7 Question 7. A 56-year-old man, with no cardiac history, presents with one severe episode of chest pain that started after pushing some furniture. The pain lasted 20 minutes and did not recur. His admission BP is 160/95 mmHg, and no murmur or rub is heard. His ECG is normal. His initial troponin I is 0.02 ng/ml, and peaks at 0.05 ng/ml (99th percentile < 0.04 ng/ml). Renal function is normal. What is the next step?Initiate antithrombotic therapy. Coronary angiography within 24 hours.Initiate antithrombotic therapy. Coronary angiography within 72 hours.Stress testing before discharge for risk stratification.
8 Question 8. A 47-year-old man, smoker, diabetic, presents to the emergency department with sharp chest pain that has been occurring intermittently at rest for the last 2 days. It does not prevent him from performing his daily activities. On exam, his BP is 145/92 mmHg, heart rate 85 bpm. He has no HF or murmur. ECG shows inferior T-wave inversion of 1 mm, and the admission hs-troponin I is undetectable (< 0.005 ng/ml). What is the next step?Perform inpatient stress testing. Home discharge followed by outpatient stress testing is not acceptablePerform inpatient stress testing. Home discharge followed by outpatient stress testing (within 72 hours) is acceptablePerform coronary angiographyDischarge home and arrange for clinic follow-up within a week. Further workup depends on progression of symptoms
9 Question 9. A 56-year-old woman has a history of RCA PCI 8 months previously. She presents with one episode of chest pain that felt similar to her prior angina. It occurred once at rest, 2 days ago, lasted 20 minutes and did not recur. ECG shows LVH with strain and inferior Q waves. Serial troponin levels are < 0.04 ng/ml. Creatinine is normal. What is the next step?Coronary angiography within 72 hoursCoronary angiography within 24 hoursStress testing 3–6 hours after presentation
10 Question 10. In comparison with men, women with ACS (multiple answers)Have a higher in-hospital mortalityAre less likely to benefit from an early invasive strategyHave fewer underlying comorbiditiesHave a higher proportion of non-obstructive CAD and less extensive CAD Have a higher bleeding riskHave a higher ischemic burden despite a lower prevalence and extent of CAD
11 Question 11. A 56-year-old woman presents with severe chest pressure that lasted 2 hours. Her ECG shows deep T-wave inversion across the precordial leads. BP was 190/105 mmHg on presentation. Troponin rises to 2.5 ng/ml. A coronary angiography is performed and only shows minimal plaques < 25%. What is the differential diagnosis at this point (multiple answers)?Stabilized plaque ruptureCoronary vasospasmTakotsubo cardiomyopathyMyopericarditisPulmonary embolismHypertensive crisis with elevated LVEDP and ischemic imbalanceDemand/supply mismatch from anemia or tachyarrhythmia
12 Question 12. For the patient in Question 11, what additional testing best helps establish a diagnosis?Cardiac MRIIVUSEcho
13 Question 13. A 62-year-old man presents with angina and a troponin of 0.12 ng/ml. ECG shows 1 mm dynamic lateral ST depression. He is started on antithrombotic therapy. Coronary angiography is performed and reveals a 40% hazy lesion in the mid RCA with TIMI grade 3 flow. It is eccentric with overhanging edges (Figure 1.9, Appendix 1). There is minimal disease otherwise. What is the next step?PCI of the hazy lesionFFR of the RCAIVUS of the RCAMedical therapy since lesion is < 50%
14 Question 14. A 66-year-old woman presents with severe chest pain that started 2 hours ago. The pain is ongoing, unrelieved with NTG, with severe distress, diaphoresis, and severe nausea. BP = 165/90, heart rate 90 bpm, O2 saturation 100% on ambient air. Exam does not reveal signs of HF. No rub is heard, and BP is equal in both arms. The abdomen is soft and non-tender. ECG is normal. Initial troponin is detectable but below MI cutoff. What is the next step?The pain is unlikely cardiac, as ECG is normal during ongoing pain. ACS likelihood is low. Obtain serial troponin levels then perform stress testingThe pain is likely cardiac by clinical features. Give morphine, metoprolol, and anticoagulation, then perform coronary angiography within 24 hoursThe pain is likely cardiac. Perform chest X-ray. Perform urgent coronary angiography
15 Question 15. A 70-year-old man who has insulin-dependent diabetes presents with chest pain and inferior ST-segment depression (dynamic). His troponin I is 0.55 ng/ml. He is currently chest pain free. He is tachycardic (sinus tachycardia 105 bpm) with BP of 110/75 mmHg. What is the appropriate therapy?Aspirin, clopidogrel load, GPI, and UFH. Perform coronary angiography within 24 hours.Aspirin and UFH. Perform coronary angiography within 72 hoursAspirin and UFH. Perform coronary angiography within 24 hoursAspirin, clopidogrel load, and UFH. Perform coronary angiography within 24 hoursAspirin, clopidogrel load, metoprolol, and UFH. Perform coronary angiography within 24 hours
16 Question 16. A 70-year-old woman presents with NSTEMI. Her coronary angiogram shows multiple moderate lesions in the LAD and RCA. The physician decides to treat her medically. What is the best long-term antiplatelet regimen?Aspirin only, as no PCI was performedAspirin and clopidogrel for 1 yearAspirin and ticagrelor for 1 yearAspirin and prasugrel for 1 year
17 Question 17. A 52-year-old woman presents with chest pain and is found to have 2-mm T inversion in the lateral leads and troponin I of 0.14 ng/ml. She is given clopidogrel 300 mg, aspirin 325 mg, heparin 4000 units and drip on admission. She undergoes coronary angiography next day and is found to have 95% mid RCA stenosis. What PCI pharmacotherapy is associated with the best outcomes during and after PCI?HeparinBivalirudinHeparin and GPIHeparin or bivalirudin and start ticagrelor instead of clopidogrelBivalirudin and start ticagrelor instead of clopidogrel
18 Question 18.Should the patient in Question 16 receive anticoagulation after coronary angiography? Yes/NoShould the patient in Question 17 receive anticoagulation after PCI? Yes/No
19 Question 19. Choose the correct answer(s) (multiple answers possible):Ticagrelor reduces mortality in invasively and non-invasively managed ACSTicagrelor may be administered before coronary angiographyTicagrelor is a reversible ADP receptor antagonist, but because of a 15-hour half-life, its effect lasts ~3–4 daysTicagrelor has a higher non-CABG bleeding risk than clopidogrel, but this bleeding hazard is not clearly accentuated in older patients or those with prior strokePrasugrel is only used in patients managed with PCI, and is loaded after coronary angiography (may be loaded before angiography in STEMI)Prasugrel reduces MI but does not reduce mortality, except in STEMI patients (also, a mortality reduction trend is seen in diabetics)Prasugrel showed excessive bleeding hazard in older patients or those with prior stroke
20 Question 20. Concerning prasugrel and ticagrelor:Ticagrelor and prasugrel are preferred over clopidogrel in all ACS patients (all ACS for ticagrelor, ACS managed with PCI for prasugrel) (class I recommendation in ESC)Prasugrel and ticagrelor are particularly beneficial in high-risk conditions (STEMI, diabetes, recurrent events, and complex PCI)Consider the bleeding risk, particularly age >75 and prior stroke with both agents, especially prasugrelEven in the absence of the high-risk conditions (STEMI, diabetes, recurrent events), prasugrel and ticagrelor are warranted in ACSA head-to-head trial of prasugrel vs ticagrelor showed superiority of prasugrel on ischemic outcomes, with a similar bleeding risk
21 Question 21. A 56-year-old man has NSTEMI and undergoes BMS placement in the mid-RCA. He does not have any prior bleeding history. His EF is normal. Beside lifelong aspirin, which antiplatelet and β-blocker therapies should he receive (multiple answers possible)?Clopidogrel for 1 monthClopidogrel or ticagrelor for 1 yearClopidogrel, prasugrel or ticagrelor for 1 year.Consider chronic clopidogrel therapy beyond 1 year if his bleeding risk is deemed lowLifelong metoprolol (medium or high doses)1 year of metoprolol (medium doses)
22 Question 22. A 42-year-old woman with a smoking history presents with a severe episode of resting angina. ECG shows diffuse T inversion. Troponin I peaks at 2 ng/ml. Coronary angiography shows a long (~35 mm), smooth, non-calcified 70% stenosis of the mid-RCA. Her coronary arteries are tortuous.