Percutaneous Coronary Intervention for Acute Coronary Syndromes

Question 1

What is the medical therapy recommended for STEMI patients?

Answer 1

Aspirin, beta-blockers, statins, and ACE inhibitors

Medical therapy is crucial for managing patients with STEMI.

Question 2

What did the Occluded Arteries Trial (OAT) conclude about PCI in asymptomatic patients?

Answer 2

No benefit with PCI regarding death, reinfarction, or reduction in heart failure at 4-year follow-up

The trial involved over 2,000 patients with total occlusion of the infarct-related artery.

Question 3

What is the recommended dose of enoxaparin for patients undergoing PCI?

Answer 3

0.3 mg/kg IV once

This is typically administered at the time of PCI for adequate anticoagulation.

Question 4

What is a significant risk associated with fondaparinux during PCI?

Answer 4

Significant increase in catheter-related thrombosis

Fondaparinux is an indirect inhibitor of factor Xa with no effect on thrombin.

Question 5

When is early angiography indicated in patients?

Answer 5

In patients with refractory angina or hemodynamic instability

The term ‘early’ generally means within 24 hours.

Question 6

What is the recommended action for patients who received thrombolytic therapy 2 hours ago?

Answer 6

Admit to the coronary care unit for evaluation

Angiography should be considered within 3- to 24-hours after thrombolysis.

Question 7

What are high-risk features that support an ‘early invasive’ strategy?

Answer 7

[“Recurrent angina/ischemia at rest”, “Elevated TnT or TnI”, “New ST-segment depression”, “Recurrent angina with symptoms”, “High-risk findings on stress testing”, “Depressed systolic function”, “Hemodynamic instability”, “Sustained ventricular tachycardia”, “Prior CABG”]

Question 8

What is the Class III recommendation regarding PCI of a non-infarct-related artery?

Answer 8

Due to concerns over additional contrast use and higher complication rates

Recent trials have shown safety and efficacy for PCI of a non-infarct-related artery.

Question 9

What are GP IIb/IIIa inhibitors primarily used for in ACS patients?

Answer 9

In patients considered for early invasive approach not adequately preloaded with a P2Y12 inhibitor

They provide rapid antiplatelet activity but are associated with increased bleeding risk.

Question 10

What is the recommended treatment for a patient in cardiogenic shock with inferior STEMI?

Answer 10

Thrombolyze and transfer immediately

This approach is known as ‘drip and ship’ to a PCI-capable facility.

Question 11

What procedure should be performed for a patient with a large thrombus burden?

Answer 11

Angioplasty and stent placement

This is to prevent distal embolization and poor cardiovascular outcomes.

Question 12

What is the ideal strategy for antiplatelet therapy in patients undergoing PCI?

Answer 12

IV cangrelor loading followed by an infusion for 4 hours, transitioned to ticagrelor

Cangrelor provides immediate antiplatelet effects, suitable for patients inadequately loaded with P2Y12 inhibitors.

Question 13

True or False: Patients undergoing PCI should receive a loading dose of P2Y12 inhibitors.

Answer 13

True

This is critical for achieving rapid platelet inhibition.

Question 14

What is the outcome of the TAPAS trial regarding aspiration thrombectomy?

Answer 14

Significant improvement in myocardial blush grade with aspiration thrombectomy plus PCI

However, subsequent trials showed no benefit with routine thrombus aspiration.

Question 15

What is a key benefit of clopidogrel in PCI?

Answer 15

Reduction in stent thrombosis

Cited from Bhatt DL, et al. N Engl J Med 2013;368(14):1303–1313.

Question 16

When is cangrelor ideally suited for use?

Answer 16

For patients who couldn’t be adequately loaded with P2Y12 inhibitors before PCI and in whom GP inhibitors are not used.

Question 17

What is a risk of administering clopidogrel hours after PCI?

Answer 17

Increased risk of stent thrombosis.

Question 18

Why is it less desirable to use GP IIb/IIIa inhibitors with bivalirudin?

Answer 18

It negates the bleeding risk reduction provided by bivalirudin.

Question 19

What is the recommendation for PCI of completely occluded vein grafts?

Answer 19

Class III recommendation against it due to low success rates and high risk for complications.

Question 20

What intervention reduces MACE in vein graft procedures?

Answer 20

Distal embolic protection with a filter.

Question 21

What is the bleeding risk range for patients on triple therapy?

Answer 21

10% to 14%.

Question 22

What did the WOEST trial find regarding single antiplatelet treatment?

Answer 22

Fewer bleeding complications and no increase in thrombotic events compared to DAPT.

Question 23

What does the PIONEER AF-PCI trial compare?

Answer 23

Rivaroxaban plus clopidogrel, very low-dose rivaroxaban plus DAPT, or warfarin plus DAPT.

Question 24

What is a Class I recommendation for NSTEMI patients regarding P2Y12 inhibitors?

Answer 24

Give a loading dose of P2Y12 inhibitor.

Question 25

What is the difference between thienopyridines and ticagrelor?

Answer 25

Thienopyridines are prodrugs; ticagrelor does not require activation.

Question 26

Why is ticagrelor preferred over clopidogrel for a clopidogrel nonresponder?

Answer 26

Due to prior stent thrombosis indicating clopidogrel failure.

Question 27

What are the independent predictors of major bleeding in ACS?

Answer 27

* Advanced age * Female gender * History of bleeding * Renal insufficiency

Question 28

What is a major predictor of contrast-induced nephropathy (CIN)?

Answer 28

Volume of contrast.

Question 29

What strategies are beneficial in reducing CIN?

Answer 29

* Infusion of normal saline * Minimizing contrast use

Question 30

When is routine stress testing indicated after PCI?

Answer 30

Only for patients with high-risk features.

Question 31

What is the recommended dosing of bivalirudin for a patient with eGFR <30 mL/min?

Answer 31

1 mg/kg/h infusion.

Question 32

What did the ISAR-REACT 3 trial compare?

Answer 32

Bivalirudin versus UFH in patients undergoing PCI.

Question 33

What is a common misconception regarding platelet function testing?

Answer 33

It can tailor antiplatelet therapy effectively.

Question 34

What is the role of clopidogrel in patients undergoing PCI?

Answer 34

Patients were pretreated with clopidogrel 600 mg more than 2 hours before PCI ## Footnote Clopidogrel is an antiplatelet medication used to prevent blood clots in patients undergoing percutaneous coronary intervention (PCI).

Question 35

What is the bleeding risk comparison between bivalirudin and heparin?

Answer 35

Bivalirudin is as effective as UFH or LMW heparin plus a GP IIb/IIIa inhibitor and associated with a lower bleeding risk ## Footnote The effectiveness and safety of bivalirudin versus heparin were evaluated in patients with acute coronary syndrome (ACS).

Question 36

What is the ideal treatment strategy for a patient with cardiogenic shock?

Answer 36

Emergent angiography and revascularization as indicated ## Footnote This strategy is essential for managing patients presenting with cardiogenic shock.

Question 37

When should hemodynamic support devices be used in cardiogenic shock?

Answer 37

When patients are refractory to pharmacologic measures ## Footnote Hemodynamic support devices assist patients who are not responding adequately to medications.

Question 38

What is the function of the intra-aortic balloon pump?

Answer 38

Improves diastolic coronary blood flow but does not provide meaningful cardiac output in pump failure ## Footnote It is commonly used in cardiogenic shock situations.

Question 39

What is the Impella device used for?

Answer 39

Provides a forward flow of up to 2.5 L (Impella 2.5) or 3.5 L (Impella CP) ## Footnote The Impella is a percutaneous left ventricular assist device used in cardiogenic shock.

Question 40

Have hemodynamic support devices shown improved outcomes in cardiogenic shock?

Answer 40

No, none have shown improved outcomes in randomized clinical trials ## Footnote Observational data may show improved hemodynamics, but randomized trials do not support outcome improvements.

Question 41

What is the only strategy consistently shown to improve outcomes in cardiogenic shock?

Answer 41

Early revascularization ## Footnote Early intervention is crucial for improving prognosis in patients with cardiogenic shock.

Question 42

What is the benefit of supervised cardiac rehabilitation programs?

Answer 42

Significant reduction in all-cause mortality and cardiovascular mortality ## Footnote These programs improve exercise tolerance, cardiac symptoms, and overall psychosocial well-being.

Question 43

In which patients should cardiac rehabilitation be particularly considered?

Answer 43

Intermediate- to high-risk patients ## Footnote Cardiac rehabilitation is beneficial for patients with a higher risk of cardiovascular events.

Question 44

What improvements are associated with cardiac rehabilitation?

Answer 44

Improvements in exercise tolerance, cardiac symptoms, lipid levels, smoking cessation rates, stress levels, medical regimen compliance, and psychosocial well-being ## Footnote These benefits contribute to the recommendation of cardiac rehabilitation in clinical guidelines.

Question 45

What is indicated by a thin fibrotic cap and large atheromatous burden?

Answer 45

Most likely would provoke an ACS in the event of rupture ## Footnote This finding suggests a higher risk for acute coronary syndrome due to plaque instability.

Question 46

What does normal vessel anatomy with very mild atherosclerotic changes indicate?

Answer 46

Normal vessel anatomy with very mild atherosclerotic changes ## Footnote This finding is typically not associated with significant clinical risk.

Question 47

What does the presence of a side branch in coronary angiography indicate?

Answer 47

Presence of a side branch ## Footnote Side branches are anatomical features that may influence blood flow and treatment options.

Question 48

What is indicated by unstable angina in the context of coronary artery disease?

Answer 48

Shows plaque rupture/dissection ## Footnote Unstable angina is a clinical manifestation of acute coronary syndrome and indicates significant plaque instability.

Question 49

What is associated with a significant atheromatous burden and decreased mean lumen area?

Answer 49

Most likely would be associated with stable angina ## Footnote Stable angina typically arises from chronic ischemia due to atheromatous changes in coronary arteries.