p.8
Electrocardiogram (ECG) Changes in ACS
What is the first electrocardiographic change observed in myocardial infarction (STEMI)?
A) Q waves develop
B) T waves become tall, pointed, and upright
C) ST segment returns to normal
D) R-wave voltage increases
E) T waves invert
B) T waves become tall, pointed, and upright
Explanation: In the early minutes after a myocardial infarction, the T waves become tall, pointed, and upright, along with ST segment elevation, indicating the initial phase of the electrocardiographic evolution of STEMI.
p.3
Risk Stratification in ACS
What is the TIMI risk score used for in acute coronary syndrome?
A) To determine treatment for heart failure
B) To assess the risk of death or myocardial infarction
C) To measure troponin levels
D) To evaluate exercise tolerance
E) To assess ST segment changes
B) To assess the risk of death or myocardial infarction
Explanation: The TIMI risk score is utilized to evaluate the risk of death or myocardial infarction in patients with acute coronary syndrome, helping to guide treatment decisions.
p.5
Pharmacological Management of ACS
Which medication is used for analgesia in acute coronary syndrome?
A) Aspirin
B) Metoprolol
C) Diamorphine
D) Simvastatin
E) Ramipril
C) Diamorphine
Explanation: Diamorphine (or morphine) is used for analgesia in acute coronary syndrome to manage pain associated with myocardial infarction.
p.8
Management Strategies for STEMI
Which of the following is an absolute contraindication to thrombolysis?
A) Oral anticoagulant therapy
B) Recent major trauma/surgery
C) Pregnancy
D) Non-compressible vascular punctures
E) Refractory hypertension
B) Recent major trauma/surgery
Explanation: Recent major trauma or surgery (within the preceding 3 weeks) is listed as an absolute contraindication to thrombolysis, as it poses significant risks for the patient.
p.3
Pharmacological Management of ACS
What is the primary purpose of dual antiplatelet therapy in acute coronary syndrome?
A) To lower blood pressure
B) To prevent platelet activation and aggregation
C) To increase heart rate
D) To enhance myocardial oxygen supply
E) To reduce cholesterol levels
B) To prevent platelet activation and aggregation
Explanation: Dual antiplatelet therapy, which includes aspirin and an ADP-receptor antagonist, is aimed at preventing platelet activation and aggregation, which is crucial in the management of acute coronary syndrome.
p.2
Diagnosis of Myocardial Infarction
Which of the following is NOT a criterion for diagnosing acute myocardial infarction?
A) Symptoms of ischaemia
B) Imaging evidence of new loss of viable myocardium
C) Presence of pathological Q waves
D) Normal ECG findings
E) New left bundle branch block (LBBB)
D) Normal ECG findings
Explanation: Normal ECG findings do not support the diagnosis of acute myocardial infarction; rather, significant changes such as new LBBB or ST-segment changes are required.
p.8
Complications of Myocardial Infarction
What classification is used to assess heart failure post-myocardial infarction?
A) Killip classification
B) NYHA classification
C) ASA classification
D) APACHE classification
E) Glasgow classification
A) Killip classification
Explanation: The Killip classification is specifically used to assess patients with heart failure following a myocardial infarction, categorizing them based on clinical findings.
p.1
Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG)
In comparative trials, which procedure has shown a higher need for repeat revascularization?
A) CABG
B) PCI
C) Both CABG and PCI equally
D) Neither CABG nor PCI
E) Only in patients with diabetes
B) PCI
Explanation: Trials demonstrate a higher need for repeat revascularization with PCI compared to CABG, indicating that PCI may not provide a long-term solution for some patients.
p.1
Acute Coronary Syndromes (ACS)
Which of the following is NOT included in the acute coronary syndromes (ACS)?
A) ST-elevation myocardial infarction (STEMI)
B) Non-ST-elevation myocardial infarction (NSTEMI)
C) Unstable angina (UA)
D) Stable angina
E) All of the above are included
D) Stable angina
Explanation: Acute coronary syndromes (ACS) include STEMI, NSTEMI, and unstable angina, but stable angina is not classified as an acute coronary syndrome.
p.8
Pharmacological Management of ACS
What is a common treatment for mild heart failure post-STEMI?
A) Intravenous inotropes
B) Oral anticoagulants
C) Intravenous furosemide
D) Surgical intervention
E) Coronary artery bypass grafting
C) Intravenous furosemide
Explanation: Mild heart failure post-STEMI may respond to intravenous furosemide, which helps manage fluid overload, along with monitoring blood pressure and administering oxygen as needed.
p.6
Risk Stratification in ACS
What does a total TIMI score of 6 indicate regarding the risk of death at 30 days?
A) 0.8%
B) 12.4%
C) 16.1%
D) 23.4%
E) 35.9%
C) 16.1%
Explanation: A total TIMI score of 6 corresponds to a 16.1% risk of death at 30 days, indicating a significant risk level for patients with this score.
p.5
Pharmacological Management of ACS
Which of the following is a common loading dose for Clopidogrel in acute coronary syndrome?
A) 150 mg
B) 300 mg
C) 60 mg
D) 75 mg
E) 5000 units
B) 300 mg
Explanation: The loading dose for Clopidogrel in the context of acute coronary syndrome is typically 300 mg orally, followed by a maintenance dose of 75 mg daily.
p.5
Pharmacological Management of ACS
What is the effect of Glyceryl trinitrate in acute coronary syndrome?
A) Increases myocardial oxygen demand
B) Causes coronary vasodilation
C) Increases platelet aggregation
D) Decreases heart rate
E) Reduces blood pressure significantly
B) Causes coronary vasodilation
Explanation: Glyceryl trinitrate is used to cause coronary vasodilation, which helps improve blood flow to the heart muscle and alleviate angina symptoms.
p.3
Biochemical Markers for ACS
What is the relationship between troponin I levels and mortality risk in acute coronary syndrome?
A) Higher troponin levels correlate with lower mortality risk
B) Troponin levels have no impact on mortality risk
C) Higher troponin levels correlate with higher mortality risk
D) Troponin levels are only relevant in chronic conditions
E) Troponin levels are only relevant in heart failure
C) Higher troponin levels correlate with higher mortality risk
Explanation: The data indicates that as troponin I levels increase, the percentage of patients who experience mortality at 42 days also increases, demonstrating a clear relationship between elevated troponin levels and increased risk of death in acute coronary syndrome.
p.8
Complications of Myocardial Infarction
What is a potential complication of myocardial infarction that may require surgical repair?
A) Atrial fibrillation
B) Ventricular septal defect
C) Ischemic stroke
D) Hypertension
E) Myocardial ischemia
B) Ventricular septal defect
Explanation: A ventricular septal defect (VSD) can occur in 1-2% of patients with STEMI and may require surgical intervention if it develops as a complication of the myocardial infarction.
p.6
Diagnosis of Myocardial Infarction
What is the typical initial symptom of a myocardial infarction (MI)?
A) Severe chest pain lasting more than 20 minutes
B) Nausea and vomiting
C) Sudden headache
D) Blurred vision
E) Shortness of breath without chest pain
A) Severe chest pain lasting more than 20 minutes
Explanation: The classic presentation of an MI is severe chest pain that lasts for more than 20 minutes, which may not respond to sublingual nitroglycerin.
p.5
Pharmacological Management of ACS
What is the recommended initial dose of Heparin in acute coronary syndrome?
A) 5000 units i.v. bolus
B) 150 mg
C) 2.5 mg s.c.
D) 180 mg
E) 1 mg/kg
A) 5000 units i.v. bolus
Explanation: The initial recommended dose of Heparin for patients with acute coronary syndrome is a 5000 units intravenous bolus, followed by a continuous infusion.
p.3
Biochemical Markers for ACS
What was the standard marker for myocyte death used in acute coronary syndrome before troponin?
A) Myoglobin
B) Creatine kinase MB (CK-MB)
C) Serum creatinine
D) C-reactive protein (CRP)
E) Fibrinogen
B) Creatine kinase MB (CK-MB)
Explanation: CK-MB was historically the standard marker for myocyte death in acute coronary syndrome, although its accuracy is limited due to the presence of low levels in normal individuals and in patients with skeletal muscle damage.
p.6
Risk Stratification in ACS
What is the TIMI risk score used for in STEMI?
A) To assess kidney function
B) To evaluate risk of death at 30 days
C) To determine blood type
D) To measure cholesterol levels
E) To predict heart rate variability
B) To evaluate risk of death at 30 days
Explanation: The TIMI risk score in STEMI is specifically designed to identify risk factors that predict the likelihood of death within 30 days after a myocardial infarction, helping guide clinical decisions.
p.5
Pharmacological Management of ACS
What is the primary purpose of antiplatelet drugs in acute coronary syndrome?
A) To lower blood pressure
B) To prevent clot formation
C) To increase heart rate
D) To enhance oxygenation
E) To reduce cholesterol levels
B) To prevent clot formation
Explanation: Antiplatelet drugs, such as Aspirin and Clopidogrel, are used in acute coronary syndrome primarily to prevent the formation of blood clots, which can exacerbate ischemia and myocardial damage.
p.7
Pharmacological Management of ACS
What is the recommended dual antiplatelet therapy for patients undergoing primary PCI?
A) Aspirin and warfarin
B) Aspirin and clopidogrel
C) Aspirin and an ADP-receptor blocker
D) Clopidogrel and ticagrelor
E) Aspirin and heparin
C) Aspirin and an ADP-receptor blocker
Explanation: Patients undergoing primary PCI should receive dual antiplatelet therapy with aspirin and an ADP-receptor blocker, such as prasugrel or ticagrelor.
p.1
Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG)
What does PTCA stand for in the context of coronary procedures?
A) Percutaneous Transluminal Coronary Angioplasty
B) Primary Transluminal Coronary Angioplasty
C) Percutaneous Total Coronary Angioplasty
D) Primary Total Coronary Angioplasty
E) Percutaneous Transluminal Coronary Artery
A) Percutaneous Transluminal Coronary Angioplasty
Explanation: PTCA refers to Percutaneous Transluminal Coronary Angioplasty, a procedure used to open blocked coronary arteries.
p.1
Management Strategies for STEMI
What was the 2-year incidence of death or Q wave MI in PCI patients according to the SoS Trial?
A) 5%
B) 10%
C) 9%
D) 2%
E) 15%
C) 9%
Explanation: The SoS Trial reported a 2-year incidence of death or Q wave myocardial infarction (MI) of 9% in PCI patients, indicating the outcomes associated with this procedure.
p.2
Myocardial Infarction (MI) Definitions and Types
What defines Type 1 myocardial infarction?
A) Secondary to increased oxygen demand
B) Related to percutaneous coronary intervention
C) Spontaneous MI due to a primary coronary event
D) Associated with stent thrombosis
E) Related to coronary artery bypass grafting
C) Spontaneous MI due to a primary coronary event
Explanation: Type 1 myocardial infarction is characterized by spontaneous myocardial infarction due to primary coronary events such as plaque rupture or erosion.
p.4
Risk Stratification in ACS
What does the GRACE score assess?
A) Risk of stroke
B) Risk of post-discharge mortality after acute coronary syndrome
C) Risk of diabetes complications
D) Risk of heart failure
E) Risk of pulmonary embolism
B) Risk of post-discharge mortality after acute coronary syndrome
Explanation: The GRACE score is specifically designed to evaluate the risk of mortality within six months after hospitalization for acute coronary syndrome, making it a critical tool in cardiovascular care.
p.4
Pharmacological Management of ACS
Which medication is a direct thrombin inhibitor mentioned in the text?
A) Fondaparinux
B) Eptifibatide
C) Bivalirudin
D) Abciximab
E) Tirofiban
C) Bivalirudin
Explanation: Bivalirudin is identified as a direct thrombin inhibitor that reversibly binds to thrombin, making it effective in managing patients undergoing procedures related to acute coronary syndrome.
p.7
Management Strategies for STEMI
What should be done for patients who fail to reperfuse by 60-90 minutes after thrombolysis?
A) Continue medical management
B) Re-thrombolysis or referral for rescue coronary angioplasty
C) Administer more fibrinolytics
D) Increase anticoagulant dosage
E) Perform a cardiac catheterization
B) Re-thrombolysis or referral for rescue coronary angioplasty
Explanation: For patients who do not show 50% resolution of ST-segment elevation within 60-90 minutes, re-thrombolysis or referral for rescue coronary angioplasty is recommended.
p.8
Electrocardiogram (ECG) Changes in ACS
What happens to the T waves after a few hours post-myocardial infarction?
A) They remain upright
B) They become inverted
C) They disappear
D) They become flat
E) They increase in amplitude
B) They become inverted
Explanation: After a few hours following a myocardial infarction, the T waves invert, indicating a progression in the ECG changes associated with the event.
p.1
Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG)
What is the primary purpose of coronary artery bypass grafting (CABG)?
A) To perform angioplasty
B) To relieve coronary obstruction
C) To insert a stent
D) To measure blood flow
E) To perform coronary angiography
B) To relieve coronary obstruction
Explanation: CABG is a surgical technique designed to bypass coronary obstructions, thereby improving blood flow to the heart.
p.1
Management Strategies for STEMI
According to the draft NICE guidance, who is recommended to receive PCI?
A) Patients with diabetes
B) Young patients with single or multivessel disease
C) Patients with three-vessel disease
D) Older patients only
E) Patients with unstable angina
B) Young patients with single or multivessel disease
Explanation: The draft NICE guidance recommends PCI for young patients with single or multivessel disease who do not have diabetes, highlighting a specific patient population for this intervention.
p.2
Biochemical Markers for ACS
Which cardiac biomarker is preferred for diagnosing myocardial infarction?
A) Creatine kinase-MB (CK-MB)
B) Myoglobin
C) Cardiac troponin (cTn)
D) Lactate dehydrogenase (LDH)
E) B-type natriuretic peptide (BNP)
C) Cardiac troponin (cTn)
Explanation: Cardiac troponin (cTn) is the preferred biomarker for diagnosing myocardial infarction due to its specificity and sensitivity in detecting myocardial necrosis.
p.2
Electrocardiogram (ECG) Changes in ACS
What is the significance of ST-segment elevation on an ECG in the context of myocardial infarction?
A) Indicates normal heart function
B) Suggests the presence of a transient ischemia
C) Indicates complete occlusion of a coronary vessel
D) Suggests a previous myocardial infarction
E) Indicates low blood pressure
C) Indicates complete occlusion of a coronary vessel
Explanation: Persistent ST-segment elevation on an ECG is indicative of complete occlusion of a coronary vessel, which is a critical finding in diagnosing STEMI.
p.4
Risk Stratification in ACS
What systolic blood pressure (BP) points are assigned for a reading of 80-99.9 mmHg in the GRACE score?
A) 0 points
B) 12 points
C) 24 points
D) 18 points
E) 9 points
B) 12 points
Explanation: In the GRACE score, a systolic BP reading of 80-99.9 mmHg is assigned 12 points, which contributes to the overall risk assessment for post-discharge mortality.
p.4
Pharmacological Management of ACS
What is the recommended resting heart rate for patients on beta-blockers?
A) 60-70 b.p.m.
B) 70-80 b.p.m.
C) 50-60 b.p.m.
D) 40-50 b.p.m.
E) 80-90 b.p.m.
C) 50-60 b.p.m.
Explanation: The target resting heart rate for patients receiving beta-blockers is typically set at 50-60 beats per minute to effectively reduce myocardial oxygen consumption.
p.3
Risk Stratification in ACS
Which of the following is a long-term risk factor for acute coronary syndrome?
A) Elevated troponin levels
B) Age
C) Acute thrombosis
D) ST segment changes
E) Myoglobin levels
B) Age
Explanation: Long-term risks in acute coronary syndrome are defined by clinical risk factors such as age, prior myocardial infarction, diabetes, and heart failure, which are critical for risk stratification.
p.6
Risk Stratification in ACS
Which of the following is NOT a risk factor in the TIMI score for STEMI?
A) Age > 75 years
B) History of diabetes
C) Systolic BP < 100
D) History of asthma
E) Heart rate > 100
D) History of asthma
Explanation: The TIMI risk score includes factors such as age, history of diabetes, low systolic blood pressure, and elevated heart rate, but does not include a history of asthma.
p.6
Electrocardiogram (ECG) Changes in ACS
Which ECG leads show ST elevation in an anterior myocardial infarction?
A) II, III, AVF
B) V1-V3
C) I, AVL
D) V4-V5
E) V3-V4
B) V1-V3
Explanation: In an anterior myocardial infarction, ST elevation is typically seen in leads V1-V3, indicating the affected area of the heart.
What is a common mechanism leading to acute coronary syndromes (ACS)?
A) Increased heart rate
B) Rupture or erosion of the fibrous cap of a coronary artery plaque
C) Decreased blood pressure
D) Increased oxygen supply
E) Normal coronary blood flow
B) Rupture or erosion of the fibrous cap of a coronary artery plaque
Explanation: The common mechanism in ACS is the rupture or erosion of the fibrous cap of a plaque, leading to thrombosis and subsequent myocardial ischaemia.
p.7
Pharmacological Management of ACS
What is the role of fibrinolytic agents in the treatment of myocardial infarction?
A) They prevent heart attacks
B) They enhance the breakdown of occlusive thromboses
C) They increase blood pressure
D) They are used exclusively for stroke treatment
E) They are ineffective after 12 hours
B) They enhance the breakdown of occlusive thromboses
Explanation: Fibrinolytic agents activate plasminogen to form plasmin, enhancing the breakdown of occlusive thromboses, particularly in cases where PCI is unavailable.
p.2
Myocardial Infarction (MI) Definitions and Types
What is the primary criterion for diagnosing acute myocardial infarction (MI)?
A) Presence of chest pain only
B) Detection of a rise and/or fall of cardiac biomarker values
C) New onset of heart murmurs
D) High blood pressure
E) Abnormal lung sounds
B) Detection of a rise and/or fall of cardiac biomarker values
Explanation: The diagnosis of acute myocardial infarction (MI) requires evidence of myocardial necrosis, which is typically indicated by changes in cardiac biomarker values, particularly cardiac troponin.
p.6
Pharmacological Management of ACS
What is the recommended initial medical therapy for a patient with suspected STEMI?
A) Only aspirin
B) Oxygen, intravenous opioids, and aspirin
C) Nitroglycerin only
D) Beta-blockers
E) Statins
B) Oxygen, intravenous opioids, and aspirin
Explanation: The initial medical management for a suspected STEMI includes administering oxygen, intravenous opioids (such as morphine), and aspirin to manage pain and reduce clotting risk.
p.5
Management Strategies for STEMI
In what situation is coronary intervention recommended for patients with acute coronary syndrome?
A) In all patients regardless of risk
B) Only in low-risk patients
C) In high-risk patients
D) Only for patients with single-vessel lesions
E) In patients without chest pain
C) In high-risk patients
Explanation: Coronary revascularization, such as PCI, is recommended specifically for high-risk patients with acute coronary syndrome to improve outcomes and reduce mortality.
p.4
Pharmacological Management of ACS
What is the main action of fondaparinux?
A) Inactivates thrombin
B) Binds to antithrombin and inhibits factor Xa
C) Directly inhibits GP IIb/IIIa receptors
D) Reduces myocardial oxygen consumption
E) Stabilizes atherosclerotic plaques
B) Binds to antithrombin and inhibits factor Xa
Explanation: Fondaparinux is a synthetic pentasaccharide that selectively binds to antithrombin, which inactivates factor Xa, thus playing a crucial role in preventing clot formation.
p.4
Risk Stratification in ACS
What is the mortality risk for high-risk NSTEMI-ACS patients in the hospital according to the GRACE score?
A) < 1%
B) 1-3%
C) > 3%
D) < 2%
E) > 5%
C) > 3%
Explanation: High-risk NSTEMI-ACS patients, as categorized by the GRACE score, have a mortality risk of greater than 3% during hospitalization, indicating a significant risk that requires careful management.
p.7
Electrocardiogram (ECG) Changes in ACS
Which leads show pathological Q waves in an acute anterolateral myocardial infarction?
A) I, II, III
B) V1, V2
C) V2-V6
D) AVR, AVL, AVF
E) V4, V5
C) V2-V6
Explanation: Pathological Q waves are observed in leads V2-V6 during an acute anterolateral myocardial infarction, indicating significant myocardial damage.
p.7
Electrocardiogram (ECG) Changes in ACS
What does ST segment elevation in leads I, AVL, and V2-V6 indicate in a 12-lead ECG?
A) Acute inferior wall myocardial infarction
B) Acute anterolateral myocardial infarction
C) Normal heart function
D) Chronic heart failure
E) Atrial fibrillation
B) Acute anterolateral myocardial infarction
Explanation: The ST segment elevation in leads I, AVL, and V2-V6 is indicative of an acute anterolateral myocardial infarction, as described in the ECG findings.
p.7
Management Strategies for STEMI
What is the recommended door-to-needle time for prompt reperfusion therapy?
A) <60 minutes
B) <30 minutes
C) <90 minutes
D) <15 minutes
E) <45 minutes
B) <30 minutes
Explanation: A door-to-needle time of less than 30 minutes is recommended to reduce the death rate following myocardial infarction, emphasizing the importance of rapid intervention.
