Coronary Intervention for Acute Coronary Syndromes

Coronary Intervention for Acute Coronary Syndromes
Coronary Intervention for Acute Coronary Syndromes
1 A 62-year-old man presents to the emergency room
(ER) with complaints of newly onset waxing and
waning chest pain over the past 4 hours. His initial
electrocardiogram EKG is shown in the following
figure. In deciding whether to initiate treatment with
a glycoprotein IIb/IIIa receptor antagonist (and if
so which agent to use) all of the following should
influence your decision, except:
V1 V4
V5V2
V3aVF
aVL
I aVR
II
III
II
V6
(A) Plans for a conservative or invasive management approach and the timing of any potential
invasive approach
(B) Whether the patient has already received 600 mg
of clopidogrel from the ER physician
(C) In the setting of a percutaneous coronary intervention (PCI), head-to-head trials have found
all three available agents (abciximab, eptifibatide, and tirofiban) to be equally efficacious
in decreasing peri-PCI thrombotic events
(D) Troponin status
2 For a patient presenting to the catheterization
laboratory in the setting of a recent acute coronary
syndrome, which of the following is false regarding
the use of aspirin therapy?
(A) To minimize the risk of gastric bleeding, an
enteric-coated aspirin should be used long-term
(B) Chewing 160 mg to 325 mg leads to complete
antiplatelet effects within 15 to 20 minutes
(C) In placebo-controlled trials in acute coronary
and PCI, aspirin decreases death and myocardial
infarction (MI) rates by approximately 50%
(D) Patients who have aspirin allergy or intolerance
should receive clopidogrel
3 An 87-year-old woman is transferred to your facility
for catheterization and possible PCI after presenting
with chest pain with ST-segment depressions and
an elevated troponin level. Her creatinine level is
1.9 mg/dL and she weighs 58 kg. The patient is started
on aspirin, 600 mg clopidogrel, enoxaparin, and
eptifibatide. All of the following are independently
associated with an increased risk of major bleeding,
except:
(A) Renal dysfunction
(B) Female gender
(C) Previous coronary artery bypass graft (CABG)
(D) Advanced age
73
74 900 Questions: An Interventional Cardiology Board Review
4 Which of the following is true regarding the use
of clopidogrel in a patient presenting with acute
coronary syndromes (ACSs)?
(A) A loading dose of at least 300 mg should be used
(B) Clinical outcomes in patients treated with
clopidogrel are significantly worse in the setting
of concomitant atorvastatin
(C) Doubling the loading dose and maintenance
dose of clopidogrel has been shown to be more
effective than standard therapy in high-risk
patients
(D) A loading dose of clopidogrel is efficacious
regardless of the time of dosing as long as it
is before the percutaneous intervention
5 A 48-year-old man was admitted the previous day
with a troponin-positive non–ST-segment elevation
ACS and was started on enoxaparin 1 mg per kg
subcutaneously. The patient is now in the catheterization laboratory preparing for coronary angiography and possible intervention. His last subcutaneous
dose of enoxaparin was documented to have been
given 5 hours earlier. Optimizing antithrombotic
therapy in the setting of a possible PCI for this patient would require:
(A) Additional intravenous enoxaparin of 0.3 mg
per kg
(B) 50 to 70 units per kilogram of unfractionated
heparin (UFH) titrated to an ACT of >200 if
a GPIIb/IIIa inhibitor is being used, and to an
ACT of 300 if no GPIIb/IIIa inhibitor is planned
(C) No additional anticoagulant is necessary
(D) Further use of additional anticoagulant is based
on whether a GPIIb/IIIa inhibitor is to be used
6 The Folts model was developed as a method to study
thrombosis in the setting of a stenosed artery with
endothelial damage, and therefore has been used as
a means to study various therapeutic interventions
to minimize thrombotic complications in the setting
of an ACS or PCI. Key aspects of the Folts model
include all of the following, except:
(A) A flow probe placed on the artery to measure
cyclic flow reductions (CFRs)
(B) The ability to vary the severity of the arterial
stenosis
(C) The inability of weaker antiplatelet agents such
as aspirin to influence thrombosis in this model
(D) The ability to collect the coronary thrombus for
histologic study
7 A 56-year-old diabetic woman is transferred directly
to your catheterization laboratory in the setting
of an anterior ST-segment elevation myocardial
infarction (STEMI) treated with fibrinolytic therapy
at an outside hospital. She has also been treated
with aspirin, UFH, and 600 mg clopidogrel. Her ST
segments have normalized, and she is pain free and
hemodynamically stable. By the time you arrive the
coronary angiography has already been completed
by your partner and demonstrates the following:
The optimal treatment approach to this patient
would be:
(A) PCI with stenting of the left anterior descending
(LAD) only
(B) PCI with stenting of the LAD and likely clinically
significant right coronary artery (RCA) lesions
(C) Cardiothoracic surgery consults for urgent
CABG surgery for this diabetic patient with
multivessel disease
(D) Medical stabilization with plans to risk stratify
before discharge
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