Acs

Front 1

What diseases includes Acute coronary syndrome (ACS)?

Back 1

1. Unstable angina (UA),

2. non-ST elevation myocardial infarction (NSTEMI),

3. ST-elevation myocardial infarction (STEMI).

Front 2

Major difference between Stable Angina and ACS?

Back 2

ACS should be distinguished from stable angina, which develops during exertion and resolves at rest.

Front 3

36. Definition of Acute Coronary Syndrome (ACS)?

Back 3

a. Causes acute chest pain
b. Can be w/exercise or at rest
c. Can have ST segment elevation, depression, or even a normal EKG.
d. Not based on enzyme levels, angiography, or stress test results.
e. Based on a hx of chest pain w/features suggestive of ischaemic disease.

Front 4

37. Best initial therapy for all cases of Acute Coronary Syndrome (ACS)?

Back 4

Aspirin

Front 5

38. Utility of Aspirin?

Back 5

a. It has an INSTANT effect on inhibiting platelets.
b. Aspirin alone reduces mortality by 25% for acute MI and by 50% for “unstable angina,” which may become a non–ST segment elevation MI (NSTEMI).

Front 6

39. Other drugs that should be administered in Acute Coronary Syndrome (ACS)?

Back 6

a. Nitrates and morphine should also be administered in acute coronary syndromes, but they do NOT lower mortality.
b. Oxygen has no benefit if the patient is not hypoxic.

Front 7

40. What 1 of 2 possible drugs is added to aspirin for all patients w/an acute MI?

Back 7

Prasugrel or Clopidogrel.
One of these is also added to everyone getting angioplasty and a stent.

Front 8

42. Do Thrombolytics and primary angioplasty lower mortality in STEMI?

Back 8

Yes, both do.
They are time dependent.
Their benefit markedly diminishes w/time.

Front 9

Do Thrombolytics and primary angioplasty lower mortality in NSTEMI?

Back 9

NO

Front 10

43. Primary angioplasty?

Back 10

a. Means angioplasty during an acute episode of chest pain.
b. Angioplasty is one type of “percutaneous coronary intervention” (PCI)

Front 11

44. What is the single best evidence for mortality benefit w/angioplasty?

Back 11

Infarction.

Front 12

45. When must “percutaneous coronary intervention” (PCI) be performed for Acute Coronary Syndrome (ACS) STEMI?

Back 12

a. Within 12 hours of the onset of ischemic
symptoms

b. Within 90 minutes of arrival at the emergency department
Angioplasty has NOT been shown to ↓ mortality in stable angina more than medical therapy (aspirin, beta blockers, and statins) alone.

Front 13

46. If Primary Coronary Intervention cannot be performed within 90 minutes of arrival in the emergency department, what should be done?

Back 13

a. The patient should receive thrombolytics.
b. The question will clearly state that “the pt is at a small rural hospital” or “the nearest cath facility is over an hour away”. The question must be clear on this point

Front 14

Tx. for pt. with STEMI but Late presentation (>12 hours after symptom onset)?

Back 14

Coronary artery bypass grafting (CABG).

Front 15

47. When are thrombolytics indicated?

Back 15

a. When the pt has chest pain for <12 hours
b. AND
c. Has ST segment elevation in 2 or more leads.
d. A new Left Bundle Branch Block (LBBB) is also an indication for thrombolytic therapy.

Front 16

48. When should thrombolytics be given?

Back 16

Within 30 minutes of a pt’s arrival in the ED w/pain.

Front 17

Absolute Contraindications to thrombolytic therapy?

Back 17

• Active bleeding or bleeding diathesis
• Significant closed head or facial trauma within 3 months
• Suspected aortic dissection
• Prior intracranial hemorrhage
• Ischemic stroke within 3 months

Front 18

49. When is the answer “urgent angioplasty” or PCI?

Back 18

a. The question asks “what has the single greatest efficacy?” in lowering mortality in STEMI.
b. The question includes a contraindication to the use of thrombolytics.

Front 19

50. Utility of β–blockers for Acute Coronary Syndrome?

Back 19

a. β–blockers lower mortality, but the timing of their administration is NOT critical.
b. β–blockers such as metoprolol, should be given, but they are not as urgent to give as aspirin, thrombolytics, or primary angioplasty.

Front 20

51. Utility of Ace inhibitors and Angiotensin receptor blockers (ARBs)?!

Back 20

Should be given to all pts w/an acute coronary syndrome, but they only lower morality if there is left ventricular disfunction or systolic dysfunction!!

Front 21

52. Other tests to run w/acute coronary syndrome?

Back 21

Make sure there is a lipid profile and start the pt on HMG CoA reductase inhibitors (statins), if indicated i.e., if LDL is not at goal.

Front 22

53. A 72 yo man comes to the emergency department having had chest pain for the last hour. His initial EKG shows ST segment elevation in leads V2–V4. Aspirin has been given. Which of the following will most likely benefit this pt?

Back 22

Angioplasty.
Angioplasty will lower the risk of mortality most for this patient. If it can be obtained w/I 90 minutes, angioplasty is the best therapy. Metoprolol lowers mortality but is not dependent on how soon you give it, as long as the pt receives it before going home.

Front 23

54. Utility of Statins such as atorvastatin with Acute Coronary Syndrome?

Back 23

Statins should be given to all patients w/acute coronary syndrome, regardless of what the EKG shows or troponin or CK–MB levels.

Front 24

55. 6 drugs/classes/therapies that always lower mortality when used in Acute Coronary Syndrome?

Back 24

1. Aspirin
2. Thrombolytics
3. Primary angioplasty
4. Metoprolol
5. Statins
6. Clopidogrel or prasugrel.

Front 25

56. 2 classes of drugs that Lower mortality in certain conditions w/Acute Coronary Syndrome?

Back 25

a. Ace inhibitors if ejection fraction is low
b. ARBs if ejection fraction is low.

Front 26

57. 6 classes of drugs that do not lower mortality in Acute Coronary Syndrome?

Back 26

1. Morphine
2. Oxygen
3. Nitrates
4. Calcium Channel blockers
5. Lidocaine
6. Amiodarone

Front 27

58. When is Prasugrel or Clopidogrel the answer w/ACS?

Back 27

a. When a platelet antagonist is to be used for acute chest pain, there is aspirin allergy, the patient is to undergo angioplasty, or an acute infarction is occurring.
b. Add wither clopidogrel or Prasugrel to aspirin when there is an acute MI.

Front 28

How long a pt. with STEMI should take clopidogrel?

Back 28

1. At least a month after fibrinolytic therapy,

or

2. Up to 9–12 months after stent implantation, depending on the type of stent used.

Front 29

When Clopidogrel should be avoided?

Back 29

In patients likely to require emergency coronary bypass surgery. Prasugrel and ticagrelor are alternatives to clopidogrel.

If possible, clopidogrel should be discontinued 5 days before coronary bypass surgery.

Front 30

59. AE of Ticlopidine?

Back 30

Neutropenia.

Front 31

60. When are calcium channel blockers (verapamil, diltiazem) the answer w/ACS (3 things)?

Back 31

1. If the pt has an INTOLERANCE to beta blockers, such as severe asthma.
2. If there is cocaine–induced chest pain
3. There is coronary vasospasm/Prinzmetal’s angina.

Front 32

61. When is a pacemaker the answer for acute MI (5 things)?

Back 32

1. 3rd degree AV block
2. Mobitz II, second–degree AV block
3. Bifascicular block
4. New left bundle branch block
5. Symptomatic bradycardia

Front 33

62. When is lidocaine or amiodarone the answer for acute MI?

Back 33

a. ONLY when there is ventricular tachycardia or ventricular fibrillation.
b. Do not give antiarrhythmic medications to prevent ventricular arrhythmias!!!

Front 34

63. 3 times when Prasugrel or Clopidogrel is used?

Back 34

1. When there is aspirin allergy
2. The pt undergoes angioplasty and stenting
3. There is acute MI.

Front 35

64. Prasugrel vs. Clopidogrel?

Back 35

Prasugrel has greater efficacy than clopidogrel but causes more bleeding.

Front 36

65. Complications of MI?

Back 36

All the complications of MI result in HYPOTENSION.

Front 37

67. 2 Diagnostic tests for Cardiogenic shock?

Back 37

a. Echo
b. Swan–Ganz (right heart) catheter

Front 38

68. Tx of Cardiogenic shock?

Back 38

a. ACEI
b. Urgent revascularization

Front 39

69. Diagnostic test for Valve rupture?

Back 39

Echo

Front 40

70. Tx of valve rupture?

Back 40

a. ACEI
b. Nitroprusside
c. Intra–aortic balloon pump as a bridge to surgery.

Front 41

71. 2 Diagnostic tests for Septal Rupture?

Back 41

a. Echo
b. Right heart catheter showing a step up in saturation from the right atrium to right ventricle.

Front 42

72. Tx of Septal Rupture?

Back 42

a. ACEI
b. Nitroprusside
c. Urgent surgery

Front 43

73. Diagnostic test for Myocardial wall rupture?

Back 43

Echo

Front 44

74. Tx of Myocardial wall rupture?

Back 44

a. Pericardiocentesis
b. Urgent cardiac repair

Front 45

75. Tx of Sinus bradycardia?

Back 45

Atropine, followed by pacemaker if there are still symptoms.

Front 46

76. Diagnostic test for third–degree (complete) heart block?

Back 46

EKG, Canon “a” waves.

Front 47

77. Tx of third–degree (complete) heart block?

Back 47

Atropine and a pacemaker even if symptoms resolve.

Front 48

78. Treatment of right ventricular infarction?

Back 48

Fluid loading

Front 49

79. Post–MI discharge instructions–all patients post–MI should go home on..?

Back 49

a. Aspirin
b. Clopidogrel (or prasugrel)
c. β–blocker
d. Statin
e. ACE inhibitor

Front 50

80. A pt’s wife comes to take her husband home after an MI and asks how long they should wait before they have sex. What do you tell her?

Back 50

2–6 weeks
Some waiting is necessary to have sex after infarction. Sex minimally increase the risk of infarction.
The duration and intensity of exertion are sufficient to provoke ischaemia in some cases.

Front 51

81. Main differences for the treatment of Non–ST Segment from STEMI?

Back 51

a. No thrombolytic use
b. Heparin is used routinely. Low molecular weight heparin is superior to the IV form.
c. Glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) lower mortality, particularly in those undergoing angioplasty.

Front 52

When Glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide)?

Back 52

Tirofiban or eptifibatide is particularly recommended in high-risk patients with UA/NSTEMI in whom an invasive strategy is planned.

Front 53

82. A 54 yo man w/a hx of DM and HTN comes to the ED w/crushing, substernal chest pain that radiates to his left arm. The pain has been on and off for several hours, w/this last episode being 30 minutes in duration. He has had chest pain on exertion before, but this is the first time it has developed at rest. The EKG is normal. Aspirin, Oxygen, and nitrates have been given. Troponin levels are elevated. Which of the following is most likely to benefit this pt?
a. Low molecular weight heparin
b. Thrombolytics
c. Diltiazem
d. Morphine
e. CK–MB level

Back 53

Answer: A
Heparin is the only one of these choices that has been shown to produce lower mortality. Thrombolytics do not lower mortality, unless there is ST elevation of new LBBB.
Positive cardiac enzymes are not an indication for thrombolytics!!!
Other answers that could be right if they were choices are GPIIb/IIIa inhibitors, such as eptifibatide, tirofiban, abciximab, or the use of angioplasty/PCI.

Front 54

When unfractionated heparin or subcutaneous enoxaparin should be given?

Back 54

until angiography or for 48–72 hours

Front 55

In what patients the enoxaparin dose must be reduced?

Back 55

with impaired renal function

Front 56

83. What is the single greatest benefit from GPIIb/IIIa inhibitors w/ACS?

Back 56

The single greatest benefit is in combination w/angioplasty and stent placement.

Front 57

84. Does Abciximab benefit ST segment elevation MI (GPIIb/IIIa inhibitor)?

Back 57

No

Front 58

85. When are thrombolytics used for ACS?

Back 58

Only if there is ST segment elevation or a new LBBB within 12 hours of the onset of chest pain.

Front 59

86. Value of ARBs?

Back 59

ARBs are used interchangeably w/ACE inhibitors, especially if the patient has a cough w/ACE inhibitors

Front 60

87. Common SE to both ACEs and ARBs?

Back 60

Both cause hyperkalemia.

Front 61

88. Tx of stable angina?

Back 61

a. Aspirin and Metoprolol.
b. These are the 2 main routinely indicated meds bc of their benefit on mortality
c. Nitrates should be used for angina pain but they do not lower mortality.

Front 62

89. With what 3 complications associated with stable angina should ACE inhibitors and ARBs be used?

Back 62

1. CHF
2. Systolic dysfunction
3. Low ejection fraction.

Front 63

90. Primary use of Coronary Angiography?

Back 63

a. Used to determine who is a candidate for coronary artery bypass grafting (CABG).
b. You do no need to do angiography to diagnose CAD.

Front 64

91. Stress testing vs. coronary angiography?

Back 64

a. Stress testing can show reversible ischaemia.
b. However, you MUST do angiography to see who needs CABG.

Front 65

92. When do you not need angiography for Stable angina?

Back 65

To initiate:
1. Aspirin + metoprolol (mortality benefit)
2. Give nitrates (pain)
3. ACE/ARB (low ejection fraction).
4. Clopidogrel or Prasugrel (acute MI or cannot tolerate aspirin)
5. Statins (LDL >70–100)

Front 66

93. What is the main difference between saphenous vein grafts and internal mammary artery grafts?

Back 66

a. Internal mammary artery grafts remain open for 10 years.
b. Vein grafts become occluded after 5 years.
c. There is no difference in the need for medications.

Front 67

94. Indications for CABG (2)?

Back 67

1. 3 coronary vessels with 70% stenosis
2. Left main coronary artery stenosis

Front 68

95. 4 Coronary artery disease equivalents?

Back 68

1. Diabetes Mellitus
2. Peripheral artery disease
3. Aortic disease
4. Carotid disease

Front 69

96. Single strongest indication for lipid–lowering therapy with a statin?

Back 69

A pt w/an acute coronary syndrome and an LDL >130.

Front 70

97. Goal of therapy for LDL in those w/ CAD?

Back 70

LDL <130.

Front 71

When to answer “statin therapy” for ANY case of CAD or an EQUIVALENT w/an LDL >100?

Back 71

Note: although there is strong evidence for an LDL < 130, you will answer “statin therapy” for ANY case of CAD or an EQUIVALENT w/an LDL >100.

Front 72

99. If a question asks for the LDL goal in a pt w/DM, the answer is?

Back 72

LDL < 70.

Front 73

101. Risk factors in lipid management?

Back 73

1. Tobacco use
2. HTN (≥140/90) or on BP meds!
3. Low HDL cholesterol (<40)
4. Family hx of early coronary heart disease (female relatives <65, male relatives < 55).
5. Age (males ≥45, females ≥55).

Front 74

102. Many meds, such as statins, cholestyramine, gemfibrozil, ezetimibe, and niacin, lower LDL, lower triglycerides, and total cholesterol, and raise HDL. Which of the following is the most important reason for using Statins?

Back 74

Greatest mortality benefit.

Front 75

103. When is the goal of therapy an LDL <70 (2 things)?

Back 75

Coronary Artery Disease and diabetes
The goal of LDL can be < 70 for pts at the very highest risk of infarction. This includes those w/acute coronary syndrome or the combination of coronary disease and a very severe risk factor, such as DM.

Front 76

104. Most common adverse effet of statins?

Back 76

a. Liver toxicity.
b. As many as 1% of pts will stop taking statins because of an elevation of transaminases.
c. LFTs should be routinely checked.
d. Rhabdo is NOT the most common AE.

Front 77

105. Is there a routine indication to check CPK with statins?

Back 77

No

Front 78

106. A man develops erectile dysfunction after an infarction. What is the most common cause?

Back 78

a. Anxiety
b. Anxiety is the most common cause of erectile dysfunction postinfarction. Although beta blockers may be the most common medication associated w/ED, anxiety is still a more common cause of erectile dysfunction that beta blockers.

Front 79

107. A man develops erectile dysfunction postinfarction. You are planning to start sildenafil. Which med must you stop?

Back 79

Nitrates.

Front 80

Area of Infarction and Artery Involved if EKG Changes (Q Waves, ST Elevation,
T Wave Inversions) are present in the following leads: II, III, aVF.

Back 80

Inferior Wall

Right coronary

Front 81

Area of Infarction and Artery Involved if EKG Changes (Q Waves, ST Elevation,
T Wave Inversions) are present in the following leads: V1–V3.

Back 81

Anteroseptal Wall

Left anterior descending

Front 82

Area of Infarction and Artery Involved if EKG Changes (Q Waves, ST Elevation,
T Wave Inversions) are present in the following leads: V2–V4.

Back 82

Anterior Wall

Left anterior descending

Front 83

Area of Infarction and Artery Involved if EKG Changes (Q Waves, ST Elevation,
T Wave Inversions) are present in the following leads: I, aVL, V4, V5, and V6.

Back 83

Lateral Wall

Left anterior descending or circumflex

Front 84

Area of Infarction and Artery Involved if EKG Changes (Q Waves, ST Elevation,
T Wave Inversions) are present in the following leads: V1–V2: tall broad initial R wave, ST depression, tall upright T wave; usually occurs in association with inferior or lateral MI.

Back 84

Posterior Wall

Posterior descending

Front 85

Tx. of inferior MIs.

Back 85

Fluids.