an elevation in serum cardiac troponin, is a prerequisite for
the diagnosis of MI, there must also be clinical evidence of myocardial ischemia to
distinguish MI from cardiac troponin elevation caused by nonischemic myocardial injury
(e.g., myocarditis, sepsis, chronic kidney disease). The European Society of Cardiology
(ESC), the American College of Cardiology Foundation (ACCF), the AHA, and the World Heart
Federation jointly developed a Universal Definition of MI Consensus Document, last updated
in 2018, which states: "the clinical definition of MI denotes the presence of acute
myocardial injury detected by abnormal cardiac biomarkers in the setting of evidence of
acute myocardial ischemia" [31]. Detection
of an elevated cardiac troponin value above the 99th percentile of the upper reference limit
is the preferred diagnostic indicator of myocardial injury. The injury is considered acute
if there is a rise and/or fall of troponin value. Myocardial ischemia in a clinical setting
is most often determined from the patient's history, the EKG, or cardiac imaging studies, as
evidenced by any one of the following [31]:
Symptoms of ischemia
New or presumed new significant ST-segment elevations in two contiguous leads, T
wave changes or new left bundle branch block
Development of pathologic Q waves in the ECG
Imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality
Identification of an intracoronary thrombus by angiography or autopsy
2 . The lowest prevalence of STEMI is found in which population?
| A) | | Black |
| B) | | White |
| C) | | Hispanic |
| D) | | Hawaiian/Pacific Islander |
OVERVIEW OF ACUTE CORONARY SYNDROME
PREVALENCE OF NON-ST-ELEVATION MYOCARDIAL INFARCTION (NSTEMI) AND ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) ACCORDING TO RACE/ETHNICITY
| Type of MI | White | Black | Asian | AI/AN | Hawaiian/PI | Hispanic or Latino Ethnicity |
|---|
| NSTEMI (111,535) | 83.4% | 13.0% | 1.9% | 0.9% | 0.2% | 6.6% |
| STEMI (71,368) | 85.7% | 10.1% | 2.5% | 0.7% | 0.2% | 6.7% |
| AI = American Indian, AN = Alaskan Native, PI = Pacific Islander. |
3 . Of the following, which is the most common cause of ACS?
| A) | | Vasoconstriction |
| B) | | Coronary artery spasm |
| C) | | Atheromatous plaque rupture |
| D) | | Progressive mechanical obstruction |
OVERVIEW OF ACUTE CORONARY SYNDROME
The most common cause of ACS is atherosclerotic CAD, a multi-decade process augmented by aging and acquired factors that impact the degree of atherosclerosis. Atherogenesis proceeds by sequential pathologic change within the vessel wall that leads to formation of an atheromatous plaque. Further progression of the atheroma results in a necrotic core beneath a fibrous cap, accompanied by some degree of plaque instability. ACS is most often precipitated by plaque rupture (especially in men) and acute thrombosis as vascular endothelium is exposed to highly thrombogenic necrotic core material [32,41]. Plaque erosion or fissuring may also lead to ACS [41]. The mechanisms underlying plaque erosion are not as well understood as those for plaque rupture, but inflammation plays a central role in both [41,42,43].
4 . Which of the following types of atherosclerotic lesions is usually involved in plaque erosion?
| A) | | Intimal xanthoma |
| B) | | Thin-cap fibroatheroma |
| C) | | Pathologic intimal thickening |
| D) | | All of the above |
OVERVIEW OF ACUTE CORONARY SYNDROME
A system for classifying the severity of atherosclerotic plaques (lesions) was developed in the 1990s, with lesions categorized into several types according to their histologic composition and structure [45,46,47,48]. A simpler classification, based on morphologic characteristics, was later introduced [49]. According to this system, lesions are defined in seven categories: intimal xanthoma (so-called fatty streak), intimal thickening, pathologic intimal thickening, fibrous cap atheroma, thin-cap fibroatheroma (TCFA), calcified nodule, and fibrocalcific plaque [49]. Pathologic intimal thickening or a thick-cap fibroatheroma is usually involved in plaque erosion [43]. Erosion is often the cause of thrombosis in young patients, particularly women younger than 50 years of age [34,43]. The least often cause of thrombosis is a calcified nodule, which is usually found in older patients with substantially calcified and tortuous arteries [43].
5 . Which of the following is associated with vulnerable plaque?
| A) | | Small lipid core |
| B) | | A thick fibrous cap |
| C) | | High smooth-muscle density |
| D) | | Neovascularization from the vasa vasorum |
OVERVIEW OF ACUTE CORONARY SYNDROME
The stability of plaque is a crucial factor in the potential for rupture. Plaque that is at high risk of rupture is referred to as vulnerable plaque [50]. Vulnerable plaque has the following hallmark characteristics [41,51]:
Large lipid core (more than 40% of the total lesion area)
Thin, fibrous cap (usually less than 65 micrometers)
High infiltration of macrophages
Few smooth muscle cells
Expansive remodeling preserving the lumen
Neovascularization from the vasa vasorum
Adventitial/perivascular inflammation
Spotty calcification
6 . Which of the following is NOT one of the risk factors included in the Framingham Risk Score?
| A) | | Age |
| B) | | Cigarette smoking |
| C) | | Treatment for hypertension |
| D) | | Low-density lipoprotein cholesterol |
OVERVIEW OF ACUTE CORONARY SYNDROME
The Framingham Heart Study identified the first risk factors, and these factors were integrated into a risk-assessment tool, the Framingham Risk Score [62]. The factors in the Framingham Risk Score include age, total cholesterol level, HDL level, systolic blood pressure, treatment for hypertension, and cigarette smoking, and the score is used to determine the 10-year risk of so-called hard CHD (defined as MI or coronary-related death) among asymptomatic adults. The Framingham risk score is one of several scores that involve several traditional risk factors for assessing risk; other scores recommended include the Systematic Coronary Risk Evaluation (SCORE), PROCAM (men) and Reynolds (separate scores for men and women) [63]. The use of one of these risk calculators is a class IB recommendation from the American College of Cardiology Foundation and American Heart Association [63]. It is important to consider the populations on which these risk scores are based. For example, the Framingham Risk Score was developed on the basis of risk factors identified in the Framingham Heart Study, which involved a primarily White, middle-aged population. When the risk score has been evaluated in other populations, it has been found to underestimate the risk of CHD among older (mean age: 73.5 years) Black and White individuals, especially women [64]. ACC/AHA guidelines published in 2013 recommend that race- and sex-specific Pooled Cohort Equations be used to predict 10-year risk of a first hard atherosclerotic cardiovascular disease event in non-Hispanic Black and non-Hispanic White individuals (class IB) [65]. These equations were developed on the basis of data on participants from several large racially and geographically diverse studies [65]. The guidelines also note that the sex-specific pooled cohort equations for non-Hispanic White individuals may be considered to estimate risk for people other than Black and non-Hispanic White individuals (class IB) [65].
7 . Which of the following imaging studies may be considered for asymptomatic adults with hypertension at intermediate risk for ACS?
| A) | | Stress echocardiography |
| B) | | Coronary CT angiography |
| C) | | Transthoracic echocardiography |
| D) | | Stress myocardial perfusion imaging |
OVERVIEW OF ACUTE CORONARY SYNDROME
The 2010 ACCF/AHA guideline and the ACP screening guideline note that stress echocardiography is not indicated for asymptomatic adults at low or intermediate risk [63,79]. Transthoracic echocardiography (to detect left ventricular hypertrophy) is not recommended for asymptomatic adults but "may be considered" for asymptomatic adults with hypertension. Coronary CT angiography is not recommended for asymptomatic adults. Stress myocardial perfusion imaging is not indicated for asymptomatic adults at low or intermediate risk but "may be considered" for assessment of advanced cardiovascular risk in asymptomatic adults with diabetes or with a strong family history of CHD [63,79].
8 . What percentage of individuals who are evaluated for chest pain in the emergency department are ultimately found to have ACS?
| A) | | Fewer than 10% |
| B) | | 45% to 50% |
| C) | | 70% to 75% |
| D) | | 85% to 90% |
DIAGNOSIS AND RISK STRATIFICATION
Most emergency department clinicians err on the side of caution when evaluating patients with chest pain because of the serious consequences of a missed diagnosis of ACS, in terms of adverse patient outcome as well as threat of medical malpractice [105]. As a result, fewer than 10% of patients who are evaluated for chest pain are ultimately found to have ACS [106].
9 . So-called classic ACS-related chest pain is characterized by all of the following, EXCEPT:
| A) | | Begins abruptly |
| B) | | Pain usually worse with rest |
| C) | | Lasts at least 15 to 20 minutes |
| D) | | Diffuse pain or pressure in the substernal or epigastric area |
DIAGNOSIS AND RISK STRATIFICATION
So-called classic ACS-related chest pain has been described as diffuse pain or pressure in the substernal or epigastric area that frequently radiates to the neck, throat, jaw, back, shoulder, and left arm [123]. Chest pain related to ACS usually begins abruptly and lasts at least 15 to 20 minutes; however, the duration of pain varies among patients [123,124]. The intensity of classic ACS chest pain increases over time, reaching maximal intensity after a few minutes [123]. Pain is usually worse with activity and improves with rest.
10 . Women and older individuals with ACS are more likely to have which of the following symptoms?
| A) | | Fatigue |
| B) | | Diaphoresis |
| C) | | Cold sweats |
| D) | | Pressure in the substernal or epigastric area |
DIAGNOSIS AND RISK STRATIFICATION
The classic presentation of ACS includes some symptoms in addition to chest pain, primarily dyspnea, diaphoresis, nausea, abdominal pain, or syncope [2,3]. Again, there is wide variation in the symptoms reported by patients with ACS, as well as differences in subgroups of patients. Patients with STEMI more commonly report nausea, cold sweats, and vomiting [134]. Diaphoresis occurs more often in men with ACS compared with women [128]. In contrast, the likelihood of nonspecific symptoms is greater for women with ACS, with higher rates of fatigue, nausea and/or vomiting, indigestion, palpitations, dyspnea, and dizziness, and lightheadedness [128,129,133,134,135,136]. Among older individuals, dyspnea and fatigue have been noted to be the most common symptoms and diaphoresis has been reported less often [11,125,126].
11 . Among individuals with ACS, hypertension is most common in the
| A) | | White population. |
| B) | | Asian population. |
| C) | | Black population. |
| D) | | Hispanic population. |
DIAGNOSIS AND RISK STRATIFICATION
RISK FACTORS FOR CHD ACCORDING TO RACE/ETHNICITY AMONG PATIENTS WITH ACS
| Patient Characteristics | White | Black | Hispanic | Native American | Asian |
|---|
| Age | 63.9 years ±13 | 59.4 years ±13 | 61.3 years ±13 | 58.7 years ±12 | 63.7 years ±12 |
| Male sex | 62% | 50% | 61% | 62% | 61% |
| Risk Factors |
| Family history of CHD | 42% | 38% | 37% | 42% | 28% |
| Hypertension | 69% | 81% | 71% | 70% | 75% |
| Diabetes | 28% | 40% | 44% | 54% | 37% |
| Current smoker | 26% | 31% | 22% | 38% | 16% |
| ACS = acute coronary syndrome; CHD = coronary
heart disease. |
12 . Which of the following is the most important history-related factor related to the likelihood of ischemia due to CHD?
| A) | | Sex |
| B) | | Smoking history |
| C) | | Nature of the chest pain |
| D) | | Number of traditional CHD risk factors |
DIAGNOSIS AND RISK STRATIFICATION
The five most important history-related factors that relate to the likelihood of ischemia due to CHD are (in order of importance) [139]:
13 . The greatest advantage of cardiac troponins compared with other cardiac biomarkers is their
| A) | | high specificity. |
| B) | | short time to peak elevation. |
| C) | | duration of elevation after an MI. |
| D) | | high sensitivity during the first six hours after symptom onset. |
DIAGNOSIS AND RISK STRATIFICATION
Cardiac biomarkers are detectable intracellular macromolecules released into the circulation after cardiomyocyte injury and death. The biomarkers once used—creatinine kinase (CK)-MB and myoglobin—have been replaced by cardiac-specific troponin (troponin I or T) because of the latter's high concentration in myocardium, near-absolute specificity for myocardial tissue, absence in the blood of healthy individuals, and high clinical sensitivity [2,3,31]. Measurement of CK-MB or myoglobin levels was not useful or cost-effective [145].
As noted, cardiac troponin I and T are sensitive and specific biomarkers of myocardial injury, and serum measurements are used to identify whether patients with ACS have had an MI. A variety of troponin assays are in use. Contemporary ("sensitive") troponin assays have been in use for many years, while "highly sensitive" assays were only approved in 2017 for use in the United States. The Fourth Universal Definition of MI recommends using highly sensitive troponin assays when available [31]. The time to initial elevation of cardiac troponin levels following MI is 2 to 12 hours when measured by sensitive assays, with peak elevation at 24 hours (troponin I) and 12 to 48 hours (troponin T) [3,146]. Levels may remain elevated for 5 to 10 days (troponin I) or up to 14 days (troponin T) after an MI [146]. Highly sensitive assays detect significant elevations of cardiac troponin within one hour, which has the advantage of more rapid diagnosis and triage. The sensitivity of cardiac troponin for the diagnosis of MI is relatively low during the first six hours, especially in patients who present shortly after symptom onset [146]. However, for most patients with ACS, MI can be ruled out or confirmed within six hours, in part because of the high rate of delayed presentation associated with chest pain [3].
14 . The ACC/AHA guideline for UA/NSTEMI states that troponin levels should be measured at
| A) | | three hours after presentation. |
| B) | | 12 hours after presentation. |
| C) | | six hours after the onset of symptoms and every two hours thereafter. |
| D) | | the time of presentation and three to six hours after the onset of symptoms. |
DIAGNOSIS AND RISK STRATIFICATION
The ACC/AHA guideline for UA/NSTEMI states that troponin levels should be measured at the time of presentation and three to six hours after the onset of symptoms in all patients suspected of having ACS [3]. If the time of symptom onset is unclear, the time of presentation should be used instead. When initial serial troponin levels are normal but ECG changes and/or clinical features increase the suspicion for ACS, additional troponin levels should be measured beyond six hours [3]. The lack of elevated troponin levels at the time of presentation should not rule out an MI, as the initial level is normal in as many as 23% of patients with MI [148]. Troponin levels appear to have value in ruling out an MI; the negative predictive value of undetectable troponin levels has been reported to be 99% to 100%.
15 . Which of the following risk factors is part of the TIMI risk score but NOT the GRACE risk model?
| A) | | Age |
| B) | | ST-segment deviation |
| C) | | Elevated cardiac biomarkers |
| D) | | Multiple recent episodes of angina |
DIAGNOSIS AND RISK STRATIFICATION
The TIMI risk score is based on seven independent risk factors [151]:
Advanced age (65 years or older)
At least three risk factors for CHD
Previous coronary artery stenosis of 50% or more
ST-segment deviation on initial ECG
At least two episodes of angina in the past 24 hours
Use of aspirin in the past seven days
Elevated levels of cardiac biomarkers
One point is given for each factor, and the total score corresponds to the risk of all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization through 14 days [151]. That risk ranges from 4.7% for a TIMI risk score of 0 or 1 to 40.9% for a score of 6 or 7. Patients with a higher TIMI score will derive greater benefit from an invasive strategy [3]. The TIMI risk calculator can be accessed online at https://timi.org.
The GRACE risk model includes eight variables [152]:
16 . The ACC/AHA UA/NSTEMI guideline recommends that supplemental oxygen be given to
| A) | | all patients with suspected ACS. |
| B) | | patients who complain of fatigue. |
| C) | | patients at high risk for hyperoxia. |
| D) | | patients who have an arterial oxygen saturation of less than 90%. |
The general care of patients with UA/NSTEMI is directed at the severity of symptoms. Bed rest is recommended while patients have ischemic pain. After symptoms have subsided, patients may move to a chair. The ACC/AHA guideline notes that there is no benefit to the routine use of supplemental oxygen, and it may, in fact, even be harmful [3]. Instead, supplemental oxygen should be given only to patients who have an arterial oxygen saturation of less than 90%, respiratory distress, or other high-risk features of hypoxemia. Continuous ECG monitoring should also be carried out, not only to detect ECG changes that may provide additional diagnostic and prognostic information but also because sudden ventricular fibrillation is the primary preventable cause of death during this initial period [3].
17 . Which of the following medications is recommended with the highest level of evidence for the treatment of chest pain in patients with UA/NSTEMI?
| A) | | Aspirin |
| B) | | Morphine |
| C) | | Nitroglycerin |
| D) | | Acetaminophen |
ADJUNCTIVE TREATMENT INDICATIONS FOR PATIENTS WITH UA/NSTEMI OR STEMI
| Adjunctive Therapy | UA/NSTEMI | STEMI | Comments |
|---|
| Analgesia |
| Nitroglycerin | All patients, unless contraindicated (class IC) | No recommendation | Contraindicated for patients with hypotension or who have used
sildenafil or vardenafil within previous 24 hours or tadalafil within previous 48
hours (class IIIB). |
| All patients, unless contraindicated (class IB) | No recommendation |
| Morphine | Reasonable for patients who have chest pain unrelieved by maximally tolerated
anti-ischemic medications (class IIbB) |
Not specifically recommended.
Narcotics should be considered if high-dose aspirin fails to relieve pain
(class IIbC)
| — |
| Anti-Ischemia Therapy |
| Beta blocker |
| All patients, unless contraindicated (class IA) | | Continue during and after hospitalization, unless contraindicated (class
IC) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
| All patients, unless contraindicated (class IB) | | Continue during and after hospitalization, unless contraindicated (class
IB) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
Administer in the first 24 hours.
Contraindicated for patients with signs of heart failure, evidence of
low-output state, increased risk of cardiogenic shock, or other contraindications
to beta blockers.
|
| ACE inhibitor | Started and continued in all patients with left ventricular ejection fraction
less than 40% and in patients with hypertension, diabetes, or stable CKD, unless
contraindicated (class IA) | All patients (within the first 24 hours) with anterior location, HF, or
ejection fraction less than or equal to 0.40, unless contraindicated (class
IA) |
| Contraindicated for patients with hypotension (systolic blood pressure of
<100 mm Hg or <30 mm Hg below baseline). | | An angiotensin receptor blocker should be used for patients intolerant of
ACE inhibitors. |
|
| Calcium-channel blocker | Patients with continued or recurrent ischemia or with contraindications to beta
blockers (class IB) | No recommendation | — |
| Antiplatelet Therapy |
| Aspirin (non-enteric coated, chewable) |
All patients (class IA)
Continued indefinitely
|
All patients (class IA)
Continued indefinitely
|
| Should be given as soon as possible at time of evaluation. | | Contraindicated for patients who have aspirin allergy or active
bleeding. | | Lower dose is reasonable during initial period post-stent implantation in
patients at risk of bleeding. | | Consider clopidogrel or warfarin if aspirin is contraindicated. Monitor
closely. |
|
| Clopidogrel |
| All patients (class IB) | | Administer to patients who are unable to take aspirin (class IB) | | Maintenance dose daily, continued preferably for up to one year (class
IB) |
|
| All patients (in addition to aspirin), before or at the time of PCI, if
not already started and who are undergoing PCI within 24 hours of receiving
fibrinolytic therapy (class IC) | | Daily dose should be continued for one year (class IC) |
| Loading dose not recommended for older (>75 years of age) patients with
STEMI. Should be withheld for five days in patients to have CABG (class IB). Monitor
closely when used in conjunction with warfarin. |
| Prasugrel |
| Not recommended for initial platelet therapy. | | All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). |
|
| All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). | | Should not be given sooner than 24 hours after administration of a
fibrin-specific agent or 48 hours after administration of a non-fibrin-specific
agent (class IIaB) |
|
| Should be withheld for at least seven days in patients to have CABG (class
IB). | | Should not be administered to patients with history stroke or transient
ischemic attack (class IIIB). |
|
| Ticagrelor | All patients undergoing PCI with stenting should be given a loading dose and at
least one year of maintenance therapy with this or other P2Y inhibitor if not given
clopidogrel (class IB). | All patients (in addition to aspirin) undergoing PCI with stenting should be
given a loading dose and at least one year of maintenance therapy with this or other
P2Y inhibitor if not given clopidogrel (class IB). |
| Should be withheld for at least five days in patients to have CABG (class
IB). | | May only be used with lower doses (81 mg) of aspirin. | | Requires twice daily administration. |
|
| Glycoprotein IIb/IIIa inhibitor | Patients selected for early invasive treatment, along with dual-antiplatelet
therapy, who are at intermediate or high risk (high troponin levels) (class
IIbB) |
| Reasonable for selected patients who are receiving unfractionated heparin
to have abciximab with primary PCI (class IIaA); eptifibatide or tirofiban may
also be considered with primary PCI (class IIaB) | | May be reasonable to administer in emergency department to patients
selected for primary PCI (class IIbB) |
|
| The rate of IV infusion of eptifibatide or tirofiban should be reduced by
50% for patients with estimated creatinine clearance <50 mgL/min. | | Eptifibatide or tirofiban should be discontinued two to four hours before
CABG (class IB). |
|
| Anticoagulant Therapy |
| Unfractionated heparin (UFH) |
| Option for patients selected for early invasive treatment (class IB) and
early conservative treatment (class IB) | | Dose adjusted according to hospital protocol to maintain therapeutic
anticoagulation for 48 hrs or until PCI (class IB) |
| Option for patients selected for primary PCI (class IC) or fibrinolytic therapy
(class IC); administer for at least 48 hours or until revascularization |
| The UFH dose should be reduced when a glycoprotein IIb/IIIa inhibitor is
also given (class IC). | | For patients undergoing PCI after receiving anticoagulant regimen,
administer additional boluses of UFH as needed to support procedure (class
IC). |
|
| Enoxaparin | Option for patients selected for early invasive treatment (class IA) and early
conservative treatment (class IA) | Option for patients selected for fibrinolytic therapy (class IA); administer
for at least 48 hours; for use up to eight days or until revascularization |
| Discontinue enoxaparin 12 to 24 hours before CABG (class IB). | | Reduce dose for creatinine clearance less than 30 mL/ min and/or ≥75 yrs
of age. |
|
| Bivalirudin | Option for patients selected for early invasive treatment (class IB) |
| Preferred over UFH with glycoprotein IIb/IIIa inhibitor in patients
selected for PCI at high risk of bleeding (class IIaB) | | Useful supportive measure for primary PCI with/without prior treatment
with UFH (class IB) |
|
| Reduce dose for creatinine clearance less than 30 mL/min. | | Discontinue bivalirudin three hours before CABG (class IB). |
|
| Fondaparinux | Option for patients selected for early invasive treatment (class IB) and early
conservative treatment (IB) | Option for patients selected for fibrinolytic therapy (class IB) |
| Should not be used as sole anticoagulant to support PCI in patients with
NSTE-ACS due to an increased risk of catheter thrombosis. | | Avoid for creatinine clearance less than 30 mL/min. | | Discontinue 24 hrs before CABG. |
|
| ACE = angiotensin-converting enzyme; CABG =
coronary artery bypass graft; CKD = chronic kidney disease; HF = heart failure; PCI
= percutaneous coronary intervention. |
18 . Which antiplatelet therapy should be discontinued for at least seven days in patients who are scheduled to have CABG?
| A) | | Prasugrel |
| B) | | Ticagrelor |
| C) | | Eptifibatide |
| D) | | Clopidogrel |
ADJUNCTIVE TREATMENT INDICATIONS FOR PATIENTS WITH UA/NSTEMI OR STEMI
| Adjunctive Therapy | UA/NSTEMI | STEMI | Comments |
|---|
| Analgesia |
| Nitroglycerin | All patients, unless contraindicated (class IC) | No recommendation | Contraindicated for patients with hypotension or who have used
sildenafil or vardenafil within previous 24 hours or tadalafil within previous 48
hours (class IIIB). |
| All patients, unless contraindicated (class IB) | No recommendation |
| Morphine | Reasonable for patients who have chest pain unrelieved by maximally tolerated
anti-ischemic medications (class IIbB) |
Not specifically recommended.
Narcotics should be considered if high-dose aspirin fails to relieve pain
(class IIbC)
| — |
| Anti-Ischemia Therapy |
| Beta blocker |
| All patients, unless contraindicated (class IA) | | Continue during and after hospitalization, unless contraindicated (class
IC) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
| All patients, unless contraindicated (class IB) | | Continue during and after hospitalization, unless contraindicated (class
IB) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
Administer in the first 24 hours.
Contraindicated for patients with signs of heart failure, evidence of
low-output state, increased risk of cardiogenic shock, or other contraindications
to beta blockers.
|
| ACE inhibitor | Started and continued in all patients with left ventricular ejection fraction
less than 40% and in patients with hypertension, diabetes, or stable CKD, unless
contraindicated (class IA) | All patients (within the first 24 hours) with anterior location, HF, or
ejection fraction less than or equal to 0.40, unless contraindicated (class
IA) |
| Contraindicated for patients with hypotension (systolic blood pressure of
<100 mm Hg or <30 mm Hg below baseline). | | An angiotensin receptor blocker should be used for patients intolerant of
ACE inhibitors. |
|
| Calcium-channel blocker | Patients with continued or recurrent ischemia or with contraindications to beta
blockers (class IB) | No recommendation | — |
| Antiplatelet Therapy |
| Aspirin (non-enteric coated, chewable) |
All patients (class IA)
Continued indefinitely
|
All patients (class IA)
Continued indefinitely
|
| Should be given as soon as possible at time of evaluation. | | Contraindicated for patients who have aspirin allergy or active
bleeding. | | Lower dose is reasonable during initial period post-stent implantation in
patients at risk of bleeding. | | Consider clopidogrel or warfarin if aspirin is contraindicated. Monitor
closely. |
|
| Clopidogrel |
| All patients (class IB) | | Administer to patients who are unable to take aspirin (class IB) | | Maintenance dose daily, continued preferably for up to one year (class
IB) |
|
| All patients (in addition to aspirin), before or at the time of PCI, if
not already started and who are undergoing PCI within 24 hours of receiving
fibrinolytic therapy (class IC) | | Daily dose should be continued for one year (class IC) |
| Loading dose not recommended for older (>75 years of age) patients with
STEMI. Should be withheld for five days in patients to have CABG (class IB). Monitor
closely when used in conjunction with warfarin. |
| Prasugrel |
| Not recommended for initial platelet therapy. | | All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). |
|
| All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). | | Should not be given sooner than 24 hours after administration of a
fibrin-specific agent or 48 hours after administration of a non-fibrin-specific
agent (class IIaB) |
|
| Should be withheld for at least seven days in patients to have CABG (class
IB). | | Should not be administered to patients with history stroke or transient
ischemic attack (class IIIB). |
|
| Ticagrelor | All patients undergoing PCI with stenting should be given a loading dose and at
least one year of maintenance therapy with this or other P2Y inhibitor if not given
clopidogrel (class IB). | All patients (in addition to aspirin) undergoing PCI with stenting should be
given a loading dose and at least one year of maintenance therapy with this or other
P2Y inhibitor if not given clopidogrel (class IB). |
| Should be withheld for at least five days in patients to have CABG (class
IB). | | May only be used with lower doses (81 mg) of aspirin. | | Requires twice daily administration. |
|
| Glycoprotein IIb/IIIa inhibitor | Patients selected for early invasive treatment, along with dual-antiplatelet
therapy, who are at intermediate or high risk (high troponin levels) (class
IIbB) |
| Reasonable for selected patients who are receiving unfractionated heparin
to have abciximab with primary PCI (class IIaA); eptifibatide or tirofiban may
also be considered with primary PCI (class IIaB) | | May be reasonable to administer in emergency department to patients
selected for primary PCI (class IIbB) |
|
| The rate of IV infusion of eptifibatide or tirofiban should be reduced by
50% for patients with estimated creatinine clearance <50 mgL/min. | | Eptifibatide or tirofiban should be discontinued two to four hours before
CABG (class IB). |
|
| Anticoagulant Therapy |
| Unfractionated heparin (UFH) |
| Option for patients selected for early invasive treatment (class IB) and
early conservative treatment (class IB) | | Dose adjusted according to hospital protocol to maintain therapeutic
anticoagulation for 48 hrs or until PCI (class IB) |
| Option for patients selected for primary PCI (class IC) or fibrinolytic therapy
(class IC); administer for at least 48 hours or until revascularization |
| The UFH dose should be reduced when a glycoprotein IIb/IIIa inhibitor is
also given (class IC). | | For patients undergoing PCI after receiving anticoagulant regimen,
administer additional boluses of UFH as needed to support procedure (class
IC). |
|
| Enoxaparin | Option for patients selected for early invasive treatment (class IA) and early
conservative treatment (class IA) | Option for patients selected for fibrinolytic therapy (class IA); administer
for at least 48 hours; for use up to eight days or until revascularization |
| Discontinue enoxaparin 12 to 24 hours before CABG (class IB). | | Reduce dose for creatinine clearance less than 30 mL/ min and/or ≥75 yrs
of age. |
|
| Bivalirudin | Option for patients selected for early invasive treatment (class IB) |
| Preferred over UFH with glycoprotein IIb/IIIa inhibitor in patients
selected for PCI at high risk of bleeding (class IIaB) | | Useful supportive measure for primary PCI with/without prior treatment
with UFH (class IB) |
|
| Reduce dose for creatinine clearance less than 30 mL/min. | | Discontinue bivalirudin three hours before CABG (class IB). |
|
| Fondaparinux | Option for patients selected for early invasive treatment (class IB) and early
conservative treatment (IB) | Option for patients selected for fibrinolytic therapy (class IB) |
| Should not be used as sole anticoagulant to support PCI in patients with
NSTE-ACS due to an increased risk of catheter thrombosis. | | Avoid for creatinine clearance less than 30 mL/min. | | Discontinue 24 hrs before CABG. |
|
| ACE = angiotensin-converting enzyme; CABG =
coronary artery bypass graft; CKD = chronic kidney disease; HF = heart failure; PCI
= percutaneous coronary intervention. |
19 . Which of the following anticoagulant agents is a class IA option for patients with UA/ NSTEMI regardless of the initial strategy (invasive or ischemia-guided)?
| A) | | Bivalirudin |
| B) | | Enoxaparin |
| C) | | Fondaparinux |
| D) | | Unfractionated heparin |
ADJUNCTIVE TREATMENT INDICATIONS FOR PATIENTS WITH UA/NSTEMI OR STEMI
| Adjunctive Therapy | UA/NSTEMI | STEMI | Comments |
|---|
| Analgesia |
| Nitroglycerin | All patients, unless contraindicated (class IC) | No recommendation | Contraindicated for patients with hypotension or who have used
sildenafil or vardenafil within previous 24 hours or tadalafil within previous 48
hours (class IIIB). |
| All patients, unless contraindicated (class IB) | No recommendation |
| Morphine | Reasonable for patients who have chest pain unrelieved by maximally tolerated
anti-ischemic medications (class IIbB) |
Not specifically recommended.
Narcotics should be considered if high-dose aspirin fails to relieve pain
(class IIbC)
| — |
| Anti-Ischemia Therapy |
| Beta blocker |
| All patients, unless contraindicated (class IA) | | Continue during and after hospitalization, unless contraindicated (class
IC) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
| All patients, unless contraindicated (class IB) | | Continue during and after hospitalization, unless contraindicated (class
IB) | | Re-evaluate patients with initial contraindications to beta blockers for
subsequent use (class IC) |
|
Administer in the first 24 hours.
Contraindicated for patients with signs of heart failure, evidence of
low-output state, increased risk of cardiogenic shock, or other contraindications
to beta blockers.
|
| ACE inhibitor | Started and continued in all patients with left ventricular ejection fraction
less than 40% and in patients with hypertension, diabetes, or stable CKD, unless
contraindicated (class IA) | All patients (within the first 24 hours) with anterior location, HF, or
ejection fraction less than or equal to 0.40, unless contraindicated (class
IA) |
| Contraindicated for patients with hypotension (systolic blood pressure of
<100 mm Hg or <30 mm Hg below baseline). | | An angiotensin receptor blocker should be used for patients intolerant of
ACE inhibitors. |
|
| Calcium-channel blocker | Patients with continued or recurrent ischemia or with contraindications to beta
blockers (class IB) | No recommendation | — |
| Antiplatelet Therapy |
| Aspirin (non-enteric coated, chewable) |
All patients (class IA)
Continued indefinitely
|
All patients (class IA)
Continued indefinitely
|
| Should be given as soon as possible at time of evaluation. | | Contraindicated for patients who have aspirin allergy or active
bleeding. | | Lower dose is reasonable during initial period post-stent implantation in
patients at risk of bleeding. | | Consider clopidogrel or warfarin if aspirin is contraindicated. Monitor
closely. |
|
| Clopidogrel |
| All patients (class IB) | | Administer to patients who are unable to take aspirin (class IB) | | Maintenance dose daily, continued preferably for up to one year (class
IB) |
|
| All patients (in addition to aspirin), before or at the time of PCI, if
not already started and who are undergoing PCI within 24 hours of receiving
fibrinolytic therapy (class IC) | | Daily dose should be continued for one year (class IC) |
| Loading dose not recommended for older (>75 years of age) patients with
STEMI. Should be withheld for five days in patients to have CABG (class IB). Monitor
closely when used in conjunction with warfarin. |
| Prasugrel |
| Not recommended for initial platelet therapy. | | All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). |
|
| All patients undergoing PCI with stenting should be given a loading dose
and at least one year of maintenance therapy with this or other P2Y inhibitor if
not given clopidogrel (class IB). | | Should not be given sooner than 24 hours after administration of a
fibrin-specific agent or 48 hours after administration of a non-fibrin-specific
agent (class IIaB) |
|
| Should be withheld for at least seven days in patients to have CABG (class
IB). | | Should not be administered to patients with history stroke or transient
ischemic attack (class IIIB). |
|
| Ticagrelor | All patients undergoing PCI with stenting should be given a loading dose and at
least one year of maintenance therapy with this or other P2Y inhibitor if not given
clopidogrel (class IB). | All patients (in addition to aspirin) undergoing PCI with stenting should be
given a loading dose and at least one year of maintenance therapy with this or other
P2Y inhibitor if not given clopidogrel (class IB). |
| Should be withheld for at least five days in patients to have CABG (class
IB). | | May only be used with lower doses (81 mg) of aspirin. | | Requires twice daily administration. |
|
| Glycoprotein IIb/IIIa inhibitor | Patients selected for early invasive treatment, along with dual-antiplatelet
therapy, who are at intermediate or high risk (high troponin levels) (class
IIbB) |
| Reasonable for selected patients who are receiving unfractionated heparin
to have abciximab with primary PCI (class IIaA); eptifibatide or tirofiban may
also be considered with primary PCI (class IIaB) | | May be reasonable to administer in emergency department to patients
selected for primary PCI (class IIbB) |
|
| The rate of IV infusion of eptifibatide or tirofiban should be reduced by
50% for patients with estimated creatinine clearance <50 mgL/min. | | Eptifibatide or tirofiban should be discontinued two to four hours before
CABG (class IB). |
|
| Anticoagulant Therapy |
| Unfractionated heparin (UFH) |
| Option for patients selected for early invasive treatment (class IB) and
early conservative treatment (class IB) | | Dose adjusted according to hospital protocol to maintain therapeutic
anticoagulation for 48 hrs or until PCI (class IB) |
| Option for patients selected for primary PCI (class IC) or fibrinolytic therapy
(class IC); administer for at least 48 hours or until revascularization |
| The UFH dose should be reduced when a glycoprotein IIb/IIIa inhibitor is
also given (class IC). | | For patients undergoing PCI after receiving anticoagulant regimen,
administer additional boluses of UFH as needed to support procedure (class
IC). |
|
| Enoxaparin | Option for patients selected for early invasive treatment (class IA) and early
conservative treatment (class IA) | Option for patients selected for fibrinolytic therapy (class IA); administer
for at least 48 hours; for use up to eight days or until revascularization |
| Discontinue enoxaparin 12 to 24 hours before CABG (class IB). | | Reduce dose for creatinine clearance less than 30 mL/ min and/or ≥75 yrs
of age. |
|
| Bivalirudin | Option for patients selected for early invasive treatment (class IB) |
| Preferred over UFH with glycoprotein IIb/IIIa inhibitor in patients
selected for PCI at high risk of bleeding (class IIaB) | | Useful supportive measure for primary PCI with/without prior treatment
with UFH (class IB) |
|
| Reduce dose for creatinine clearance less than 30 mL/min. | | Discontinue bivalirudin three hours before CABG (class IB). |
|
| Fondaparinux | Option for patients selected for early invasive treatment (class IB) and early
conservative treatment (IB) | Option for patients selected for fibrinolytic therapy (class IB) |
| Should not be used as sole anticoagulant to support PCI in patients with
NSTE-ACS due to an increased risk of catheter thrombosis. | | Avoid for creatinine clearance less than 30 mL/min. | | Discontinue 24 hrs before CABG. |
|
| ACE = angiotensin-converting enzyme; CABG =
coronary artery bypass graft; CKD = chronic kidney disease; HF = heart failure; PCI
= percutaneous coronary intervention. |
20 . Which of the following is a contraindication to the use of beta blockers in the treatment of UA/NSTEMI?
| A) | | Hypotension |
| B) | | Tachycardia |
| C) | | Heart failure |
| D) | | Recent use of sildenafil |
The inhibition of beta-1 adrenergic receptors by beta blockers acts to decrease cardiac work and myocardial oxygen demand. Beta blockers also slow the heart rate, which helps enhance coronary blood flow. A beta blocker should be given orally to all patients (unless contraindicated) within 24 hours after presentation [3]. This use of beta blocker therapy has been associated with significantly lower in-hospital mortality [159]. The evidence for the benefit of beta-blocker therapy is well established, but it diminishes as the time from the index cardiac event elapses [160]. Contraindications include signs of heart failure, low-output state, increased risk of cardiogenic shock, or other relative contraindications to beta blockade.
21 . The most important factor in selecting an early invasive or ischemia-guided strategy is the patient's
| A) | | age. |
| B) | | sex. |
| C) | | risk. |
| D) | | history of CHD. |
FACTORS Associated With Appropriate Selection of Early Invasive Strategy or
Ischemia-Guided Strategy in Patients With NSTE-ACS
| Treatment Strategy | Factors Guiding Selection |
|---|
| Immediate invasive (within two hours) |
| Refractory angina | | Signs or symptoms of HF or new or worsening mitral regurgitation | | Hemodynamic instability | | Recurrent angina or ischemia at rest or with low-level activities despite
intensive medical therapy | | Sustained VT or VF |
|
| Ischemia-guided strategy |
| Low-risk score (e.g., TIMI [0 or 1], GRACE [<109]) | | Low-risk, Tn-negative female patients | | Patient or clinician preference in the absence of high-risk
features |
|
| Early invasive (within 24 hours) |
| None of the above, but GRACE risk score 140 | | Temporal change in Tn | | New or presumably new ST depression |
|
| Delayed invasive (within 25 to 72 hours) |
| None of the above, but diabetes mellitus | | Renal insufficiency (GFR <60 mL/min/1.73
m2) | | Reduced LV systolic function (EF <40%) | | Early postinfarction angina | | PCI within six months | | Prior CABG | | GRACE risk score 109–140; TIMI score ≥2 |
|
| CABG = coronary artery bypass graft; EF = ejection
fraction; GFR = glomerular filtration rate; GRACE = Global Registry of Acute
Coronary Events; HF = heart failure; LV = left ventricular; NSTE-ACS =
non-ST-elevation acute coronary syndrome; PCI = percutaneous coronary intervention;
TIMI = Thrombolysis In Myocardial Infarction; Tn = troponin; VF = ventricular
fibrillation; VT = ventricular tachycardia. |
22 . Low-risk, troponin-negative female patients with NSTE-ACE should be treated with a(n)
| A) | | early invasive strategy. |
| B) | | ischemia-guided strategy. |
| C) | | delayed invasive strategy. |
| D) | | immediate invasive strategy. |
FACTORS Associated With Appropriate Selection of Early Invasive Strategy or
Ischemia-Guided Strategy in Patients With NSTE-ACS
| Treatment Strategy | Factors Guiding Selection |
|---|
| Immediate invasive (within two hours) |
| Refractory angina | | Signs or symptoms of HF or new or worsening mitral regurgitation | | Hemodynamic instability | | Recurrent angina or ischemia at rest or with low-level activities despite
intensive medical therapy | | Sustained VT or VF |
|
| Ischemia-guided strategy |
| Low-risk score (e.g., TIMI [0 or 1], GRACE [<109]) | | Low-risk, Tn-negative female patients | | Patient or clinician preference in the absence of high-risk
features |
|
| Early invasive (within 24 hours) |
| None of the above, but GRACE risk score 140 | | Temporal change in Tn | | New or presumably new ST depression |
|
| Delayed invasive (within 25 to 72 hours) |
| None of the above, but diabetes mellitus | | Renal insufficiency (GFR <60 mL/min/1.73
m2) | | Reduced LV systolic function (EF <40%) | | Early postinfarction angina | | PCI within six months | | Prior CABG | | GRACE risk score 109–140; TIMI score ≥2 |
|
| CABG = coronary artery bypass graft; EF = ejection
fraction; GFR = glomerular filtration rate; GRACE = Global Registry of Acute
Coronary Events; HF = heart failure; LV = left ventricular; NSTE-ACS =
non-ST-elevation acute coronary syndrome; PCI = percutaneous coronary intervention;
TIMI = Thrombolysis In Myocardial Infarction; Tn = troponin; VF = ventricular
fibrillation; VT = ventricular tachycardia. |
23 . CABG is preferred over PCI for patients who have
| A) | | discrete lesions. |
| B) | | left main disease. |
| C) | | one-vessel disease. |
| D) | | disease in large-caliber vessels. |
A comprehensive comparison of CABG and PCI was carried out in the Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) study, and the findings were considered in the formulation of the 2011 ACC/AHA/Society for Cardiac Angiography and Interventions (SCAI) guideline recommendations for PCI [5]. In a meta-analysis (31 trials, 15,004 patients) published after the guideline, among patients eligible for either PCI or CABG, the latter procedure was associated with lower rates of repeat revascularization, and death; the rate of MI was similar, and the rate of stroke was higher with CABG [204]. Class I recommendations for the use of PCI include patients who have refractory angina or hemodynamic or electrical instability (without comorbidities or contraindications), and initially stabilized patients who have an elevated risk for clinical events [5]. PCI is preferred for patients with discrete lesions, in large-caliber vessels, or one or two vessels, whereas CABG is recommended for more extensive CHD, including left main disease, three-vessel disease, or two-vessel disease with severe involvement of the proximal left anterior descending coronary artery [6]. For patients with multivessel disease, CABG has been associated with higher adjusted rates of long-term survival and lower rates of MI and repeat vascularization compared with PCI with stenting [205,206]. CABG is also recommended for patients with left ventricular systolic dysfunction [6].
24 . The recommended time from first medical contact to PCI is within less than
| A) | | 120 minutes. |
| B) | | 90 minutes. |
| C) | | 5 minutes. |
| D) | | 250 seconds. |
The 2013 ACCF/AHA guideline indicates that PCI is preferred over fibrinolytic therapy for patients with STEMI when it can be performed in a timely manner by experienced operators [2]. PCI should be done within less than 90 minutes after the patient's first medical contact [2]. If PCI cannot be done within 90 minutes, fibrinolytic therapy should be initiated as the reperfusion strategy within 120 minutes of the first medical contact.
25 . The most important variable in selecting a reperfusion therapy for patients with STEMI is
| A) | | timing. |
| B) | | patient's age. |
| C) | | ECG findings. |
| D) | | availability of a cardiac catheterization laboratory. |
The most significant factor in achieving an optimal outcome from PCI is timing. Findings from hospitals reporting to the Centers for Medicare and Medicaid Services have shown an improvement in the number of patients treated with primary PCI within the recommended 90-minute window, from 44.2% in 2005 to 91.4% in 2010 [210]. In addition, the median door-to-balloon or door-to-device time declined from 96 minutes in 2005 to 64 minutes in 2010 [210].
26 . The ACCF/AHA guideline recommends that a goal be set for the PCI team to arrive in the catheterization laboratory within
| A) | | 5 minutes after being paged. |
| B) | | 20 minutes after being paged. |
| C) | | 90 minutes after being paged. |
| D) | | 120 minutes after being paged. |
Specific strategies that have improved the door-to-device time interval focus on three key components: door-to-ECG time, ECG-to-catheterization laboratory time, and laboratory arrival-to-device time. The ACCF/AHA provides the following steps as a general protocol in improving door-to-device times [2]:
A prehospital ECG to diagnose STEMI is used to activate the PCI team while he patient is en route to the hospital.
Emergency physicians activate the PCI team.
A single call to a central page operator activates the PCI team.
A goal is set for the PCI team to arrive in the catheterization laboratory within 20 minutes after being paged.
Timely data feedback and analysis are provided to members of the STEMI care team.
27 . Which of the following is NOT a Class I indication for primary PCI?
| A) | | STEMI symptoms within 12 hours |
| B) | | Severe heart failure or cardiogenic shock |
| C) | | Treatment that is delayed more than 120 minutes |
| D) | | Contraindications to fibrinolytic therapy with ischemic symptoms less than 12 hours |
Class I indications for primary PCI include the following [5]:
STEMI symptoms within 12 hours (level A)
Severe heart failure or cardiogenic shock (level B)
Contraindications to fibrinolytic therapy with ischemic symptoms less than 12 hours (level B)
28 . When used with PCI, stents reduce the rate of
| A) | | stroke. |
| B) | | mortality. |
| C) | | reinfarction. |
| D) | | target-vessel revascularization. |
The use of coronary stents during PCI reduces the rates of adverse events such as re-occlusion, restenosis, and target-vessel revascularization [5,209,211]. Drug-eluting stents have been associated with lower long-term rates of target-vessel revascularization and restenosis compared with bare-metal stents, but the reduction has varied among the many types of drug-eluting stents and stent thrombosis was originally a complication [213,214]. Subsequent-generation drug-eluting stents were developed to overcome this complication, and thin-strut fluoropolymer-coated cobalt chromium everolimus-eluting stents have been associated with rates of stent thrombosis that are lower than those for other types of drug-eluting stents or bare-metal stents [214]. One small study that included 372 patients compared the efficacy of drug-eluting stents with drug-coated balloons for use during PCI [215]. The primary outcome was a composite of major adverse cardiovascular events (e.g., cardiac death, MI, target lesion revascularization) at one year [215]. Major adverse events occurred in 10 patients (12%) in the drug-coated balloon group and in 50 patients (13.4%) in the drug-eluting stent group. Other studies have confirmed the potential benefit of using drug-coated balloons during PCI [216,217].
29 . What loading dose of clopidogrel should be given to patients with STEMI receiving PCI within 24 hours after fibrinolytic therapy?
| A) | | 150 mg |
| B) | | 300 mg |
| C) | | 600 mg |
| D) | | 900 mg |
The aspirin dose before PCI should be 325 mg for patients who had not been taking aspirin therapy and 81 mg to 325 mg for patients who had already been taking daily aspirin [5]. If stents are to be implanted during PCI, a loading dose of a P2Y12 inhibitor should be given (clopidogrel, 600 mg; prasugrel, 60 mg; or ticagrelor, 180 mg) [5]. For clopidogrel, a 300-mg loading dose is recommended for patients who have PCI within 24 hours after receiving fibrinolytic therapy; a 600-mg loading dose is recommended for patients who have PCI more than 24 hours after receiving fibrinolytic therapy [5]. This recommendation is based on the results of several investigations to explore various loading doses of clopidogrel before or during PCI. A meta-analysis of seven studies demonstrated that a 600 mg loading of clopidogrel reduces the rate of adverse cardiovascular events without an increase in major bleeding compared with 300 mg [5]. The findings of another study suggested that a 600-mg loading dose (compared with a 300-mg dose) is associated with improvements in procedural angiographic endpoints and one-year clinical outcomes in patients with STEMI who undergo primary PCI [5]. No benefit is derived from increasing the loading dose to 900 mg compared with 600 mg [5]. The guideline acknowledges that the safety and efficacy of pretreatment with clopidogrel remains controversial [5].
30 . Prasugrel is contraindicated in patients
| A) | | being treated for STEMI. |
| B) | | with a history of smoking. |
| C) | | younger than 60 years of age. |
| D) | | with a history of transient ischemic attack. |
When compared with clopidogrel, prasugrel was associated with a 2.2% reduction in a composite endpoint of cardiovascular-related death, nonfatal reinfarction, or nonfatal stroke [5]. Prasugrel is contraindicated in patients with active pathologic bleeding or history of transient ischemic attack or stroke. Its use is not recommended for patients older than 75 years of age because of increased risk of fatal intracranial bleeding [5].
31 . Which of the following fibrinolytic agents is least effective because it is non-fibrin specific?
| A) | | Alteplase |
| B) | | Reteplase |
| C) | | Tenecteplase |
| D) | | Streptokinase |
COMPARISON OF FIBRINOLYTIC AGENTS FOR TREATMENT OF STEMI
| Characteristic | Streptokinase | Alteplase | Reteplase | Tenecteplase |
|---|
| Dose | 1.5 MU | Up to 100 mg | 10 U + 10 U | 30–50 mg |
| Administration | Infusion (over 30 to 60 minutes) | Bolus and infusion (over 90 minutes) | Bolus (over 2 minutes) given 30 minutes apart | Bolus |
| Weight-based dosing | No | Yes | No | Yes |
| Antigenic | Yes | No | No | No |
| Patency ratea | 60% to 68% | 73% to 84% | 84% | 85% |
| Fibrin specificityb | No | Yes (++) | Yes (++) | Yes (++++) |
| TIMI = Thrombolysis in Myocardial Infarction. | | a90-minute grade 2 or 3 TIMI blood flow. | | b++++ is stronger than ++. |
|
32 . What is the most common complication of fibrinolytic therapy?
| A) | | Nausea |
| B) | | Hypertension |
| C) | | Major bleeding |
| D) | | Dizziness and syncope |
The most common complication of fibrinolytic therapy is major bleeding, which occurs in approximately 5% to 6% of patients [208]. Adverse outcomes after fibrinolytic therapy are generally more common among women and older patients [228,229]. Many instances of bleeding can be traced to incorrect dosing, particularly with weight-based agents [222]. In addition, patients who receive an improperly high dose of fibrinolytic agents have increased 30-day mortality.
33 . An absolute contraindication to fibrinolytic therapy is
| A) | | pregnancy. |
| B) | | current use of anticoagulants. |
| C) | | chronic, severe, poorly controlled hypertension. |
| D) | | significant closed-head or facial trauma within three months. |
CONTRAINDICATIONS AND CAUTIONS FOR FIBRINOLYSIS USE IN ST-ELEVATION MYOCARDIAL INFARCTION
(STEMI)a
| Absolute Contraindications |
| Any prior intracranial hemorrhage | | Known structural cerebral vascular lesion (e.g., arteriovenous
malformation) | | Known malignant intracranial neoplasm (primary or metastatic) | | Ischemic stroke within three months EXCEPT acute ischemic stroke within
4.5 hours | | Suspected aortic dissection | | Active bleeding or bleeding diathesis (excluding menses) | | Significant closed-head or facial trauma within three months | | Intracranial or intraspinal surgery within two months | | Severe uncontrolled hypertension (unresponsive to emergency
therapy) | | For streptokinase, prior treatment within the previous six
months |
|
| Relative Contraindications |
| History of chronic, severe, poorly controlled hypertension | | Substantial hypertension on presentation (systolic greater than 180 mm
Hg or diastolic greater than 110 mm Hg) | | History of prior ischemic stroke (greater than three months) | | Dementia | | Known intracranial pathology not covered in absolute
contraindications | | Traumatic or prolonged (greater than 10 minutes) CPR | | Major surgery (within less than three weeks) | | Recent (within two to four weeks) internal bleeding | | Noncompressible vascular punctures | | Pregnancy | | Active peptic ulcer | | Oral anticoagulant therapy |
|
| aViewed as advisory for clinical decision making and may not be all-inclusive or definitive. | | CPR = cardiopulmonary resuscitation, INR = international normalization ratio. |
|
34 . The ACCF/AHA guideline for STEMI and the ACC/AHA guideline for CABG surgery recommend emergent or urgent CABG when
| A) | | PCI has failed. |
| B) | | coronary anatomy is not amenable to PCI. |
| C) | | a mechanical defect is being surgically repaired. |
| D) | | All of the above |
Although PCI is performed more frequently, several situations call for the use of CABG. The ACCF/AHA guideline for STEMI and the ACC/AHA guideline for CABG surgery recommend emergent or urgent CABG when PCI has failed, for coronary anatomy not amenable to PCI, and at the time of surgical repair of a mechanical defect (e.g., ventricular septal, papillary muscle, free-wall rupture) [2,6].
35 . The 2013 ACCF/AHA guideline for the management of STEMI recommend patients be given what dose of aspirin before PCI or fibrinolytic therapy?
| A) | | 81 mg |
| B) | | 162–325 mg |
| C) | | 500–650 mg |
| D) | | 810 mg |
The 2013 ACCF/AHA guideline for the management of STEMI recommends aspirin at a dose of 162–325 mg as a loading dose before either PCI or fibrinolytic therapy [2]. A P2Y12 inhibitor is used along with aspirin as dual-antiplatelet therapy. For patients treated with PCI, clopidogrel (600 mg), prasugrel (60 mg), or ticagrelor (180 mg) should be given as a loading dose as early as possible or at the time of the PCI [2]. Treatment with a P2Y12 inhibitor is continued for one year. Clopidogrel is the recommended P2Y12 inhibitor to support fibrinolytic therapy; a loading dose of 300 mg is used for patients 75 years of age or younger, and no loading dose is used for patients older than 75 years of age [2]. Treatment with clopidogrel is continued for at least 14 days and up to one year.
36 . Recurrent myocardial infarction or fatal coronary heart disease will occur within five years after ACS in
| A) | | 2% of women 45 years of age or older. |
| B) | | 10% of men 45 years of age or older. |
| C) | | 15% of men 45 years of age or older. |
| D) | | 21% of women 45 years of age or older. |
DISCHARGE PLANNING AND SECONDARY PREVENTION
STRATEGIES TO HELP ENHANCE EFFECTIVENESS OF PATIENT EDUCATION
| Ask the patient what language he or she prefers for educational
resources and use that language for oral education and written resources (as
much as possible). | | Assess the patient's baseline understanding of the disease and
treatment. | | Ask the patient what and how much he or she wants to know. | | Discuss epidemiologic and clinical evidence. | | Involve other healthcare specialists in the educational
process. | | Use a variety of educational resources in a variety of media. | | Try innovative approaches, such as interactive modules. | | Offer online resources to patients (e.g., the AHA website [https://www.heart.org ] or the
NHLBI website [https://www.nhlbi.nih.gov]). | | Ascertain potential barriers to compliance. | | Develop an action plan. | | Have patient focus on one behavior change at a time, if
necessary. | | Involve family members in educational efforts. | | Reinforce recommendations at all office visits. | | Provide positive reinforcement for each step toward goals. | | Provide telephone follow-up. |
|
37 . Secondary prevention strategies should be implemented to achieve which of the following goals?
| A) | | Weight loss of 15% of the baseline |
| B) | | A body mass index of 18.5–24.9 |
| C) | | A waist circumference among men of 35 inches |
| D) | | Exercise for 45 minutes each day, three or four times per week |
DISCHARGE PLANNING AND SECONDARY PREVENTION
Obesity is another well-documented risk factor for CHD, and weight management programs and information on healthy eating/caloric intake should be promoted as appropriate [260]. The patient's body mass index and waist circumference should be measured at each visit. The goal is to attain a body mass index of 18.5–24.9 and a waist circumference of 35 inches (women) or 40 inches (men) [260]. When weight reduction is needed, the initial goal is weight loss of 5% to 10% from baseline [260].
38 . The recommended antiplatelet therapy after ACS is
| A) | | aspirin at a daily dose of 325 mg. |
| B) | | aspirin at a daily dose of 75–162 mg. |
| C) | | combination of aspirin (75–162 mg daily) and warfarin. |
| D) | | combination of aspirin (75–162 mg daily) and a P2Y12 inhibitor. |
DISCHARGE PLANNING AND SECONDARY PREVENTION
The recommended antiplatelet therapy after discharge is a combination of aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) [2,260,264]. The findings of studies have suggested that low-dose aspirin is as effective as higher doses but has a better safety profile [170,266,267]. The recommended daily dose of aspirin is 75–162 mg for all patients, and the ACC/AHA guidelines for the management of STEMI and NSTE-ACS state that it is reasonable to a use an 81-mg dose [2,3,264,267]. However, despite the better safety profile of low-dose aspirin, data have indicated that 325 mg is the most common dose, prescribed for 55.7% of patients with UA/NSTEMI [268].
39 . Among patients with ACS, major depression occurs in
| A) | | 5% to 10%. |
| B) | | 15% to 20%. |
| C) | | 30% to 35%. |
| D) | | 45% to 50%. |
DISCHARGE PLANNING AND SECONDARY PREVENTION
An ACS event can be distressing for many patients, leading to a heightened fear of dying and anxiety about adjusting to life with cardiac disease [281]. These emotions can substantially affect a patient's psychosocial status and lead to depression [282,283]. Some degree of clinically significant depression has been reported to occur in up to half of patients with ACS, with major depression occurring in 15% to 20% of patients [282]. Depression has been found more often in women compared with men and in men with a history of MI [284]. In addition to the negative effect on the patient's quality of life, depression has also been shown to be associated with lack of adherence to secondary prevention measures and with increased mortality [283,285,286].
40 . Which of the following has been a factor in lack of patient compliance with medication therapy after ACS?
| A) | | Female sex |
| B) | | Younger age |
| C) | | Higher educational level |
| D) | | Lower number of prescribed medications |
DISCHARGE PLANNING AND SECONDARY PREVENTION
Lack of patient compliance with medications is also a serious problem and has been referred to as an unrecognized risk factor for CHD, because of its association with significant increases in adverse events and health costs [305,306]. Among individuals with CHD (many of whom had experienced a recent ACS event), compliance with guideline-recommended medications has ranged from 18% to 55%. Approximately 54% of individuals have been compliant with all of their initial medications, and compliance decreases over time [305,307,308]. One study showed that compliance was 60.3% at one year, 53.7% at two years, and 48.8% at five years [309]. Individuals who discontinue medications are more likely to be older, female, unmarried, and less educated [307]. Several other factors have been found to be associated with noncompliance with medications [305,307,308]:
Choice of medication
Tolerability
Duration of treatment
Dosing frequency
Higher number of prescribed medications
Lack of symptoms as indication for the medication
Uncertainty about how to take the medication
Lack of transportation to the pharmacy
