Podcast
Questions and Answers
What is the recommended ESC algorithm to measure high-sensitivity cardiac troponin?
What is the recommended ESC algorithm to measure high-sensitivity cardiac troponin?
Which of the following scores should be considered for prognosis estimation in CAD?
Which of the following scores should be considered for prognosis estimation in CAD?
In non-ST elevation acute coronary syndrome patients, when is routine antithrombotic pretreatment with a P2Y12 inhibitor indicated?
In non-ST elevation acute coronary syndrome patients, when is routine antithrombotic pretreatment with a P2Y12 inhibitor indicated?
What condition indicates the need for an immediate invasive strategy in NSTE-ACS patients?
What condition indicates the need for an immediate invasive strategy in NSTE-ACS patients?
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When should an early invasive strategy (< 24 h) be warranted for NSTE-ACS patients?
When should an early invasive strategy (< 24 h) be warranted for NSTE-ACS patients?
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Which approach should low-risk NSTE-ACS patients ideally follow?
Which approach should low-risk NSTE-ACS patients ideally follow?
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Which of the following statements regarding anticoagulation therapy in NSTE-ACS is correct?
Which of the following statements regarding anticoagulation therapy in NSTE-ACS is correct?
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What factor is NOT considered when determining the urgency of treatment for NSTE-ACS patients?
What factor is NOT considered when determining the urgency of treatment for NSTE-ACS patients?
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Which statement regarding the use of fibrinolytics is correct?
Which statement regarding the use of fibrinolytics is correct?
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What is the preferred P2Y12 inhibitor for Acute coronary syndrome with ST segment elevation undergoing primary PCI?
What is the preferred P2Y12 inhibitor for Acute coronary syndrome with ST segment elevation undergoing primary PCI?
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What is the maximum recommended time from successful fibrinolysis to coronary angiography for stable patients?
What is the maximum recommended time from successful fibrinolysis to coronary angiography for stable patients?
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Which antithrombotic agents are not indicated for the treatment of unstable angina?
Which antithrombotic agents are not indicated for the treatment of unstable angina?
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How long is dual antithrombotic therapy recommended after the acute myocardial infarction for a patient with sinus rhythm?
How long is dual antithrombotic therapy recommended after the acute myocardial infarction for a patient with sinus rhythm?
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Which drug is recommended for secondary prevention of recurrent cardiovascular events after acute anterior STEMI?
Which drug is recommended for secondary prevention of recurrent cardiovascular events after acute anterior STEMI?
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When should a Troponin test be repeated if the first one is negative in suspected Acute coronary syndrome without ST segment elevation?
When should a Troponin test be repeated if the first one is negative in suspected Acute coronary syndrome without ST segment elevation?
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Which criterion is NOT a typical indicator of myocardial infarction?
Which criterion is NOT a typical indicator of myocardial infarction?
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Which high-risk criteria indicates the need for an early invasive strategy within 24 hours in NSTE-ACS patients?
Which high-risk criteria indicates the need for an early invasive strategy within 24 hours in NSTE-ACS patients?
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Which of the following is NOT considered a criterion for type 1 myocardial infarction?
Which of the following is NOT considered a criterion for type 1 myocardial infarction?
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Which of the following involves the medical treatment of coronary artery disease?
Which of the following involves the medical treatment of coronary artery disease?
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Which diagnostic tool is least effective at determining the location of myocardial damage?
Which diagnostic tool is least effective at determining the location of myocardial damage?
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What is the main purpose of thrombolytic therapy in patients with ST-segment elevation myocardial infarction (MI)?
What is the main purpose of thrombolytic therapy in patients with ST-segment elevation myocardial infarction (MI)?
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In a patient who experienced a myocardial infarction, which complication is he most at risk for developing within a few days of the event?
In a patient who experienced a myocardial infarction, which complication is he most at risk for developing within a few days of the event?
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Which exclusion criteria must a patient meet for fibrinolytic therapy in STEMI cases?
Which exclusion criteria must a patient meet for fibrinolytic therapy in STEMI cases?
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Which of the following medications is likely to be part of the initial treatment for an ST-segment elevation myocardial infarction?
Which of the following medications is likely to be part of the initial treatment for an ST-segment elevation myocardial infarction?
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Study Notes
ECG and Biomarkers in ACS
- ECG and CK-MB levels are helpful in diagnosing acute coronary syndrome (ACS).
- High-sensitivity cardiac troponin (hs-cTn) and echocardiography are also used for diagnosis.
- Symptoms and clinical history play a crucial role in diagnosis.
ESC Algorithm for hs-cTn
- According to ESC, hs-cTn should be measured at 0h and 2h for assessment of ACS.
- This is recommended especially if CK-MB is not available.
- 0h/1h measurement is also acceptable as an alternative.
Prognostic Score for ACS
- GRACE (Global Registry of Acute Coronary Events)
- CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Aggressive Management)
- DAPT (Dual Antiplatelet Therapy)
- EUROSCORE (European System for Cardiac Operative Risk Evaluation)
- ACUITY (Acute Coronary Treatment and Intervention Outcomes Network)
P2Y12 Inhibitors in NSTE-ACS
- Routine pre-treatment with P2Y12 inhibitors is not recommended for all NSTE-ACS patients.
- It may be considered in patients with established Coronary Artery Disease (CAD) and prior Percutaneous Coronary Intervention (PCI).
- It's recommended for high-risk NSTE-ACS patients.
- It should be avoided in patients with advanced age due to increased bleeding risk.
- If the symptom onset is > 6 hours, it may not be indicated.
Timing of Invasive Strategy in NSTE-ACS
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Immediate invasive strategy (< 2 hours from hospital admission) is recommended for:
- Stabilized resuscitated out-of-hospital cardiac arrest
- Very high-risk NSTE-ACS patients
- NSTE-ACS patients with no contraindications to invasive treatment.
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Early invasive strategy (< 24 hours of hospital admission) is recommended for:
- Very high-risk NSTE-ACS patients irrespective of ECG or biomarker findings
- Persistent chest pain
- Life-threatening arrhythmias
- Dynamic ST segment changes and/or GRACE risk score > 140.
Management of Low-Risk NSTE-ACS
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Low-risk NSTE-ACS patients should:
- Be selectively scheduled for coronary angiography following a positive non-invasive test.
- Undergo cardiac computer tomography angiography or coronary angiography according to their preferences.
Fibrinolysis in STEMI
- Fibrinolysis is indicated in patients with ST-segment elevation myocardial infarction (STEMI), especially when timely primary PCI cannot be performed.
- Fibrin-specific agents are recommended.
- Fibrinolysis should be performed within 30 minutes of STEMI diagnosis for optimal outcomes.
Myocardial Infarction: Typical and High-Risk Criteria
- Increased Troponin levels are the most typical criteria for myocardial infarction.
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High-risk criteria for recurrent ischemia or cardiovascular death for NSTE-ACS include:
- GRACE score > 140
- Dynamic ST segment depressions on ECG
- Established NSTEMI diagnosis
- PCI within the last year
Treatment of High-Risk NSTE-ACS
- Percutaneous coronary intervention (PCI) is the preferred treatment for very high-risk NSTE-ACS patients.
P2Y12 Inhibitors in STEMI
- Prasugrel is recommended for patients with acute coronary syndrome with ST-segment elevation undergoing primary PCI strategy.
Timing for Coronary Angiography after Fibrinolysis
- Coronary angiography with secondary PCI within 24 hours is recommended for stable patients after successful fibrinolysis.
Antithrombotic Agents in Unstable Angina
- Warfarin is not indicated for unstable angina.
Dual Antithrombotic Therapy after MI
-
Dual antithrombotic therapy for patients with sinus rhythm after acute myocardial infarction is recommended for:
- 3 months if a stent is not implanted.
- 6-12 months if a stent is implanted.
Secondary Prevention after STEMI
- Aspirin, beta-blockers, statins, and ACEI are all recommended for secondary prevention of recurrent cardiovascular events after acute anterior STEMI.
Repeat Troponin Testing
- If the initial Troponin test is negative for suspected NSTE-ACS, it should be repeated after 3 hours.
Early Invasive Strategy in NSTE-ACS
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Early invasive strategy (< 24 hours) is recommended for high-risk NSTE-ACS patients with:
- Diagnosis of NSTEMI suggested by the diagnostic algorithm
- Recurrent or refractory chest pain despite medical treatment
- Dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischemia
- Heart failure clearly related to NSTE-ACS
Universal Definition of Myocardial Infarction
- Stress ECG test is NOT included in the universal definition of a type 1 myocardial infarction.
Medical Management of Coronary Artery Disease
- Medical management of CAD includes:
- Oral medication administration
- Cardiac catheterization
- Percutaneous transluminal coronary angioplasty
- Coronary artery bypass surgery
Diagnostic Tools for Myocardial Damage
- Cardiac catheterization is used to diagnose CAD and determine the location of myocardial damage.
- Echocardiogram, electrocardiogram, and cardiac enzymes are also used to diagnose and assess the extent of myocardial damage.
Diagnosis of CAD
- Electrocardiogram (ECG) is used to diagnose CAD.
- Treadmill stress test is another helpful diagnostic tool.
- Cardiac catheterization is the most invasive and definitive method for confirming the diagnosis.
Complication after MI
- Left atrial thrombus is a common and serious complication in the first few days following a myocardial infarction.
Fibrinolytic Therapy Exclusion Criteria
-
Exclusion criteria for receiving fibrinolytic therapy for STEMI:
- Active internal bleeding within the last 21 days
- Known bleeding disorder
- Within 3 months of intracranial surgery, serious head trauma, or stroke
- **Within 14 days of major surgery or serious trauma **
- History of intracranial hemorrhage
- Witnessed seizure at onset and history of cancer of the brain are not absolute exclusion criteria.
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