MKSAP 19 (ACS-Medical therapy for ACS)
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Questions and Answers

What is the defining characteristic of stable angina pectoris?

  • Angina associated with shortness of breath
  • Angina occurring at rest
  • Reproducible angina of at least 2 months duration (correct)
  • New onset angina

    • Which demographic groups may present only with atypical symptoms of angina?

  • Athletes and physically active individuals
  • Women and patients with diabetes mellitus (correct)
  • Elderly individuals
  • Individuals with a family history of heart disease

    • What is the first step in diagnostic testing for angina?

  • Performing a stress test
  • Conducting an echocardiogram
  • Assessing blood lipid levels
  • Determining the pretest probability of coronary artery disease (correct)

    • What is the characteristic feature of unstable angina?

    <p>New onset angina or angina occurring at a relatively low level of exertion (C)</p> Signup and view all the answers

    What is the duration criterion for stable angina pectoris?

    <p>At least 2 months (B)</p> Signup and view all the answers

    Which of the following is a characteristic used to evaluate angina?

    <p>Radiation (D)</p> Signup and view all the answers

    What may some demographic groups, including women and patients with diabetes mellitus, present with as atypical symptoms of angina?

    <p>Exertional dyspnea (B)</p> Signup and view all the answers

    What is the first step in diagnostic testing for angina?

    <p>Determine the pretest probability of coronary artery disease (A)</p> Signup and view all the answers

    What type of angina is precipitated by a stable level of exertion or emotional stress and relieved with rest?

    <p>Stable angina (C)</p> Signup and view all the answers

    Which condition is associated with increased short-term risk for acute myocardial infarction?

    <p>Unstable angina (A)</p> Signup and view all the answers

    What is an important component of guideline-directed medical therapy for stable angina pectoris?

    <p>Regular physical activity (A)</p> Signup and view all the answers

    What is the goal of blood pressure control in patients with stable angina?

    <p>To achieve blood pressure control (C)</p> Signup and view all the answers

    What is the purpose of antianginal medications in the treatment of stable angina pectoris?

    <p>To improve functional capacity through reduced cardiac workload and/or increased myocardial oxygen delivery (B)</p> Signup and view all the answers

    What is a key component of guideline-directed medical therapy for stable angina pectoris?

    <p>Regular physical activity (D)</p> Signup and view all the answers

    What is the goal of antianginal medications in the treatment of stable angina pectoris?

    <p>Improve functional capacity through reduced cardiac workload and/or increased myocardial oxygen delivery (B)</p> Signup and view all the answers

    What is the primary purpose of cardioprotective medications in the treatment of stable angina pectoris?

    <p>Prevent thrombosis and limit atherosclerotic progression (D)</p> Signup and view all the answers

    Which of the following is a key component of guideline-directed medical therapy for stable angina pectoris?

    <p>Regular physical activity (C)</p> Signup and view all the answers

    What is the primary purpose of antianginal medications in the treatment of stable angina pectoris?

    <p>To improve fractional capacity through reduced cardiac workload (D)</p> Signup and view all the answers

    What is an important aspect of risk factor modification in the treatment of stable angina pectoris?

    <p>Tobacco cessation (A)</p> Signup and view all the answers

    What is the recommended first-line therapy in patients with stable angina?

    <p>B-Blockers (A)</p> Signup and view all the answers

    What is the recommended resting heart rate range to be achieved through B-Blocker dosage titration?

    <p>55/min to 60/min (C)</p> Signup and view all the answers

    Which type of B-Blocker is preferred in patients with significant lung disease?

    <p>B1-Selective B-Blockers (B)</p> Signup and view all the answers

    In patients with reduced left ventricular (LV) function, which B-Blockers are associated with reduced long-term mortality?

    <p>Metoprolol and carvedilol (A)</p> Signup and view all the answers

    What should be used with caution in patients taking B-Blockers due to additive negative inotropic and chronotropic effects?

    <p>(CCBs) Calcium channel blockers (verapamil, diltiazem) (B)</p> Signup and view all the answers

    What are the side effects of B-Blockers?

    <p>Fatigue, lethargy, sleep disturbances, and impotence (A)</p> Signup and view all the answers

    Why should caution be exercised in using B-Blockers in the setting of significant conduction disease or LV dysfunction?

    <p>They may worsen conduction abnormalities or LV dysfunction. (D)</p> Signup and view all the answers

    What is the recommended resting heart rate range to be achieved through B-Blocker dosage titration?

    <p>55/min to 60/min (B)</p> Signup and view all the answers

    Which type of B-Blocker is preferred in patients with significant lung disease?

    <p>Metoprolol (A)</p> Signup and view all the answers

    In patients with reduced left ventricular (LV) function, which B-Blockers are associated with reduced long-term mortality?

    <p>Metoprolol succinate, bisoprolol, carvedilol (D)</p> Signup and view all the answers

    What side effects are associated with B-Blockers?

    <p>Fatigue, lethargy, sleep disturbances (A)</p> Signup and view all the answers

    Why should caution be exercised in using B-Blockers in the setting of significant conduction disease or LV dysfunction?

    <p>They may cause hypotension and bradycardia (D)</p> Signup and view all the answers

    What is a key consideration when choosing a B-Blocker for patients with stable angina?

    <p>Concomitant medical conditions such as LV dysfunction or lung disease (B)</p> Signup and view all the answers

    What is the primary reason for caution when using B-Blockers in patients taking nondihydropyridine calcium channel blockers (verapamil, diltiazem)?

    <p>Additive negative inotropic and chronotropic effects (A)</p> Signup and view all the answers

    Which type of B-Blockers is preferred in patients with significant lung disease?

    <p>B1-Selective B-Blockers (B)</p> Signup and view all the answers

    What is the recommended resting heart rate range to be achieved through B-Blocker dosage titration?

    <p>55/min - 60/min (A)</p> Signup and view all the answers

    Which B-Blockers are associated with reduced long-term mortality in patients with reduced left ventricular (LV) function?

    <p>Metoprolol succinate, bisoprolol, and carvedilol (C)</p> Signup and view all the answers

    What are the side effects associated with B-Blockers?

    <p>Fatigue, lethargy, sleep disturbances, and impotence (C)</p> Signup and view all the answers

    Why should caution be exercised in using B-Blockers in the setting of significant conduction disease or LV dysfunction?

    <p>They may precipitate ventricular arrhythmias (C)</p> Signup and view all the answers

    What demographic groups may present only with atypical symptoms of angina?

    <p>Men over the age of 50 and women under the age of 40 (C)</p> Signup and view all the answers

    Which type of calcium channel blockers should be avoided in the treatment of angina due to the risk of paradoxically worsening angina?

    <p>Short-acting dihydropyridine formulations (D)</p> Signup and view all the answers

    What is the recommended interval needed with long-acting nitrates to avoid the development of nitrate tolerance and reduced efficacy?

    <p>8 to 12 hours (A)</p> Signup and view all the answers

    Which medication can improve myocardial oxygen delivery through coronary vasodilation and reduce oxygen demand by reducing preload, thereby reducing ventricular wall stress?

    <p>Nitrates (A)</p> Signup and view all the answers

    Why should nondihydropyridine calcium channel blockers not be used in patients with left ventricular (LV) dysfunction?

    <p>They increase adverse events associated with their negative chronotropic and inotropic effects (B)</p> Signup and view all the answers

    What is the potential consequence of using short-acting sublingual nitrates for acute relief of angina without combining them with beta-blockers or calcium channel blockers?

    <p>Reflex tachycardia (C)</p> Signup and view all the answers

    What is the primary reason for prescribing short-acting sublingual nitrates for acute relief of angina?

    <p>For acute relief of angina (D)</p> Signup and view all the answers

    What is a potential side effect associated with long-acting nitrates?

    <p>Headache (C)</p> Signup and view all the answers

    What is a contraindication for concurrent use of ranolazine and phosphodiesterase 5 inhibitors?

    <p>Hypotension (D)</p> Signup and view all the answers

    What effect does ranolazine have on the QT interval?

    <p>Modest prolonging effect (C)</p> Signup and view all the answers

    When should the QT interval be monitored in patients taking ranolazine?

    <p>With co-administration of other QT-prolonging drugs (A)</p> Signup and view all the answers

    What is the recommended action when patients are receiving moderate inhibitors of cytochrome P450 3A4 (CYP3A4)?

    <p>Dose reduction of ranolazine (B)</p> Signup and view all the answers

    Why should ranolazine not be used in combination with strong CYP3A4 inhibitors?

    <p>Resultant increases in ranolazine serum levels (C)</p> Signup and view all the answers

    What is the mechanism by which ranolazine reduces angina and increases exercise time?

    <p>Inhibition of the late sodium current and prevention of calcium overload (A)</p> Signup and view all the answers

    What is the primary reason for caution when using ranolazine in combination with strong CYP3A4 inhibitors?

    <p>Increased risk of hypotension (C)</p> Signup and view all the answers

    What is the mechanism of action by which ranolazine reduces angina?

    <p>Reduction of wall tension and myocardial oxygen consumption (D)</p> Signup and view all the answers

    When should the QT interval be monitored in patients taking ranolazine?

    <p>With co-administration of other QT-prolonging drugs (A)</p> Signup and view all the answers

    What is the effect of ranolazine on the QT interval?

    <p>Modest prolongation (B)</p> Signup and view all the answers

    In patients receiving moderate inhibitors of cytochrome P450 3A4 (CYP3A4), what is indicated regarding ranolazine dosage?

    <p>Dose reduction (C)</p> Signup and view all the answers

    What is contraindicated due to the risk for hypotension when using ranolazine?

    <p>Concurrent use with strong CYP3A4 inhibitors (D)</p> Signup and view all the answers

    Which type of calcium channel blockers should be avoided in the treatment of angina due to the risk of paradoxically worsening angina?

    <p>Short-acting dihydropyridine formulations (D)</p> Signup and view all the answers

    What is the primary reason for prescribing short-acting sublingual nitrates for acute relief of angina?

    <p>To provide rapid relief by acute lowering of blood pressure (D)</p> Signup and view all the answers

    Why should nondihydropyridine calcium channel blockers not be used in patients with left ventricular (LV) dysfunction?

    <p>They increase adverse events due to negative chronotropic and inotropic effects (B)</p> Signup and view all the answers

    What is the potential consequence of using short-acting sublingual nitrates for acute relief of angina without combining them with beta-blockers or calcium channel blockers?

    <p>Reflex tachycardia and increased myocardial oxygen demand (C)</p> Signup and view all the answers

    What is the recommended interval needed with long-acting nitrates to avoid the development of nitrate tolerance and reduced efficacy?

    <p>8 to 12 hours, generally at night (A)</p> Signup and view all the answers

    What is the mechanism by which long-acting nitrates improve myocardial oxygen delivery?

    <p>Coronary vasodilation and reduction in coronary vascular resistance (D)</p> Signup and view all the answers

    What is a potential side effect associated with long-acting nitrates?

    <p>Headache (D)</p> Signup and view all the answers

    Which medication is indicated for stable angina with concomitant left ventricular dysfunction, heart failure, and chronic kidney disease?

    <p>ACE inhibitor therapy (A)</p> Signup and view all the answers

    What is the first-line therapy for stable angina?

    <p>Aspirin (C)</p> Signup and view all the answers

    What should all patients with coronary artery disease be counseled on?

    <p>Lifestyle modification and blood pressure control (D)</p> Signup and view all the answers

    Patients with coronary artery disease should not be counseled on lifestyle modification, blood pressure control, and management of diabetes mellitus.

    <p>False (B)</p> Signup and view all the answers

    First-line therapy for stable angina includes aspirin, statin therapy, and p-blocker therapy.

    <p>True (A)</p> Signup and view all the answers

    ACE inhibitor therapy is not indicated for stable angina with concomitant left ventricular dysfunction, heart failure, diabetes mellitus, chronic kidney disease, or history of myocardial infarction.

    <p>False (B)</p> Signup and view all the answers

    What is the primary goal of revascularization in stable syndromes?

    <p>To lessen angina and improve quality of life (B)</p> Signup and view all the answers

    In which patients is revascularization indicated for prevention of future events and improved survival?

    <p>Patients with left main CAD (A)</p> Signup and view all the answers

    When should patients with unstable or acute presentations undergo revascularization?

    <p>As soon as possible to prevent future events (A)</p> Signup and view all the answers

    Revascularization is indicated for prevention of future events and improved survival in unstable or acute presentations as well as in stable patients with high-risk anatomic or clinical features.

    <p>True (A)</p> Signup and view all the answers

    The primary goals of revascularization in stable syndromes are to lessen angina and improve quality of life.

    <p>True (A)</p> Signup and view all the answers

    Revascularization is not indicated for patients with angina refractory to medical therapy or markedly abnormal stress testing or coronary CT angiography results.

    <p>False (B)</p> Signup and view all the answers

    What do techniques like fractional flow reserve and instantaneous wave free ratio provide information on?

    <p>Functional hemodynamic significance of indeterminate lesions (A)</p> Signup and view all the answers

    What is the primary basis for identifying revascularization targets?

    <p>Anatomic and functional physiologic characteristics associated with myocardial ischemia (B)</p> Signup and view all the answers

    What is the purpose of revascularization in stable syndromes?

    <p>To reduce angina and improve quality of life (D)</p> Signup and view all the answers

    Fractional flow reserve and instantaneous wave free ratio provide information on the functional hemodynamic significance of indeterminate lesions identified on angiographic imaging.

    <p>True (A)</p> Signup and view all the answers

    Revascularization targets are identified based on anatomic and functional physiologic characteristics associated with myocardial ischemia.

    <p>True (A)</p> Signup and view all the answers

    Revascularization targets are identified based solely on anatomic characteristics associated with myocardial ischemia.

    <p>False (B)</p> Signup and view all the answers

    What is the primary indication for Percutaneous Coronary Intervention (PCI)?

    <p>To improve coronary blood flow in patients with medically refractory angina (B)</p> Signup and view all the answers

    What is the most common type of stent used in PCI procedures currently?

    <p>First generation drug-eluting stent (D)</p> Signup and view all the answers

    In patients with stable angina, how does PCI compare to guideline-directed medical therapy in reducing the risk for death or myocardial infarction (MI)?

    <p>Guideline-directed medical therapy is more effective than PCI (B)</p> Signup and view all the answers

    PCI is indicated to relieve symptoms in patients with medically refractory angina, those unable to tolerate optimal medical therapy, and those with high risk features on non-invasive testing.

    <p>True (A)</p> Signup and view all the answers

    PCI has been shown to be superior to guideline directed medical therapy in reducing the risk for death or MI in patients with stable angina with or without diabetes.

    <p>False (B)</p> Signup and view all the answers

    Most PCI procedures currently involve second generation drug eluting stent placement, which reduces the risk for in stent restenosis compared with bare metal stenting.

    <p>True (A)</p> Signup and view all the answers

    What is the primary benefit of coronary artery bypass grafting (CABG) with optimal medical therapy for patients with multivessel coronary artery disease (CAD)?

    <p>Decreased recurrence of angina, lower rates of MI, and fewer repeat revascularization procedures (D)</p> Signup and view all the answers

    In which patient population is CABG associated with improved survival?

    <p>Patients with left main or three vessel CAD (B)</p> Signup and view all the answers

    What is the impact of myocardial viability on survival and ventricular recovery following revascularization in patients with LV dysfunction?

    <p>It is associated with improved survival and ventricular recovery (D)</p> Signup and view all the answers

    Coronary artery bypass grafting (CABG) is generally recommended for patients with multivessel CAD due to its association with improved survival and decreased recurrence of angina.

    <p>True (A)</p> Signup and view all the answers

    CABG results in lower rates of MI and fewer repeat revascularization procedures compared with PCI or medical therapy alone.

    <p>True (A)</p> Signup and view all the answers

    Myocardial viability testing before revascularization has been established as a predictor of outcome.

    <p>False (B)</p> Signup and view all the answers

    What is the minimum duration of dual antiplatelet therapy (DAPT) recommended for patients treated with bare metal stent placement?

    <p>1 month (B)</p> Signup and view all the answers

    For how long is dual antiplatelet therapy (DAPT) recommended for patients with stable angina after drug eluting stent placement, according to current guidelines?

    <p>6 months without interruption (C)</p> Signup and view all the answers

    In patients at high risk for bleeding, what duration of dual antiplatelet therapy (DAPT) followed by lifelong antiplatelet monotherapy is supported by current evidence?

    <p>3 months of DAPT (C)</p> Signup and view all the answers

    For patients requiring oral anticoagulation for atrial fibrillation, when can warfarin or a direct oral anticoagulant (preferred) plus clopidogrel be considered without aspirin?

    <p>After 2 to 4 weeks of triple therapy (A)</p> Signup and view all the answers

    Revascularization is only indicated for a specific duration of time

    <p>False (B)</p> Signup and view all the answers

    Aspirin is recommended indefinitely after revascularization

    <p>True (A)</p> Signup and view all the answers

    DAPT duration depends on clinical considerations such as patient presentation and bleeding and ischemic risks

    <p>True (A)</p> Signup and view all the answers

    In patients requiring oral anticoagulation for atrial fibrillation, warfarin or a direct oral anticoagulant plus clopidogrel can be considered without aspirin, often after 2 to 4 weeks of triple therapy

    <p>True (A)</p> Signup and view all the answers

    What is the preferred revascularization method for stable angina patients with left main or three-vessel coronary artery disease?

    <p>Coronary artery bypass graft revascularization (B)</p> Signup and view all the answers

    How long should dual antiplatelet therapy be continued after drug eluting stent placement in patients with stable angina who undergo percutaneous coronary intervention?

    <p>At least 6 months (C)</p> Signup and view all the answers

    What is the impact of percutaneous coronary intervention on mortality and risk for myocardial infarction in patients with stable angina?

    <p>Does not decrease mortality or risk for myocardial infarction (B)</p> Signup and view all the answers

    In patients with coronary artery disease and severe left ventricular dysfunction, how does coronary artery bypass grafting compare with medical therapy in terms of survival?

    <p>Survival is better with coronary artery bypass grafting (C)</p> Signup and view all the answers

    Is percutaneous coronary intervention the preferred revascularization method for patients with left main or three-vessel coronary artery disease or multivessel coronary artery disease plus diabetes mellitus?

    <p>False (B)</p> Signup and view all the answers

    Is ten-year survival improved in patients with coronary artery disease and severe left ventricular dysfunction who undergo coronary artery bypass grafting compared with those who receive medical therapy?

    <p>True (A)</p> Signup and view all the answers

    Should dual antiplatelet therapy be continued for at least 6 months after drug eluting stent placement in patients with stable angina who undergo percutaneous coronary intervention?

    <p>True (A)</p> Signup and view all the answers

    Does percutaneous coronary intervention decrease mortality or risk for myocardial infarction in patients with stable angina?

    <p>False (B)</p> Signup and view all the answers

    What is the key differentiation between ST elevation MI (STEMI) and non ST elevation acute coronary syndrome (NSTE ACS)?

    <p>Findings on ECG (D)</p> Signup and view all the answers

    What ECG feature is characteristic of Posterior MI?

    <p>ST segment depression in the anterior leads (V1 through V4) (B)</p> Signup and view all the answers

    What is a potential equivalent of ST elevation MI (STEMI)?

    <p>New bundle branch block (A)</p> Signup and view all the answers

    How is NSTE-ACS categorized?

    <p>According to the presence of serum biomarkers of myocardial injury (C)</p> Signup and view all the answers

    Acute Coronary Syndrome (ACS) can result from acute or subacute plaque rupture or erosion and coronary blood flow impairment.

    <p>True (A)</p> Signup and view all the answers

    ST elevation MI (STEMI) is differentiated from non ST elevation acute coronary syndrome (NSTE ACS) by findings on ECG.

    <p>True (A)</p> Signup and view all the answers

    Posterior MI typically manifests as ST segment elevation in the anterior leads (V1 through V4) with tall R waves.

    <p>False (B)</p> Signup and view all the answers

    New bundle branch block may be considered a STEMI equivalent and potentially reflects an acute left anterior descending artery occlusion or extensive injury.

    <p>True (A)</p> Signup and view all the answers

    Which ECG finding is commonly associated with patients presenting with accelerated hypertension, significant LV hypertrophy, and cardiomyopathies?

    <p>ST-segment elevation injury currents (D)</p> Signup and view all the answers

    What ECG changes may look similar to ST segment elevation injury currents but are typically concave in appearance?

    <p>ST-segment elevation injury currents (A)</p> Signup and view all the answers

    What ECG findings are associated with patients presenting with supraventricular tachycardias?

    <p>ST-segment depression (C)</p> Signup and view all the answers

    What is a distinguishing feature of acute pericarditis that helps differentiate it from ST-elevation myocardial infarction (STEMI)?

    <p>Localized concave ST-segment elevation (B)</p> Signup and view all the answers

    What is a diagnostic clue for acute aortic syndromes that can cause ST-segment elevation?

    <p>Mediastinal widening on chest radiograph (B)</p> Signup and view all the answers

    What is the manifestation of transmural myocardial ischemia in ST-elevation myocardial infarction (STEMI)?

    <p>ST-segment elevation (A)</p> Signup and view all the answers

    What is the primary purpose of reperfusion therapy in the context of STEMI?

    <p>Restore coronary blood flow (C)</p> Signup and view all the answers

    Severe hypercalcemia may result in ST segment depression that mimics ACS.

    <p>False (B)</p> Signup and view all the answers

    Supraventricular tachycardias may present with chest pain, ST-segment elevation, and elevated cardiac enzyme levels.

    <p>False (B)</p> Signup and view all the answers

    Comparison with previous ECG findings is not helpful in identifying acute changes.

    <p>False (B)</p> Signup and view all the answers

    ST-segment elevation in acute pericarditis is usually concave in shape and may be diffusely or locally distributed

    <p>True (A)</p> Signup and view all the answers

    Acute aortic syndromes can cause ST-segment elevation only if the dissection involves the left coronary artery

    <p>False (B)</p> Signup and view all the answers

    Reperfusion therapy for STEMI should be initiated rapidly to restore blood flow to the myocardium

    <p>True (A)</p> Signup and view all the answers

    Acute pericarditis and myopericarditis can cause confusion in diagnosis due to release of cardiac enzymes

    <p>True (A)</p> Signup and view all the answers

    What is the goal time from first medical contact until PPCI?

    <p>90 minutes or less (A)</p> Signup and view all the answers

    Why is PPCI preferred over thrombolysis for treating STEMI?

    <p>PPCI achieves higher and more reliable vessel patency rates (D)</p> Signup and view all the answers

    When is PPCI the preferred method of treating STEMI?

    <p>When the patient presents to a PCI-capable hospital (A)</p> Signup and view all the answers

    PPCI is the preferred method of treating STEMI when the patient can be transferred quickly to a PCI-capable center

    <p>True (A)</p> Signup and view all the answers

    The goal time from first medical contact until PPCI is 120 minutes or less

    <p>False (B)</p> Signup and view all the answers

    PPCI results in higher and more reliable vessel patency compared to thrombolysis

    <p>True (A)</p> Signup and view all the answers

    When is thrombolytic therapy recommended for patients with STEMI?

    <p>When symptom onset is within 12 hours and PPCI is not available within 120 minutes (B)</p> Signup and view all the answers

    Which thrombolytic agents are associated with improved infarct artery patency and fewer allergic reactions compared to streptokinase?

    <p>Alteplase, reteplase, tenecteplase (B)</p> Signup and view all the answers

    When does fibrin cross linking render the clot relatively resistant to lysis in thrombolytic therapy for STEMI?

    <p>After the first 3 to 6 hours from symptom onset (B)</p> Signup and view all the answers

    Thrombolytic therapy is recommended for patients with STEMI even if PPCI is available within 120 minutes of first medical contact

    <p>False (B)</p> Signup and view all the answers

    Thrombolytic therapy is most effective within the first 3 to 6 hours from symptom onset

    <p>True (A)</p> Signup and view all the answers

    Newer fibrin specific thrombolytic agents are associated with improved infarct artery patency and fewer allergic reactions compared to streptokinase

    <p>True (A)</p> Signup and view all the answers

    What is the recommended loading dose of aspirin for all patients without a specific contraindication?

    <p>81-162 mg (B)</p> Signup and view all the answers

    What is the primary risk associated with thrombolytic therapy?

    <p>Bleeding (B)</p> Signup and view all the answers

    What ECG finding confirms reperfusion after thrombolytic therapy, reflected by at least 50% improvement in maximal ST segment elevation?

    <p>$ ext{At least 50% improvement in maximal ST segment elevation}$ (B)</p> Signup and view all the answers

    What is the recommended action when rescue PCI is available following thrombolytic therapy?

    <p>$ ext{Immediate transfer to a PCI capable center}$ (D)</p> Signup and view all the answers

    Thrombolytic therapy is without risk of bleeding.

    <p>False (B)</p> Signup and view all the answers

    All patients without a specific contraindication should receive a loading dose of aspirin.

    <p>True (A)</p> Signup and view all the answers

    Clopidogrel loading has been demonstrated to decrease rates of vessel patency.

    <p>False (B)</p> Signup and view all the answers

    Rescue PCI is associated with improved outcomes compared with conservative management in cases of failed reperfusion.

    <p>True (A)</p> Signup and view all the answers

    What is a potential consequence of untreated cardiogenic shock?

    <p>Acute kidney failure (C)</p> Signup and view all the answers

    Which factor is associated with a higher rate of survival in patients with cardiogenic shock?

    <p>Age younger than 75 years (C)</p> Signup and view all the answers

    What is the primary purpose of weaning the patient from mechanical and inotropic support in cardiogenic shock treatment?

    <p>To reduce reliance on external support (B)</p> Signup and view all the answers

    What is the recommended approach for managing atrial fibrillation in patients with STEMI?

    <p>Managing it as it complicates management (C)</p> Signup and view all the answers

    What is the recommended action for postinfarction ventricular arrhythmias occurring beyond 48 hours?

    <p>Prolonged inpatient telemetry and predischarge implantable cardioverter defibrillator therapy (A)</p> Signup and view all the answers

    What is the recommended approach for managing accelerated idioventricular rhythm that arises after reperfusion?

    <p>No treatment required (C)</p> Signup and view all the answers

    When does Mobitz type 2 second degree atrioventricular block require permanent pacing?

    <p>When it progresses to complete heart block (A)</p> Signup and view all the answers

    Ventricular tachycardia or fibrillation may occur during MI or after reperfusion.

    <p>True (A)</p> Signup and view all the answers

    Routine suppression of ventricular ectopy with antiarrhythmic agents is recommended and is associated with increased arrhythmias and adverse outcomes.

    <p>False (B)</p> Signup and view all the answers

    Cardiogenic shock is a common complication of STEMI.

    <p>True (A)</p> Signup and view all the answers

    Permanent pacing is often required for atrioventricular block, including Wenckebach and complete heart block, after inferior infarction.

    <p>False (B)</p> Signup and view all the answers

    Cardiogenic shock carries a mortality rate of 50% to 80%, and must be recognized early.

    <p>True (A)</p> Signup and view all the answers

    Untreated cardiogenic shock can progress rapidly to end organ failure.

    <p>True (A)</p> Signup and view all the answers

    Patients younger than 75 years have a higher rate of survival if they receive emergent revascularization.

    <p>True (A)</p> Signup and view all the answers

    What is the recommended duration of anticoagulation for LV apical thrombus in cases of anterior STEMI?

    <p>At least 3 months (C)</p> Signup and view all the answers

    How is right ventricular (RV) infarction typically identified?

    <p>ST segment elevation on right sided ECG leads (B)</p> Signup and view all the answers

    What may be revealed by transthoracic echocardiography in cases of RV infarction?

    <p>RV dilatation and dysfunction (B)</p> Signup and view all the answers

    What is contraindicated in cases of LV free wall rupture to avoid worsening hypotension?

    <p>Nitrates (B)</p> Signup and view all the answers

    LV apical thrombus is generally not treated with anticoagulation in cases of anterior STEMI without other indications, such as atrial fibrillation.

    <p>False (B)</p> Signup and view all the answers

    Right ventricular (RV) infarction can be identified by ST segment elevation on right sided ECG leads V1 and V4R.

    <p>True (A)</p> Signup and view all the answers

    Nitrates are contraindicated in cases of RV infarction because they may worsen hypotension by reducing preload.

    <p>True (A)</p> Signup and view all the answers

    LV free wall rupture is more common in younger adults, men, and patients with delayed reperfusion.

    <p>False (B)</p> Signup and view all the answers

    What is the most common presentation of patients with acquired ventricular septal defect (VSD) from septal wall rupture following STEMI?

    <p>Worsening heart failure and shock (C)</p> Signup and view all the answers

    What is the approximate mortality rate in patients with medically treated postinfarct VSDs?

    <p>Approaches 100% (B)</p> Signup and view all the answers

    Why can percutaneous closure with a VSD occluder device be often unsuccessful in postinfarct VSDs?

    <p>Residual shunting around the device is common (B)</p> Signup and view all the answers

    What may result from interruption of the posteromedial papillary muscle blood supply during myocardial infarction?

    <p>Severe acute mitral regurgitation several days after STEMI (B)</p> Signup and view all the answers

    Patients with postinfarct VSDs typically present with worsening heart failure and shock

    <p>True (A)</p> Signup and view all the answers

    The mortality rate in patients with medically treated postinfarct VSDs approaches 50%

    <p>False (B)</p> Signup and view all the answers

    Percutaneous closure with a VSD occluder device is often successful in postinfarct VSDs

    <p>False (B)</p> Signup and view all the answers

    Interrupted blood supply to the posteromedial papillary muscle may result in severe acute mitral regurgitation several days after STEMI

    <p>True (A)</p> Signup and view all the answers

    What is the primary purpose of risk stratification in suspected NSTE ACS?

    <p>To determine the likelihood of a cardiac process (B)</p> Signup and view all the answers

    Which risk score predicts 14-day death, recurrent MI, and urgent revascularization rates in patients with suspected NSTE ACS?

    <p>TIMI (C)</p> Signup and view all the answers

    What do fractional flow reserve and instantaneous wave-free ratio provide information on in patients with stable angina?

    <p>Anatomic and functional physiologic characteristics associated with myocardial ischemia (B)</p> Signup and view all the answers

    What is the primary goal of revascularization in stable syndromes?

    <p>To improve blood flow to ischemic myocardium (A)</p> Signup and view all the answers

    NSTEMI ACS involves complete coronary obstruction resulting in ST segment elevation.

    <p>False (B)</p> Signup and view all the answers

    The TIMI risk score predicts in-hospital and post-discharge death and MI risk.

    <p>True (A)</p> Signup and view all the answers

    The GRACE risk score incorporates only clinical features and ECG findings.

    <p>False (B)</p> Signup and view all the answers

    Prognostic assessment helps determine the most appropriate therapeutic strategy.

    <p>True (A)</p> Signup and view all the answers

    When is urgent invasive treatment recommended for patients with NSTE ACS?

    <p>Within 2 hours for patients with hemodynamic instability (C)</p> Signup and view all the answers

    What is the timing for cardiac catheterization in patients with an elevated clinical risk score, significant ST segment deviation, or elevated cardiac biomarkers?

    <p>Usually performed within 24 hours of presentation (C)</p> Signup and view all the answers

    When is the choice of revascularization procedure (PCI or CABG) based on the results of angiography?

    <p>After cardiac catheterization within 24 hours of presentation (D)</p> Signup and view all the answers

    When is the ischemia guided approach appropriate?

    <p>For low risk patients (C)</p> Signup and view all the answers

    An early invasive strategy improves the composite clinical endpoint of death, recurrent MI, and repeat hospitalization compared with an ischemia-guided approach.

    <p>True (A)</p> Signup and view all the answers

    Cardiac catheterization is usually performed within 24 hours of presentation in patients with an elevated clinical risk score, significant ST segment deviation, or elevated cardiac biomarkers.

    <p>True (A)</p> Signup and view all the answers

    Patients with diabetes, stage 2 to 3 chronic kidney disease, LV dysfunction, and recent PCI without elevated risk scores may be safely evaluated with coronary angiography within 72 hours of presentation (delayed invasive strategy).

    <p>True (A)</p> Signup and view all the answers

    With an ischemia-guided strategy, patients undergo noninvasive stress testing with LV function assessment before hospital discharge.

    <p>True (A)</p> Signup and view all the answers

    When is cardiac catheterization usually performed for patients with an elevated clinical risk score, significant ST segment deviation, or elevated cardiac biomarkers?

    <p>Within 24 hours of presentation (C)</p> Signup and view all the answers

    For which patients is delayed invasive strategy with coronary angiography within 72 hours of presentation considered appropriate?

    <p>Patients with diabetes and recent PCI without elevated risk scores (D)</p> Signup and view all the answers

    What determines the choice of revascularization procedure (PCI or CABG) for patients with NSTE ACS?

    <p>Results of angiography (C)</p> Signup and view all the answers

    When is the ischemia guided approach considered appropriate for patients with NSTE ACS?

    <p>Low risk patients (B)</p> Signup and view all the answers

    Study Notes

    Angina Pectoris

    • Stable angina pectoris is characterized by a predictable pattern of symptoms precipitated by a stable level of exertion or emotional stress and relieved with rest.
    • The duration criterion for stable angina pectoris is 1-2 minutes.

    Atypical Symptoms

    • Demographic groups that may present only with atypical symptoms of angina include women and patients with diabetes mellitus.
    • These groups may present with symptoms such as dyspnea, fatigue, or palpitations instead of typical chest pain.

    Diagnostic Testing

    • The first step in diagnostic testing for angina is electrocardiography (ECG) to evaluate for signs of ischemia or infarction.

    Unstable Angina

    • Unstable angina is characterized by angina at rest or with minimal exertion, and is associated with increased short-term risk for acute myocardial infarction.

    Treatment of Stable Angina

    • Important components of guideline-directed medical therapy for stable angina pectoris include:
      • Antianginal medications to reduce symptoms and improve quality of life.
      • Cardioprotective medications to reduce cardiovascular risk.
      • Lifestyle modifications, such as diet and exercise, to reduce cardiovascular risk.
      • Blood pressure control to reduce cardiovascular risk.
    • The goal of blood pressure control is to achieve a blood pressure of less than 140/90 mmHg.
    • The purpose of antianginal medications is to reduce symptoms and improve quality of life.
    • The primary purpose of cardioprotective medications is to reduce cardiovascular risk.

    Beta-Blockers

    • Beta-blockers are a key component of guideline-directed medical therapy for stable angina pectoris.
    • The goal of beta-blocker therapy is to achieve a resting heart rate of 55-60 beats per minute.
    • Carvedilol is preferred in patients with significant lung disease due to its selective beta-1 receptor antagonism.
    • Beta-blockers are associated with reduced long-term mortality in patients with reduced left ventricular (LV) function.
    • Side effects of beta-blockers include bradycardia, fatigue, and dizziness.
    • Caution should be exercised in using beta-blockers in the setting of significant conduction disease or LV dysfunction due to the risk of worsening heart failure.

    Calcium Channel Blockers

    • Nondihydropyridine calcium channel blockers (verapamil, diltiazem) should be avoided in patients with left ventricular (LV) dysfunction due to the risk of worsening heart failure.
    • Dihydropyridine calcium channel blockers are preferred in patients with hypertension.

    Nitrates

    • Nitrates improve myocardial oxygen delivery through coronary vasodilation and reduce oxygen demand by reducing preload, thereby reducing ventricular wall stress.
    • The recommended interval for long-acting nitrates is 8-12 hours to avoid the development of nitrate tolerance and reduced efficacy.
    • Side effects of nitrates include headaches and orthostatic hypotension.

    Ranolazine

    • Ranolazine is indicated for stable angina pectoris with concomitant left ventricular dysfunction, heart failure, and chronic kidney disease.
    • The mechanism of action of ranolazine is to reduce angina and increase exercise time by reducing sodium channel activation and increasing the late sodium current.
    • Caution should be exercised in using ranolazine in combination with strong CYP3A4 inhibitors due to the risk of increased ranolazine levels.
    • The QT interval should be monitored in patients taking ranolazine due to the risk of QT prolongation.

    Revascularization

    • The primary goal of revascularization in stable syndromes is to lessen angina and improve quality of life.
    • Revascularization is indicated for patients with angina refractory to medical therapy or markedly abnormal stress testing or coronary CT angiography results.
    • Techniques like fractional flow reserve and instantaneous wave free ratio provide information on the functional hemodynamic significance of indeterminate lesions identified on angiographic imaging.
    • Revascularization targets are identified based on anatomic and functional physiologic characteristics associated with myocardial ischemia.

    Percutaneous Coronary Intervention (PCI)

    • PCI is indicated to relieve symptoms in patients with medically refractory angina, those unable to tolerate optimal medical therapy, and those with high-risk features on non-invasive testing.
    • Most PCI procedures currently involve second-generation drug-eluting stent placement, which reduces the risk of in-stent restenosis compared with bare metal stenting.
    • PCI has been shown to be superior to guideline-directed medical therapy in reducing the risk of death or myocardial infarction (MI) in patients with stable angina with or without diabetes.

    Coronary Artery Bypass Grafting (CABG)

    • CABG is generally recommended for patients with multivessel coronary artery disease (CAD) due to its association with improved survival and decreased recurrence of angina.
    • CABG results in lower rates of MI and fewer repeat revascularization procedures compared with PCI or medical therapy alone.
    • Myocardial viability testing before revascularization has been established as a predictor of outcome.

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    Test your knowledge of stable and unstable angina pectoris by understanding the differences in symptoms, triggers, and relief methods. Learn to differentiate between stable and unstable angina and how they are diagnosed and evaluated.

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