Practical Cardiovascular Medicine. Elias B. Hanna

      1 Question 1. A 52-year-old man presents to a non-PCI hospital with 2 hours of chest pain. His ECG shows anterior ST-segment elevation. His blood pressure is 109/67 and his heart rate is 105. He has no known contraindication to thrombolysis. The closest PCI hospital is 90 miles away and no community transfer system is in place. The best reperfusion strategy for this patient is:No administration of thrombolysis. Transfer for primary PCIImmediate thrombolysis and immediate transfer to a PCI hospital for consideration of routine early PCI within 24 hours of presentation or for rescue PCI if thrombolysis failsImmediate thrombolysis. Transfer to the PCI center only if thrombolysis fails at 90 min after starting therapyAdminister aspirin, heparin and clopidogrel 300 mg before transferB and DC and D

      2 Question 2. A 49-year-old man presents with progressive dyspnea over the last week. He recalls having 2 hours of mild chest discomfort and nausea 10 days ago. No chest pain is currently reported. His ECG shows anterior Q waves with 1 mm ST elevation and T inversion. The exam and X-ray suggest pulmonary edema. The echo shows anteroapical akinesis and thinning. Beside diuresis and medical therapy, what is the appropriate management?Coronary angiography emergentlyCoronary angiography is not urgent but should be performed before discharge. Attempt to open an occluded LADPerform stress SPECT before discharge, then perform coronary angiography if there is evidence of severe ischemiaTest for viability of anterior wall. If viable, perform coronary angiography and attempt to open an occluded LAD

      3 Question 3. A 76-year-old female presents with 2 hours of chest pain to a non-PCI hospital. The closest PCI hospital is 100 miles away. ECG shows anterior ST-segment elevation. BP = 170/85, weight 62 kg. She has not had any recent bleed, surgery, fall, or history of stroke. A recent hemoglobin is 12 g/dl. What is the next step?Administer fibrinolytics then transfer for routine early PCIDo not administer fibrinolytics, transfer for primary PCI

      4 Question 4. A 72-year-old man presents with 3–4 hours of chest pain and respiratory distress. BP = 80/60, heart rate = 120. He is intubated by paramedics and transferred to a non-PCI-capable hospital. ECG shows 5 mm ST elevation anterior leads. The closest cath lab is 3 hours away. What is the next step?Emergent transfer for PCI; thrombolysis is not helpful in cardiogenic shockThrombolysis and emergent transfer for PCIIABP and emergent transferThrombolysis, IABP, and emergent transfer for PCI

      5 Question 5. The patient in Question 4 arrives to the cath lab. He still has ST elevation and is in shock. He is found to have thrombotic 100% proximal LAD, CTO of mid RCA, and 80% stenosis of mid LCx. What is the next step?PCI of LAD onlyPCI of LAD and LCxPCI of LAD initially. If no hemodynamic improvement, proceed with PCI of LCxEmergent CABG

      6 Question 6. A 68-year-old man presents with inferior and lateral STEMI. He undergoes primary PCI of a large, thrombotic, codominant proximal LCx. While he has been doing well, he suddenly develops near syncope on day 2. BP 70/40, pulse 35, and no murmur is heard. ECG shows sinus bradycardia with re-elevation of ST segments in the inferior leads. What is the most important next step?Immediate coronary angiography ± PCIImmediate echocardiographyImmediate placement of a transvenous pacemaker

      7 Question 7. A 57-year-old man presented with anterior STEMI and received primary PCI of the proximal LAD at 16 hours after pain onset. At day 3, the patient is doing well, ambulating without angina and no HF on exam. He had an asymptomatic 14-beat run of NSVT. At day 4, a pre-discharge echo is performed and shows a large area of anterior akinesis with LVEF 25%, mild MR, and moderate size (1 cm) pericardial effusion. What is the next step?Discharge home on ACE-I, carvedilol, spironolactone, statin, aspirin/plavix, and check echo in 40 days. If EF <35% → ICDDischarge home on ACE-I, carvedilol, statin, aspirin and plavix, and check echo in 40 days. If EF <35% → ICDMonitor the patient in the hospital for a longer period of time, repeat echo next day and obtain cardiac MRI.Discharge home on ACE-I, carvedilol, statin, aspirin/plavix. Place a lifevest and then ICD at 40 days if EF <35%

      8 Question 8. A 64-year-old man presents with anterior STEMI, BP 105/75, pulse 110, and bibasilar crackles. He is found to have occluded LAD and mid RCA 80%. What is the next step?Perform multivessel PCI at the time of primary PCIPerform culprit PCI only. Plan for elective PCI of RCA only if the patient has residual anginaPerform LAD PCI, then plan for elective RCA PCI before home discharge, regardless of symptomsPerform LAD PCI, then plan for elective RCA angiography before home discharge, then RCA PCI if appropriate, regardless of symptoms

      9 Question 9. A 70-year old female had chest pain 3 days previously. The chest pain resolved after 8 hours. She has syncope on the day of presentation and is currently dizzy and dyspneic. BP 80/60, pulse 30 bpm. ECG shows complete AV block with ventricular escape rhythm, and ST elevation concordant with the wide QRS in the anterolateral leads. She has bibasilar crackles and is hypoxic. What is her 30-day mortality?<10%20%50%

      10 Question 10. For the patient in Question 9, a temporary pacemaker is placed. Her BP improves to 110/70, and she is not dizzy anymore. She is dyspneic at rest with bibasilar crackles on exam. What is the next step, beside starting diuretics?Take urgently to the cath lab for PCI of LADPerform coronary angiography after HF improvesPerform stress testing after HF improves, to assess for residual ischemia

      11 Question 11. A 66-year-old man presents with chest pain that has lasted 3 hours earlier today and has now resolved. His ECG shows subtle ST elevation (<1 mm) in leads II, aVF and in leads V5 and V6, and inferior Q waves. Should he undergo emergent reperfusion?No emergent reperfusionEmergent reperfusion with PCIEmergent reperfusion with thrombolysisB or C

      12 Question 12. A 50-year-old woman presents with a persistent, mild chest pain for the last 6 hours. Chest pain fully resolves after nitroglyc- erin administration. The ECG performed after pain resolution is shown (Figure 2.8). What is the next step?Perform coronary angiography/PCI next day (not urgent anymore)Perform emergent reperfusion, whether with thrombolysis or PCIObtain serial troponin levels, as the ECG is not definite for MI

      13 Question 13. A 72-year-old man presents with waxing and waning episodes of resting chest pain for the last 10 hours. Chest pain is reproducible with palpation and the patient does not appear to be in distress. He is not actively having chest pain. The first troponin is 0.03 ng/ml. ECG is shown (Figure 2.9). What is the next step?Emergent reperfusion with PCIEmergent reperfusion with thrombolysisFollow serial cardiac markers (ECG non-diagnostic)Initiate antiplatelet therapy, heparin, and NTG and perform non-urgent coronary angiography (next day)Figure 2.8Figure 2.9

      14 Question 14. A 66-year-old woman presents with anterior STEMI. She receives thrombolysis at a non-PCI hospital, with resolution of chest pain and >50% resolution of ST elevation. She had a mild degree of pulmonary edema on admission, which quickly responded to diuresis. Echo shows severe anterior hypokinesis with LVEF of 35%. Three days later, she is able to ambulate without chest pain and with a mild degree of dyspnea. What is the next step?Coronary angiographyTreadmill nuclear imaging (modified Bruce protocol)Pharmacological nuclear imagingContinue medical therapy without any further intervention

      15 Question 15. A 67-year-old man presents with chest pain that started 45 minutes ago. His ECG shows 5 mm anterior ST elevation with ample T waves and no Q waves. His BP is 130/75, pulse is 105 bpm. He can be transferred for PCI with a DTB <90 minutes. Which reperfusion strategy achieves the lowest mortality?Primary PCIThrombolysisThrombolysis followed by routine PCI 3–24 hours laterAny of the above

      16 Question 16. A patient presents with chest pain. ECG shows a new LBBB, severe discordant ST elevation in the anterior leads (>25% of S wave) and concordant ST elevation in the lateral leads. Which statement is incorrect?The left bundle receives dual arterial supply, hence LBBB rarely occurs in STEMILBBB implies a high-risk STEMI with extensive infarction and extensive CADLBBB is associated with 3–4 times higher mortality and a more drastic benefit from reperfusionLBBB is associated with increased mortality only when persistentA new LBBB is associated with a higher mortality than a new RBBBA new RBBB is usually seen with LAD-related infarct

      17 Question 17. Which statement is incorrect?LV pseudoaneurysm has a neck to internal