ST-Elevation Myocardial Infarction

Question 1

What is the recommended ‘door-to-needle’ time for thrombolysis in STEMI management?

Answer 1

<30 minutes

Question 2

What is the goal for total ischemic time in STEMI management?

Answer 2

<2 hours, ideally <1 hour

Question 3

What does the Sgarbossa criteria help diagnose in patients with old LBBB?

Answer 3

STEMI

Question 4

What score on the Sgarbossa criteria indicates a specificity of 90% for diagnosing MI?

Answer 4

≥3

Question 5

What defines STEMI according to the 2013 ACC/AHA guidelines?

Answer 5

New ST elevation at the J point in at least two contiguous leads

Question 6

What are the ST elevation thresholds for STEMI diagnosis in men and women?

Answer 6

• ≥2 mm in V2 to V3 for men
• ≥1.5 mm in V2 to V3 for women
• ≥1 mm in other contiguous leads

Question 7

What should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest?

Answer 7

Therapeutic hypothermia

Question 8

What is the recommended clopidogrel loading dose for STEMI patients aged 75 years or less?

Answer 8

300 mg

Question 9

What is the role of CABG in STEMI treatment?

Answer 9

Indicated in failed PCI or high-risk patients

Question 10

What does the TIMI myocardial perfusion grading (TMPG) system assess?

Answer 10

Myocardial perfusion

Question 11

What does TMPG grade 0 indicate?

Answer 11

No apparent tissue-level perfusion

Question 12

What are the relative contraindications to β-blocker therapy in STEMI patients?

Answer 12

• HR < 60 bpm
• Systolic BP < 100 mm Hg
• Moderate or severe LV failure

Question 13

What should be done for STEMI patients with persistent ST elevations after thrombolysis?

Answer 13

Transfer directly to catheterization laboratory for PCI

Question 14

What are the contraindications to nitrates in STEMI patients?

Answer 14

• Hypotension
• Marked bradycardia or tachycardia
• Recent phosphodiesterase 5 inhibitor use

Question 15

What is the ACC/AHA recommendation for routine use of aspiration thrombectomy?

Answer 15

Class III

Question 16

What does the term ‘facilitated PCI’ refer to?

Answer 16

Full- or half-dose fibrinolysis with immediate transfer for planned PCI

Question 17

What were the findings regarding bivalirudin vs. heparin plus a IIb/IIIa inhibitor in STEMI patients?

Answer 17

No significant difference for MACE or stroke

Question 18

What is the risk associated with delayed β-blocker therapy in high-risk STEMI patients?

Answer 18

Cardiogenic shock

Question 19

What complication is associated with holosystolic murmur in late presenters of STEMI?

Answer 19

Ventricular septal rupture or acute mitral regurgitation

Question 20

What is the ACC/AHA Class I recommendation regarding the use of parin at the time of PCI?

Answer 20

Parin with or without a IIb/IIIa inhibitor or bivalirudin is recommended.

Question 21

What indicates a high risk for mechanical complications in a patient presenting with anterior Q wave and shortness of breath?

Answer 21

Late presentation, evidenced by 3-day symptoms.

Question 22

What is a common sign of ventricular septal rupture (VSR)?

Answer 22

Holosystolic murmur.

Question 23

What should be confirmed immediately in a patient suspected of having VSR?

Answer 23

Echocardiogram.

Question 24

What are the indications for emergent CABG?

Answer 24

Ventricular septal rupture (VSR).

Question 25

What can be used as a bridge to surgery in cases of VSR?

Answer 25

IABP, inotropes, and vasodilators.

Question 26

In the TRANSFER AMI trial, what were the three strategies for transferring high-risk STEMI patients?

Answer 26

1. Immediate transfer for PCI within 6 hours of thrombolysis, 2. Delayed transfer for persistent ST elevations or instability, 3. Delayed transfer for angiography >24 hours after thrombolysis.

Question 27

What was the conclusion regarding immediate transfer to a PCI-capable hospital for STEMI patients?

Answer 27

Recommended for suitable patients who develop cardiogenic shock or acute severe heart failure.

Question 28

What is the Class I indication for patients who receive fibrinolytics?

Answer 28

Immediate transfer to a PCI-capable hospital for coronary angiography.

Question 29

Which contrast agents have a Class I recommendation for angiography in patients with chronic kidney disease?

Answer 29

Isosmolar and lower molecular weight contrast agents.

Question 30

What is the effect of drug-eluting stents (DES) compared to bare-metal stents (BMS)?

Answer 30

DES decreases restenosis rates without affecting mortality.

Question 31

What is the recommendation for using DES in patients who cannot comply with dual antiplatelet therapy?

Answer 31

Should be avoided.

Question 32

What were the key findings of the HORIZONS-AMI trial comparing bivalirudin and heparin?

Answer 32

Bivalirudin and heparin showed comparable outcomes in STEMI.

Question 33

What is the significance of symptom-to-balloon time in STEMI patients?

Answer 33

For every 30-minute delay from symptom onset to balloon inflation, the risk of 1-year mortality increases by 7.5%.

Question 34

What is ischemic preconditioning?

Answer 34

Brief nonlethal episodes of ischemia protect the myocardium before a prolonged ischemic event.

Question 35

What are the most frequent presenting symptoms of acute MI in women according to McSweeney et al.?

Answer 35

Shortness of breath, weakness, and fatigue.

Question 36

What is the recommendation for administering β-blockers in the acute phase of STEMI?

Answer 36

Part of the standard of care to reduce myocardial oxygen demand and improve perfusion.

Question 37

What did the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) trial find regarding multivessel PCI?

Answer 37

Associated with a reduction in composite outcomes compared to infarct-only PCI.

Question 38

What is the 'no-reflow' phenomenon?

Answer 38

Suboptimal myocardial perfusion despite restoration of epicardial flow.

Question 39

What is the indication to stop fibrinolysis during thrombolysis?

Answer 39

An abrupt decline in consciousness or new central nervous system deficit.

Question 40

What are some vasodilators used for treatment of no-reflow?

Answer 40

Nitroprusside, adenosine, verapamil ## Footnote These medications have variable success in treating no-reflow (Rezkalla SH, et al. JACC Cardiovasc Interv 2017;10(3):215–223).

Question 41

What should be done if there is an abrupt decline in consciousness during thrombolysis?

Answer 41

Stop fibrinolysis, anticoagulation, antiplatelet agents; draw PT, aPTT, platelets, fibrinogen; obtain STAT brain imaging and neurology consultation ## Footnote This is based on the algorithm for evaluation of intracranial hemorrhage complicating fibrinolytic therapy for STEMI (ACC/AHA, 2004).

Question 42

What do the ACC/AHA 2013 guidelines recommend regarding noninvasive testing for ischemia before discharge?

Answer 42

Should be performed to assess inducible ischemia in patients with STEMI without coronary angiography and without high-risk features ## Footnote Exercise stress testing is preferred over pharmacologic testing unless the patient cannot exercise.

Question 43

What is the U-shaped relationship observed in critically ill patients related to glucose levels?

Answer 43

Mortality and glucose level ## Footnote Tight glucose control (81 to 108 mg/dL) was associated with increased mortality compared to modest control (180 mg/dL) in the NICE-SUGAR trial (N Engl J Med 2009;360(13):1283–1297).

Question 44

What did the EPHESUS trial demonstrate regarding heart failure and MI treatment?

Answer 44

Reduced mortality with aldosterone antagonist added to beta-blocker and angiotensin inhibitor ## Footnote An aldosterone antagonist is recommended for STEMI patients with no contraindications who are on an ACE inhibitor and beta-blocker with ejection fraction ≤ 0.40.

Question 45

What is indicated for a patient requiring triple therapy?

Answer 45

Warfarin, aspirin, P2Y12 inhibitor ## Footnote Clopidogrel is recommended in triple therapy as per ACC/AHA 2016 guidelines on duration of DAPT (Levine GN, et al. Circulation 2016;134(10):e123–e155).

Question 46

What is the recommended duration for DAPT in patients with STEMI?

Answer 46

1 year regardless of reperfusion strategy ## Footnote Clopidogrel is the only P2Y12 inhibitor studied with fibrinolytics.

Question 47

Fill in the blank: An IV form of P2Y12 inhibitor that is used if oral agents are contraindicated is _______.

Answer 47

Cangrelor ## Footnote Cangrelor has not been studied with triple therapy and is not available in oral form for long-term use.

Question 48

True or False: Ticagrelor and prasugrel are associated with a lower risk of bleeding compared to clopidogrel.

Answer 48

False ## Footnote Ticagrelor and prasugrel are more potent but associated with a higher risk of bleeding.

Question 49

What should be given if indicated during thrombolysis complications?

Answer 49

Protamine, cryoprecipitate, fresh frozen plasma, platelets ## Footnote These should be given where clinically indicated.