B P5 C38 ST Elevation Myocardial Infarction: Management

Question 1

Major components of the time from the onset of ischemic symptoms to reperfusion include:

Answer 1

(1) Time for the patient to recognize the problem and seek medical attention

(2) Prehospital evaluation, treatment, and transportation

(3) Time for diagnostic measures and initiation of treatment in the hospital (e.g., “door-to-device” time for patients undergoing a catheter-based reperfusion strategy and “door-to-needle” time for patients receiving a fibrinolytic agent);

(4) the time from initiation of treatment to restoration of flow.

Question 2

Most deaths associated with STEMI occur within the first hour of its onset and usually result from _____.

Answer 2

Ventricular fibrillation (VF)

Question 3

Patient-related factors that correlate with a longer delay until deciding to seek medical attention include:

Answer 3

Older age
Female sex
Black race
Low socioeconomic or uninsured status
History of angina, diabetes, or both
Consulting a spouse or other relative
Consulting a physician

Question 4

Patients should also be instructed in the proper use of sublingual nitroglycerin and to call emergency services if the ischemic-type discomfort persists for more than _____ minutes.

Answer 4

> 5 minutes

Question 5

EMS systems have three major components:

Answer 5

Emergency medical dispatch
First response
EMS ambulance response

Question 6

Patients with STEMI who presented within 3 hours of symptom onset and could not undergo primary PCI within 1 hour were randomized to fibrinolysis and coronary angiography within 6 to 24 hours (n = 944) versus primary PCI (n = 948).

The primary endpoint of death, shock, heart failure, or reinfarction at 30 days occurred in 12.4% of the fibrinolysis arm and 14.3% in the primary PCI arm (p = 0.21). Prehospital fibrinolysis is reasonable in settings in which substantial time can be saved by prehospital treatment because of long transportation times (60 to 90 minutes or longer)

Answer 6

STREAM (Strategic Reperfusion Early After Myocardial Infarction)

Half dose of tenecteplase has similar efficacy and lower rates of ICH in patients >75 years old

Question 7

Interventions to Improve Door-to-Device Times

Answer 7

1. A prehospital ECG for diagnosing STEMI is used to activate the PCI team while the patient is en route to the hospital.
2. Emergency physicians activate the PCI team.
3. A single call to a central page operator activates the PCI team.
4. A goal is set for the PCI team to arrive at the catheterization laboratory within 20 min after being paged.
5. Timely data feedback and analysis are provided to members of the STEMI care team.

Question 8

Efforts to shorten the time until treatment of patients with STEMI include:

Answer 8

(1) Improvement in the medical dispatch component by expanding 911 coverage
(2) Providing AED to first responders
(3) Placing AED in critical public locations
(4) Greater coordination of the EMS ambulance response

Question 9

Multiple observational studies and several randomized trials have evaluated the potential benefits of prehospital versus in-hospital fibrinolysis. Although none of the individual trials showed a significant reduction in mortality with prehospital-initiated fibrinolytic therapy, earlier treatment generally provides greater benefit, and a meta-analysis of all the available trials demonstrated a ___% reduction in mortality

Answer 9

17%

Question 10

EMS to needle time: __________
Door to needle time: __________
Dood to device time: __________
FMC to device: __________
Total Ischemic time: __________

Answer 10

EMS to needle < 30 mins
Door to needle < 30mins
Door to device < 90mins
FMC to device: < 120 mins
Total ischemic time < 120mins

Question 11

A history of _____ and the ______ are the primary tools for screening patients with possible acute coronary syndrome (ACS) for STEMI

Answer 11

Ischemic-type discomfort

Initial 12-lead ECG

Question 12

_________ should be obtained promptly (≤10 minutes after hospital arrival)

Answer 12

ECG

Question 13

Critical factors that weigh into selection of a reperfusion strategy include the ____.

Answer 13

(1) Time elapsed since the onset of symptom
(2) Risk associated with STEMI
(3) Time required to initiate an invasive strategy
(4) If that time is expected to be prolonged, the risk related to administering a fibrinolytic

Question 14

Patients with an initial ECG that reveals ST-segment depression and/or T wave inversion without ST-segment elevation are not considered candidates for immediate reperfusion therapy unless a _____ injury current is suspected

Answer 14

Posterior (or inferobasal)

Question 15

ABSOLUTE Contraindications in the use of Fibrinolytics in STEMI

Answer 15

• Any previous intracranial hemorrhage
• Structural cerebral vascular lesion (e.g., AVM)
• Malignant intracranial neoplasm (primary or metastatic)
• Ischemic stroke within 3 months except acute ischemic stroke within 4.5 hr
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed-head or facial trauma within 3 months
• Intracranial or intraspinal surgery within 2 months
• Severe uncontrolled hypertension (unresponsive to emergency therapy)
• For streptokinase, previous treatment within the previous 6 months

Question 16

RELATIVE Contraindications in the use of Fibrinolytics in STEMI

Answer 16

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension at initial evaluation (SBP >180 mm Hg or DBP >110 mm Hg)†
• History of previous ischemic stroke >3 months
• Dementia
• Known intracranial pathology not covered in Absolute Contraindications
• Traumatic or prolonged (>10 min) CPR
• Major surgery (<3 weeks)
• Recent (within 2 to 4 weeks) internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Oral anticoagulant therapy

Question 17

This should be administered at the first opportunity after initial medical contact; effective across the entire ACS spectrum and is part of the intial management strategy for patients with suspected STEMI.

Answer 17

Aspirin 162-325mg LD

Question 18

Control of cardiac pain uses a combination of:

Answer 18

Analgesics (e.g., morphine)

Interventions to improve the balance of myocardial oxygen supply and demand, including:
Oxygen (in the setting of hypoxia)
Nitrates
Beta blockers

Question 19

This remains the analegsic drug of choice except in patients with well documented hypersensitivity

Answer 19

Morphine

4 to 8 mg can be administered intravenously initially, followed by doses of 2 to 8 mg repeated at intervals of 5 to 15 minutes until the pain is relieved or side effects emerge—hypotension, depression of respiration, or vomiting.

Reduction of anxiety with successful analgesia diminishes the patient’s restlessness and the activity of the autonomic nervous system, with a consequent reduction in the heart’s metabolic demands,

Question 20

Morphine has beneficial effects in patients with pulmonary edema as a result of peripheral arterial and venous dilation (particularly in those with excessive sympathoadrenal activity); it _____ work of breathing.

Answer 20

Reduces the work of breathing

Slows the HR secondary to combined withdrawal of sympathetic tone and augmentation of vagal tone

Question 21

Maintaining the patient in a _____ if BP falls can minimize hypotension following the administration of nitroglycerin and morphine.

Such positioning is undesirable in patients with pulmonary edema, but morphine rarely produces hypotension in these circumstances.

Answer 21

Supine position and elevating the lower extremities

Question 22

By virtue of their ability to enhance coronary blood flow by _____ and to decrease ventricular preload by _____, sublingual (SL) nitrates are indicated for most patients with an ACS

Answer 22

Coronary vasodilation

Increasing venous capacitance

Question 23

IV administration of ____ may be helpful in treating excessive vagomimetic effects of morphine.

Answer 23

Atopine

Question 24

NTG should not be given are those with
1.
2.

Answer 24

Suspected RV infarction
Marked hypotension (e.g., systolic BP <90 mm Hg), especially if accompanied by bradycardia

Question 25

____________ have the ability to enhance coronary blood flow by coronary vasodilation and to decrease ventricular preload by increasing venous capacitance

Answer 25

Nitrates

Question 26

Once hypotension is excluded, an SL nitroglycerin tablet should be administered and the patient observed for improvement in symptoms or change in hemodynamics.If an initial dose is well tolerated and appears to be beneficial, further nitrates should be administered while monitor- ing vital signs. Even small doses can produce sudden hypotension and bradycardia, a reaction that can usually be reversed with IV _____.

Answer 26

Atropine

Question 27

________- acting oral nitrate preparations should be avoided in the early course of STEMI because of the frequently changing hemodynamic status of the patient.

Answer 27

Long-acting oral nitrate preparations

Question 28

________________ aid in the relief of ischemic pain, reduce the need for analgesics in many patients, and reduce infarct size and life-threatening arrhythmias.

Answer 28

Beta blockers

Avoiding early IV beta blockers in patients with Killip class II or greater is important, however, because of the risk of precipitating cardiogenic shock.

Routine use of IV beta blockers is no longer recommended in patients with STEMI, but IV administration of a beta blocker at the initial evaluation of patients with STEMI who are hypertensive and have ongoing ischemia is reasonable.

Question 29

Avoiding early IV beta blockers in patients with Killip class ___ or greater is important, however, because of the risk of precipitating cardiogenic shock

Answer 29

Killip Class II or greater

Question 30

A practical protocol for use of a beta blocker is the following.

Answer 30

First, exclude patients with heart failure (HF), hypotension (systolic BP <90 mm Hg), bradycardia (HR <60 beats/min), or significant atrioventricular (AV) block.

Second, administer metoprolol in three 5-mg IV boluses.

Third, observe the patient for 2 to 5 minutes after each bolus, and if HR falls below 60 beats/min or systolic BP falls below 100 mm Hg, do not administer any further drug.

Fourth, if hemodynamic stability continues 15 minutes after the last IV dose, begin oral metoprolol tartrate, 25 to 50 mg every 6 hours for 2 to 3 days as tolerated and then switch to 100 mg twice daily

Question 31

Infusion of an extremely short-acting beta blocker, such as _____, may be useful in patients with relative contraindications to the administration of a beta blocker and in whom HR slowing is considered highly desirable.

Answer 31

Esmolol, 50 to 250 μg/kg/min

Question 32

Treating all patients hospitalized for STEMI with oxygen for at least 24 to 48 hours is a historical common practice based on the empiric assumption that increased oxygen in the inspired air may protect ischemic myocardium. However, augmentation of the fraction of oxygen in inspired air (FIO2) does not elevate O2 delivery significantly in patients who are not hypoxemic. Furthermore, it may _____.

Answer 32

• Promote coronary vasoconstriction
• Increase SVR and arterial pressure
• Greater oxidative stress

Question 33

Patients with STEMI and arterial hypoxemia, Sao2 _______ should receive oxygen

Answer 33

< 90%

Question 34

Efforts to limit infarct size have used several different (sometimes overlapping) approaches:

(1) early __________________
(2) reduction of ______________
(3) manipulation of energy production sources in the myocardium
(4) prevention of _______________

Answer 34

(1) Early reperfusion
(2) Reduction of myocardial energy demands
(3) Manipulation of energy production sources in the myocardium
(4) Prevention of reperfusion injury

Question 35

_______________ form of endogenous protection against STEMI, before sustained coronary occlusion decreases infarct size and associates with a more favorable outcome, along with decreased risk for extension of infarction and recurrent ischemic events.

Answer 35

Ischemic preconditioning

Brief episodes of ischemia in one coronary vascular bed may precondition myocardium in a remote zone and thereby attenuate the size of infarction in the latter when sustained coronary occlusion occurs

Question 36

Spontaneous recanalization of an occluded infarct-related artery occurs in up to ________ of patients beginning at 12 to 24 hours.

Answer 36

1/3

This delayed spontaneous reperfusion may enhance LV function because it improves healing of infarcted tissue, prevents ventricular remodeling, and reperfuses hibernating myocardium. Yet, strategies involving pharmacologically induced and catheter-based reperfusion of the infarct vessel can maximize the amount of salvaged myocardium by accelerating the process of reperfusion and also implementing it in patients who would otherwise have a persistently occluded infarct-related artery.

Question 37

Additional factors that may limit infarct size during reperfusion include _____.

Answer 37

(1) Relief of coronary spasm
(2) Prevention of damage to the microvasculature
(3) Improved systemic hemodynamics (augmentation of coronary perfusion pressure and reduced LV end-diastolic pressure)
(4) Collateral circulation

Question 38

_____________ is the most important intervention to limit infarct size

Answer 38

Timely reperfusion of ischemic myocardium

Question 39

Administration of ___________ agonists should be avoided whenever possible in STEMI to limit infarct size

Answer 39

Adrenergic agonists

Myocardial oxygen consumption should be minimized by maintaining the patient at rest both physically and emotionally and by using mild sedation

All forms of tachyarrhythmia require prompt treatment because they increase myocardial oxygen needs.

HF should also be treated swiftly to minimize increases in adrenergic tone and hypoxemia

Question 40

Severe anemia (hemoglobin ___ g/dL) can be corrected by the cautious administration of packed red blood cells

Answer 40

< 7g/dL

Question 41

_________________ is the most effective way of restoring the balance between myocardial oxygen supply and demand

Answer 41

Timely reperfusion of jeopardized myocardium

Question 42

____________________ also appear to influence LV function after reperfusion

Answer 42

Collateral coronary vessels

They provide sufficient perfusion of myocardium to slow cell death and probably have greater importance in patients undergoing reperfusion later than 1 to 2 hours after coronary occlusion.

Question 43

Even after successful reperfusion and despite the absence of irreversible myocardial damage, a period of postischemic contractile dysfunction can occur—a phenomenon called __________________

Answer 43

Myocardial stunning

Question 44

Adverse sequelae after reperfusion

Answer 44

Reperfusion injury

Question 45

_____________ refers to reperfusion induced death of cells that were still viable at restoration of coronary blood flow

Answer 45

Lethal reperfusion injury

Question 46

_____________ reperfusion injury refers to progressive damage to the microvasculature such that there is an expanding area of no-reflow and loss of coronary vasodilatory reserve

Answer 46

Vascular reperfusion injury

Question 47

In ________________ myocardium, salvaged myocytes display a prolonged period of contractile dysfunction after restoration of blood flow because of abnormalities in intracellular metabolism, leading to reduced energy production

Answer 47

Stunned myocardium

Question 48

_______________ refer to bursts of VT (and occasionally VF) that occur within seconds of reperfusion

Answer 48

Reperfusion arrhythmias

Question 49

___________________ involves introducing brief, repetitive episodes of ischemia alternating with reperfusion

Answer 49

Postconditioning

Question 50

Transient ischemia produced in other vascular beds may also reduce reperfusion injury, a concept called _____. Application of this concept to patients undergoing coronary artery bypass grafting (CABG), using repeated cycles of prolonged BP cuff inflation on the upper extremity, reduced perioperative myocardial injury but did not improve clinical outcomes in two randomized trial

Answer 50

Remote ischemic conditioning (RIC)

Question 51

Transient sinus bradycardia occurs in many patients with inferior infarcts at the time of acute reperfusion, often accompanied by some degree of hypotension.This combination of hypotension and bradycardia with a sudden increase in coronary flow may involve activation of the _____.

Answer 51

Bezold-Jarisch reflex

Question 52

Reperfusion arrhythmias may show a temporal clustering at restoration of coronary blood flow in patients after successful fibrinolysis, this brief “electrical storm” is generally innocuous and therefore does not warrant prophylactic antiarrhythmic therapy or specific treatment, except in rare cases of _____________________

Answer 52

Symptomatic or hemodynamically significant reperfusion arrhythmias.

Question 53

If the time from first medical contact to performing primary PCI is anticipated to exceed 120 minutes, administration of a _____________ is indicated for the treatment of STEMI within 12 hours of onset in the absence of contraindications

Answer 53

Fibrinolytic

Comprehensive overview of nine trials of fibrinolytic therapy, and each of which enrolled more than 1000 patients. The overall results indicated an 18% reduction in short-term mortality, but as much as a 25% reduction in mortality in the subset of 45,000 patients with ST-segment elevation or bundle branch block

Question 54

Patients treated within the first ________________ after the onset of symptoms seem to have the greatest potential for long-term improvement in survival with fibrinolysis.

Answer 54

1 to 2 hours

Question 55

_______________ should be the goal for achieving reperfusion of the epicardial infarct artery

Answer 55

TIMI grade 3 flow

21 / (Observed TIMI frame count) x 1.7

Question 56

____________ is a state of reduced myocardial perfusion after the opening of an epicardial infarct-related artery

Answer 56

No-reflow and coronary microvascular obstruction

Question 57

The four major impediments to normalization of myocardial perfusion are

Answer 57

Ischemia-related injury
Reperfusion-related injury
Distal embolization
Microcirculation to injury

Question 58

Electrocardiographic _____, when present, has a high positive predictive value (PPV) of greater than 90% for infarct artery patency.

Answer 58

ST-segment resolution

Question 59

_____ is a poor predictor of infarct-related artery occlusion, with a negative predictive value (NPV) of approximately 50%.

Answer 59

Persistent ST-segment elevation (i.e., lack of ST- segment resolution)

Question 60

However, the persistence of _____ after angiographically successful primary PCI identifies patients with a higher risk for LV dysfunction and mortality, presumably because of microvascular damage in the infarct zone

The 12-lead ECG can reflect the biologic integrity of myocytes in the infarct zone and indicate inadequate myocardial perfusion even in the presence of TIMI grade 3 flow.

Answer 60

Persistence of ST-segment elevation

Question 61

The extent of _____ provides powerful prognostic information early in the management of patients with STEMI.

Answer 61

Extent of ST-segment resolution

Question 62

Complete reperfusion requires _____, termed myocardial tissue-level reperfusion

Answer 62

Successful restoration of normal flow in both the epicardial coronary artery and the distal coronary microvasculature

Question 63

Failure of epicardial reperfusion can result from _____.

Answer 63

Failure to induce a lytic state

Persistent mechanical obstruction at the site of occlusion

Question 64

Failure of microvascular reperfusion is caused by a combination of _____.

Answer 64

Platelet microthrombi followed by endothelial swelling and myocardial edema (“no-reflow”)

Question 65

Successful reperfusion requires a _____

Answer 65

Patent artery with an intact microvascular network

Question 66

Evaluated rt-PA can reduce mortality even when used 12 hours after the onset of symptoms of an acute myocardial infarction (AMI). Alteplase initiated 6 to 24 hours after symptom onset

In treatment within 12 hours of onset of symptoms, there was a significant reduction of mortality at 35 days with alteplase. Relative reduction of mortality was 25.6% (p = 0.002). The difference for patients treated at 12-24 hours after symptom onset was less, though some patients may benefit even when treated after 12 hours.

Answer 66

LATE (Late Assessment of Thrombolytic Efficacy Study)

Question 67

Evaluated Patients treated between 6 and 24 hours after onset of symptoms will benefit from streptokinase

There was no significant difference in mortality during the hospital stay (11.9% died in streptokinase group, vs 12.4% in placebo group.

Among patients presenting 7-12 hours from symptom onset, there was a non-significant trend toward fewer deaths with streptokinase (11.7% vs. 13.2%) (14% [SD 12] reduction with 95% confidence interval [CI]of 33% reduction to 12% increase).

Answer 67

EMERAS (Estudio Multicentrico Estreptoquinasa Republicas de America del Sur)

Question 68

Two trials, _________ and __________ when viewed together provide evidence that a reduction in mortality may still be observed in patients treated with thrombolytic agents between 6 and 12 hours after the onset of ischemic symptoms.

Answer 68

LATE
EMERAS

Question 69

Barriers to initiation of therapy in older patients with STEMI include _____.

Answer 69

(1) Protracted period of delay in seeking medical care
(2) Lower incidence of ischemic discomfort and greater incidence of atypical symptoms and concomitant illnesses
(3) Increased incidence of nondiagnostic findings on the ECG

Question 70

All fibrinolytic agents exert their effect by converting the proenzyme plasminogen to the active enzyme plasmin.

The so-called ____________ are those that are relatively inactive in the absence of fibrin but in its presence substantially increase their activity on plasminogen

Answer 70

Fibrin-specific fibrinolytics

Question 71

The most fibrin specific among the fibrinolytic agents

Answer 71

Tenecteplase

Question 72

Dosing for Tenecteplase (TNK)

Answer 72

<60kg: 30 mg
60-69kg: 35 mg for 60 to 69 kg
70-79kg: 40 mg
80-89kg: 45 mg
>90kg: 50 mg

Question 73

Dosing for Reteplase (r-PA)

Answer 73

10 units + 10-unit IV boluses given 30 min apart

Question 74

Dosing for Alteplase (t-PA)

Answer 74

90-min weight-based infusion ‡

Bolus of 15 mg

Infusion of 0.75 mg/kg for 30 minutes (maximum, 50 mg)

Then 0.5 mg/kg (maximum, 35 mg) over the next 60 minutes

*The total dose not to exceed 100 mg.

Question 75

Dosing for Streptokinase

Answer 75

1.5 million units IV given over 30–60 min

• Streptokinase is no longer marketed in the United States but is available in other countries.
• Streptokinase is highly antigenic and absolutely contraindicated within 6 months of previous exposure because of the potential for serious allergic reaction.

Question 76

__________________ index is the difference between the initial perfusion defect (e.g., by CMR or sestamibi scintigraphy) and the final perfusion defect.

Answer 76

Myocardial salvage index

CMR can characterize LV volumes, the extent of the scar by gadolinium delayed hyperenhancement, and the presence of ischemia with stress perfusion imaging, providing significant incremental prognostic information over other clinical variables.

Question 77

Most serious complication of fibrinolytic therapy; its frequency is generally less than 1%

Answer 77

Intracranial hemorrhage

Question 78

Reports have demonstrated an “early hazard” with fibrinolytic therapy—that is, an excess of deaths in the first 24 hours in fibrinolytic- treated patients compared with controls, especially in elderly patients treated more than 12 hours after symptom onset. However, this excess early mortality is more than offset by deaths prevented beyond the first day, with an average 18% (range, 13% to 23%) reduction in mortality by 35 days compared with offering no reperfusion therapy. The mechanisms responsible for this early hazard are probably multiple, including an _____.

Answer 78

Increased risk for myocardial rupture
Fatal intracranial hemorrhage
Myocardial reperfusion injury

Question 79

No mortality benefit was demonstrated in the LATE and EMERAS trials when fibrinolytics were routinely administered to patients between ________________

Answer 79

12 and 24 hours

Question 80

An elderly patient with ongoing ischemic symptoms but initially seen late (>12 hours) is better managed with __________ therapy.

Answer 80

PCI over fibrinolytic

Question 81

In patients with cardiogenic shock, immediate revascularization of ________________ at the time of initial presentation is preferred based on improved outcomes for the composite of death or the need for renal replacement therapy in the __________________ study

Answer 81

Only the infarct artery

CULPRITSHOCK study

Question 82

__________________ at primary PCI has a class III recommendation based on trial data showing no improvement in cardiovascular (CV) outcomes and a possible increase in stroke risk

Answer 82

Aspiration thrombectomy

Question 83

Patients with acute coronary syndromes (ST-segment elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) were randomized to radial access (n = 4,197) versus femoral access (n = 4,207)

Among patients with acute coronary syndromes, radial access for cardiac catheterization was associated with a reduction in net adverse cardiovascular events compared with femoral access. Although there was a favorable trend toward reduction in major adverse cardiovascular events, this co-primary endpoint did not reach formal statistical significance. Benefit was the same across the spectrum of acute coronary syndromes. Radial catheterization was associated with a reduction in acute kidney injury compared with femoral catheterization.

Radial access was associated with greater radiation to the operator and the patient.

Answer 83

MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX)

Question 84

Patients with STEMI may be referred for CABG for ____.

Answer 84

(1) Persistent or recurrent ischemia after fibrinolysis or primary PCI with residual coronary disease not amenable to PCI

(2) High-risk coronary anatomy (e.g., left main stenosis) discovered at initial catheterization

(3) Complication of STEMI such as ventricular septal rupture or severe mitral regurgitation caused by papillary muscle dysfunction

Question 85

Patients who successfully undergo fibrinolysis but have important residual stenoses and on anatomic grounds are more suitable for surgical revascularization than for PCI have undergone CABG with quite low rates of mortality (approximately 4%) and morbidity, provided that the procedure is carried out more than 24 hours after STEMI; patients requiring urgent or emergency CABG within 24 to 48 hours of STEMI have mortality rates between _____%.

Answer 85

12-15%

Question 86

Newer-generation _____________ appear to result in lower rates of repeat revascularization with equivalent or lower rates of stent thrombosis compared to contemporary bare-metal stents (BMSs)

Answer 86

Drug-eluting stents (DESs)

Question 87

______________ should be performed in those with STEMI who present within 12 hours of symptom onset and those with later arrival who have ongoing ischemia, HF, or shock.

Answer 87

Primary PCI

Question 88

The greatest operational impediment to routine implementation of a PCI reperfusion strategy is the

Answer 88

Delay required for transportation to a skilled PCI center

Question 89

The best estimate of the time delay at which this advantage is lost is ________, but it may vary depending on the timing of initial evaluation and the extent of myocardium at risk

Answer 89

1 to 2 hours

Question 90

Transfer for primary PCI is generally favored if any of these conditions are present, even if the delay to revascularization will be greater than 120 minutes

Answer 90

(1) High risk for bleeding

(2) Presence of shock or acute severe heart failure

(3) Prolonged time from onset of symptoms to initiation of reperfusion therapy

Question 91

Because of the associated increased bleeding risk, _____ catheterization after the administration of fibrinolytic therapy with the intent to perform revascularization should be reserved for patients with evidence of failed fibrinolysis and significant myocardial jeopardy, for whom rescue PCI would be appropriate.

Answer 91

Very early (<2 to 3 hours)

Question 92

Class I Indications for Coronary Angiography in Patients Who Were Managed with Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

Answer 92

Cardiogenic shock or acute severe heart failure that develops after initial evaluation (IB)

Intermediate- or high-risk findings on predischarge noninvasive ischemia testing (IB)

Spontaneous or easily provoked myocardial ischemia (IC)

Question 93

Class II Indications for Coronary Angiography in Patients Who Were Managed with Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

Answer 93

Failed reperfusion or reocclusion after fibrinolytic therapy (IIa)

Stable* patients after successful fibrinolysis—before discharge and ideally between 3 and 24 hours (IIa)

*Although individual circumstances vary, clinical stability is defined as the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

Question 94

Although individual circumstances vary, clinical stability is defined as the absence of _____.

Answer 94

Low output
Hypotension
Persistent tachycardia
Apparent shock
High-grade ventricular or symptomatic SVT
Spontaneous recurrent ischemia

Question 95

Patients previously treated with thrombolytic therapy were randomized to: 1) repeat thrombolysis, 2) angiography with or without revascularization, or 3) conservative management with unfractionated heparin for 24 hours.

Patients with acute MI with failed reperfusion, treatment with rescue angiography was associated with a reduction in the primary composite endpoint at 6 months compared with both repeat thrombolysis or conservative management. Event-free survival at 1 year and longer was greatest in the rescue angiography group. The need for long-term (1-year) repeat revascularization was lowest in the rescue angiography group.

Answer 95

REACT trial (Rescue Angioplasty Versus Conservative Therapy or Repeat Thrombolysis)

Question 96

Patients with STEMI were randomized to a pharmacoinvasive strategy (emergent transfer for PCI within 6 hours of fibrinolysis) or to standard treatment after fibrinolysis (which included rescue PCI as required for ongoing chest pain and <50% resolution of ST-elevation at 60-90 minutes, or if patients were hemodynamically unstable)

The results of this large randomized clinical trial indicate that in patients presenting with STEMI to centers without timely access to a catheterization lab, a pharmacoinvasive approach consisting of full-dose thrombolytics, followed by emergent transfer for cardiac catheterization within 6 hours, is safe and efficacious compared to treatment with thrombolytics and transfer for rescue PCI only. This suggests that transfer to PCI centers should be initiated immediately after fibrinolysis without waiting to see whether reperfusion is successful or not.

Answer 96

TRANSFER AMI (Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction)

Question 97

In the setting of absolute contraindications to fibrinolysis and lack of access to PCI facilities, antithrombotic therapy should be initiated because of the slight chance (approximately ________) of restoring TIMI grade 3 flow

Answer 97

10%

Question 98

The rationale for administering anticoagulant therapy acutely to patients with STEMI includes _____.

Answer 98

(1) Establishing and maintaining patency of the infarct-related artery, regardless of whether a patient receives fibrinolytic therapy)

(2) Preventing deep venous thrombosis, pulmonary embolism, ventricular thrombus formation, and cerebral embolization.

Question 99

Trial of Streptokinase, aspirin, both, or neither for mortality in acute MI.

Reduction in 5-week vascular mortality with SK alone or aspirin alone

The combination of streptokinase and aspirin was significantly better than either agent alone. Their separate effects on vascular death appeared to be additive. The absolute mortality reductions appear to be greatest for patients at greatest risk of death (for example, women, older patients, hypotensive patients, patients with a previous MI or with anterior infarction).
SK may also be appropriate for patients with a below-average risk of cardiac death.

Answer 99

ISIS-2 (SECOND INTERNATIONAL STUDY OF INFARCT SURVIVAL)

Worthwhile survival advantages can be obtained by routine use of antiplatelet therapy in almost all patients with suspected acute MI. The same can be said for the use of fibrinolytic therapy in a wide range of patients, including the elderly.

Question 100

Mortality benefit and amelioration of LV thrombi after STEMI supports the use of heparin for at least _____________ after fibrinolysis.

Answer 100

48 hours

Question 101

The most serious complication of anticoagulant therapy is _____.

Answer 101

Bleeding, especially ICH

Major hemorrhagic events occur more frequently in patients with low body weight, advanced age, female sex, marked prolongation of the activated partial thromboplastin time (APTT) (>90 to 100 seconds), and performance of invasive procedures

Question 102

Direct thrombin inhibitors such as _________________ reduce the incidence of recurrent MI by 25% to 30% compared with heparin but have not reduced mortality.

Answer 102

Hirudin or Bivalirudin

Question 103

Patients undergoing planned primary PCI for acute STEMI were randomized to treatment during PCI with bivalirudin (n = 1,800) or heparin plus a GP IIb/IIIa inhibitor (n = 1,802)

Among patients undergoing planned primary PCI for acute MI, use of bivalirudin was associated with a reduction in the composite endpoint of death, MI, target vessel revascularization, stroke, or major bleeding at 30 days compared with heparin plus GP IIb/IIIa inhibitors. This finding was driven by a reduction in major bleeding, with no difference in MACE.

Answer 103

HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction)

At 12 months, there was still a significantly reduced incidence of the composite endpoint, but in addition to bleeding, a significant reduction in mortality and non–Q-wave MI was noted. There was an increase in early (<24 hours) stent thrombosis with the use of bivalirudin; however, there was no difference between study arms at the end of 1 year.

Question 104

Patients with ST-segment elevation myocardial infarction (STEMI) being transported for primary PCI were randomized in the ambulance to bivalirudin (n = 1,089) versus heparin (unfractionated or low-molecular weight) with optional GPI (n = 1,109)

Among STEMI patients being transported for primary PCI, the early use of bivalirudin compared with heparin/GPI reduced the frequency of death or non–coronary artery bypass grafting (CABG) major bleeding. This was due to a reduction in major bleeding. Bivalirudin was associated with an increase in acute stent thrombosis

No significant difference in death, reinfarction as secondary endpoint

Answer 104

EUROMAX (European Ambulance Acute Coronary Syndrome Angiography)

Question 105

Include a stable, reliable anticoagulant effect, high bioavailability permitting administration via the subcutaneous (SC) route, and a high anti-Xa/anti-IIa ratio producing blockade of the coagulation cascade in an upstream location and greatly reducing thrombin generation.

Answer 105

Low-Molecular-Weight Heparin

Although LMWHs do not improve the rate of early (60 to 90 minutes) reperfusion of the infarct artery, LMWH reduces rates of reocclusion of the infarct artery, reinfarction, or recurrent ischemic events.

Question 106

Patients with AMI <6 hours (n=6,095) were randomly assigned to one of three regimens: full-dose tenecteplase and enoxaparin for a maximum of seven days (enoxaparin group, n=2,040), half-dose tenecteplase with weight-adjusted low-dose UFH and a 12-hour infusion of abciximab (abciximab group, n=2,017), or full-dose tenecteplase with weight-adjusted UFH for 48 hours (UFH group, n=2,038)

The combination of the fibrin-specific agent tenecteplase with enoxaparin was more efficacious than tenecteplase with heparin, and there was no increase in the risk of bleeding or intracranial hemorrhage, even in the elderly patients over the age of 75.

Answer 106

ASSENT 3 Trial (Assessment of the Safety and Efficacy of a New Thrombolytic Regimen)

In contrast, while efficacy was improved with the combination of tenecteplase plus abciximab, this was offset by a doubling in the rate of major hemorrhage, and a higher event rate in patients over the age of 75 and in diabetic patients. Tenecteplase plus enoxaparin is a viable alternative regimen to tenecteplase plus UFH for the treatment of ST elevation AMI.

Question 107

Randomly assigned 20,506 patients with ST-elevation myocardial infarction who were scheduled to undergo fibrinolysis to receive enoxaparin throughout the index hospitalization or weight-based unfractionated heparin for at least 48 hours. The primary efficacy end point was death or nonfatal recurrent myocardial infarction through 30 days.

In patients receiving fibrinolysis for ST-elevation myocardial infarction, treatment with enoxaparin throughout the index hospitalization is superior to treatment with unfractionated heparin for 48 hours but is associated with an increase in major bleeding episodes.

Answer 107

EXTRACT TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment–Thrombolysis In Myocardial Infarction 25)

Question 108

Randomized double-blind comparison of fondaparinux 2.5 mg once daily or control for up to 8 days in 12092 patients with STEMI

Evaluated the effect of fondaparinux, a factor Xa inhibitor, when initiated early and given for up to 8 days vs usual care (placebo in those in whom unfractionated heparin [UFH] is not indicated [stratum 1] or unfractionated heparin for up to 48 hours followed by placebo for up to 8 days [stratum 2]) in patients with STEMI.

Fondaparinux reduced the composite of death or reinfarction in stratum I (hazard ratio [HR], 0.79; 95% CI, 0.68 to 0.92), but not in stratum II (HR, 0.96; 95% CI, 0.81 to 1.13). The outcome of patients in stratum II who underwent PCI tended to be worse with fondaparinux than with UFH probably because of an increased risk for catheter thrombosis.

Answer 108

OASIS-6 Trial (Effects of Fondaparinux on Mortality and Reinfarction in Patients With Acute ST-Segment Elevation Myocardial Infarction)

Question 109

ADJUNCTIVE ANTICOAGULATION FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Either _____________ is recommended as an anticoagulant to support primary PCI, with a preference for bivalirudin or heparin without a concomitant GP IIb/IIIa inhibitor for patients at high risk for bleeding.

Answer 109

UFH or Bivalirudin

Question 110

___________ is not recommended as the sole anticoagulant in PCI

Answer 110

Fondaparinux

Question 111

ANTICOAGULATION WITH FIBRINOLYSIS

Dose of UFH and duration
Target aPTT

Answer 111

UFH bolus of 60 units/kg to a maximum of 4000 units, followed by an initial infusion at 12 units/kg/hr to a maximum of 1000 units/hr for 48 hours adjusted to maintain the APTT at 1.5 to 2 times control (Approx 50 to 70 seconds)

Effective in patients receiving fibrinolytic therapy

Question 112

Duration of anticoagulation in STEMI after fibrinolysis?

___________________ is preferred when the administration of an anticoagulant for longer than 48 hours is planned in patients with STEMI treated with a fibrinolytic

Answer 112

Patients managed with pharmacologic reperfusion therapy should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of hospitalization after STEMI, up to 8 days

Enoxaparin or Fondaparinux

Question 113

Patients managed with pharmacologic reperfusion therapy should receive anticoagulant therapy for a minimum of _____ hours and preferably for the duration of hospitalization after STEMI, up to _____ days.

Answer 113

48 hours

8 days

Question 114

Enoxaparin should be administered according to age, weight, and creatinine clearance and be given as an _____.

Answer 114

IV bolus, followed in 15 minutes by SC injection for the duration of the index hospitalization, up to 8 days or until revascularization

Question 115

In patients with a known history of heparin-induced thrombocytopenia, _____ in conjunction with ______ is a useful alternative to heparin.

For patients who are referred for CABG, _____ is the preferred antithrombin.

Answer 115

Bivalirudin + Sterptokinase

UFH

Question 116

PCI is performed in a patient treated with fondaparinux, co-administration of an additional antithrombin agent with anti-factor IIa activity is required to mitigate the risk of ________________

Answer 116

Catheter-related thrombosis

Question 117

In patients with a known history of heparin-induced thrombocytopenia, ____________ in conjunction with streptokinase is a useful alternative to heparin

Answer 117

Bilavirudin

Question 118

For patients who are referred for CABG, ______ is the preferred antithrombin

Answer 118

UFH

Question 119

Current evidence does not support initiation of P2Y12 inhibitor therapy before PCI for STEMI unless the strategy is for ____________

Answer 119

Delayed invasive evaluation

Question 120

Patients with STEMI in the CLARITY-TIMI 28 trial were randomized to treatment with clopidogrel (300 mg loading dose followed by 75 mg per day) or placebo following fibrinolytic therapy and aspirin. Patients were to undergo angiography 2-8 days after study drug initiation. PCI was performed at the discretion of the investigator

Among STEMI patients treated with fibrinolytic therapy and aspirin who underwent PCI a median of three days later, pretreatment with clopidogrel was associated with a reduction in the composite of cardiovascular death, reinfarction, or stroke compared with no pretreatment in the CLARITY-TIMI 28 trial.

Answer 120

PCI-CLARITY (Clopidogrel as Adjunctive Reperfusion Therapy: Percutaneous Coronary Intervention Subgroup Study)

Question 121

2658 patients with non-ST-elevation acute coronary syndrome undergoing PCI in the CURE study had been randomly assigned double-blind treatment with clopidogrel (n=1313) or placebo (n=1345

In patients with acute coronary syndrome receiving aspirin, a strategy of clopidogrel pretreatment followed by long-term therapy is beneficial in reducing major cardiovascular events, compared with placebo (36% relative risk reduction in 30 day cardiac death, MI and urgent TVR with pretreatment use of clopidogrel)

Answer 121

PCI-CURE (Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention)

Question 122

This trial compared pretreatment compared with no pretreatment with clopidogrel prior to elective PCI - SIHD symptomatic

Demonstrated a reduction in ischemic events, including the risk of death, MI, or stroke, with a loading dose of clopidogrel and treatment up to 9 months after elective PCI.

There was a trend toward a lower event rate when preloading with a 300-mg clopidogrel dose was given >3 hours before PCI. A 600-mg loading dose of clopidogrel is associated with a shorter time to platelet inhibition and therefore is the preferred dose.

Answer 122

CREDO (Clopidogrel for the Reduction of Events During Observation) trial

The CREDO trial demonstrated that administration of a loading dose of clopidogrel before elective PCI in addition to standard aspirin was not associated with a reduction in events in the overall cohort. While the event rate was slightly higher among patients treated with clopidogrel for less than 6 hours before the PCI (7.9% vs 7.0%), the event rate was lower (5.8% vs 9.4%, p=0.05) if pretreatment lasted for more than 6 hours

Question 123

Randomized 1862 patients with ongoing STEMI of less than 6 hours’ duration, comparing prehospital (in the ambulance) versus in-hospital (in the catheterization laboratory) treatment with ticagrelor.

Prehospital administration of ticagrelor in patients with acute STEMI appeared to be safe but did not improve pre-PCI coronary reperfusion

Answer 123

ATLANTIC (Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery)

Question 124

In a double-blind, placebo-controlled trial, we randomly assigned 11,145 patients who were undergoing either urgent or elective PCI and were receiving guideline-recommended therapy to receive a bolus and infusion of cangrelor or to receive a loading dose of 600 mg or 300 mg of clopidogrel.

Cangrelor significantly reduced the rate of ischemic events, including stent thrombosis, during PCI, with no significant increase in severe bleeding.

Answer 124

CHAMPION PHOENIX (Effect of Platelet Inhibition with Cangrelor during PCI on Ischemic Events)

The rate of the primary efficacy end point was 4.7% in the cangrelor group and 5.9% in the clopidogrel group (adjusted odds ratio with cangrelor, 0.78; 95% confidence interval [CI], 0.66 to 0.93; P=0.005). The rate of the primary safety end point was 0.16% in the cangrelor group and 0.11% in the clopidogrel group (odds ratio, 1.50; 95% CI, 0.53 to 4.22; P=0.44). Stent thrombosis developed in 0.8% of the patients in the cangrelor group and in 1.4% in the clopidogrel group (odds ratio, 0.62; 95% CI, 0.43 to 0.90; P=0.01).

Question 125

The _______ was the largest trial of aspirin in patients with STEMI; it provided the single strongest piece of evidence that aspirin reduces mortality in patients treated with or without fibrinolytic. 7

Answer 125

ISIS-2 study

Question 126

Patients were randomized to clopidogrel (300 mg load, 75 mg/day; n=1,752) or placebo (n=1,739). Choice of fibrinolytic agent and anticoagulant were at the discretion of the treating physician. Patients underwent angiography 48-192 hours after the start of study medication.

Among patients with ST-elevation MI treated with an early medical management strategy, use of clopidogrel was associated with a reduction in the primary composite endpoint compared with placebo, driven by the reduction in infarct-artery occlusion.

Answer 126

CLARITY - TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy)

Question 127

45,852 patients admitted to 1250 hospitals within 24 h of suspected acute MI onset were randomly allocated clopidogrel 75 mg daily (n=22 961) or matching placebo (n=22 891) in addition to aspirin 162 mg daily.

In a wide range of patients with acute MI, adding clopidogrel 75 mg daily to aspirin and other standard treatments (such as fibrinolytic therapy) safely reduces mortality and major vascular events in hospital, and should be considered routinely.

Answer 127

COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial)

Question 128

Duration of antiplatelet therapy in ACS who underwent CABG

Answer 128

12 months

Question 129

Regardless of the administration of concomitant fibrinolytic therapy or performance of primary PCI, should receive ______________ within the first 24 hour

Answer 129

Oral beta blockers

IV administration of beta-blocking therapy during this period is also reasonable if a tachyarrhythmia or hypertension is present, in the absence of signs of HF/low output, indicators of high risk for the development of shock, or other relative contraindications to beta blockers.1

Question 130

In patients with STEMI managed in a CICU, those with an uncomplicated status, such as patients without HF, hypotension, heart block, hemodynamically com- promising ventricular arrhythmias, or persistent ischemic-type discomfort, can be safely transferred out of the CICU within _____ hours

Answer 130

24 to 36 hrs

Question 131

Delirium can be provoked by medications frequently used in the hospital,including antiarrhythmic drugs, H2 blockers, narcotics, and beta blockers. Use of potentially offending agents should be discontinued in patients with an abnormal mental status. _____ a butyrophenone, can be used safely in patients with STEMI.

Answer 131

Haloperidol

Question 132

In the absence of complications, stabilized patients with STEMI need not be confined to bed for more than ____ hours, and unless they are hemodynamically compromised, they may use a bedside commode shortly after admission

Answer 132

12 hours

Question 133

Because beta-adrenergic blockade diminishes circulating levels of free fatty acids (FFAs) by ____- and because elevated FFA levels augment myocardial oxygen consumption and probably increase the incidence of arrhythmias, these metabolic actions of beta blockers may also benefit the ischemic heart.

Answer 133

Antagonizing the lipolytic effects of catecholamines

Question 134

Given the evidence of a benefit of early administration of beta blockers for STEMI, patients without a contraindication, regardless of the administration of concomitant fibrinolytic therapy or performance of primary PCI, should receive oral beta blockers within the first _____ 24 hours

Question 135

IV administration of beta-blocking therapy during this period is also reasonable if a tachyarrhythmia or hypertension is present, in the absence of _____.

Answer 135

Signs of HF/low output
High risk for the development of shock
Other relative contraindications to beta blockers

Question 136

Identify those who are at increased risk of cardiogenic shock in STEMI

Answer 136

Age >70 years
Systolic blood pressure <120 mm Hg
Sinus tachycardia >110 beats/min or Heart rate <60 beats/min

110/60 120/70

Question 137

Beta blockers with _________ should probably not be chosen for the treatment of STEMI

Answer 137

Intrinsic sympathomimetic activity

Question 138

Patients were randomized in an open-label manner to a high daily dose of aspirin (300-325 mg) or to a low dose of aspirin (75-100 mg), and were followed for 30 days. Patients were also randomized in 2 × 2 factorial design to a clopidogrel high-dose regimen (600 mg loading dose on day 1 followed by 150 mg once daily on days 2-7, followed by 75 mg once daily on days 8-30) compared with the standard-dose regimen (300 mg loading dose on day 1, followed by 75 mg once daily on days 2-30).

Among patients with STEMI or NSTE-ACS, high-dose clopidogrel and high-dose aspirin are not superior to standard-dose clopidogrel and low-dose aspirin, respectively, in reducing cardiovascular events at 30 days. Moreover, high-dose clopidogrel results ina significant increase in major and severe bleeding, as compared with standard-dose clopidogrel; high-dose aspirin results in similar major bleeding rates as low-dose aspirin.

Answer 138

CURRENT OASIS 7 (Clopidogrel and Aspirin Optimal Dose Usage to Reduce Recurrent Events−Seventh Organization to Assess Strategies in Ischemic Syndromes)

Further, there was a significant interaction between clopidogrel dose and PCI, with patients receiving PCI showing a reduction in composite cardiovascular events and stent thrombosis at 30 days with high-dose clopidogrel, as compared with standard-dose clopidogrel. Such an interaction was not noted with aspirin dose.

In smokers, a double-dose clopidogrel regimen reduced major cardiovascular events and stent thrombosis after percutaneous coronary intervention, with no increase in major bleeding. This suggests that clopidogrel dosing in patients with acute coronary syndromes should be personalized, taking into consideration both ischemic and bleeding risk.

Question 139

1959 patients with a proven acute myocardial infarction and a left-ventricular ejection fraction of </=40% were randomly assigned 6.25 mg carvedilol (n=975) or placebo (n=984).

In patients treated long-term after an acute myocardial infarction complicated by left-ventricular systolic dysfunction, carvedilol reduced the frequency of all-cause and cardiovascular mortality, and recurrent, non-fatal myocardial infarctions. These beneficial effects are additional to those of evidence-based treatments for acute myocardial infarction including ACE inhibitors

Answer 139

CAPRICORN (CArvedilol Post-infaRct survIval COntRolled evaluatioN)

Although there was no difference between the carvedilol and placebo groups in the number of patients with the primary endpoint (340 [35%] vs 367 [37%], hazard ratio 0.92 [95% CI 0.80-1.07]), all-cause mortality alone was lower in the carvedilol group than in the placebo group (116 [12%] vs 151 [15%], 0.77 [0.60-0.98], p=0.03). Cardiovascular mortality, non-fatal myocardial infarctions, and all-cause mortality or non-fatal myocardial infarction were also lower on carvedilol than on placebo.

Question 140

Oral beta blockers should be initiated in the first 24 hr in patients with STEMI who do not have any of the following:

Answer 140

(1) Signs of heart failure or evidence of a low-output state

(2) Increased risk for cardiogenic shock:
Age > 70 years
SBP < 120 mm Hg
Sinus tachycardia > 110 or HR < 60 bpm
Increased time since onset of symptoms

(3) Other relative contraindications to use of BB
PR interval >0.24s
2nd or 3rd degree AVB
Active asthma or reactive airways disease

Question 141

Patients with initial contraindications to the use of beta blockers in the first ___ hours after STEMI should be reevaluated to determine their subsequent eligibility.

Answer 141

24 hours

Question 142

______________favorable impact on ventricular remodeling, improvement in hemodynamics, and a reduction in HF incidence.

Answer 142

RAAS inhibitors

Question 143

The benefits of ACE inhibition appear to be a ____________ because several agents reduce mortality and morbidity.

Answer 143

Class effect

Question 144

Adverse reactions of ACEi include _____.

Answer 144

Hypotension
Intolerable cough
Angioedema

Question 145

The major contraindications to ACE inhibitors in patients with STEMI include

Answer 145

Hypotension in the setting of adequate preload
Known hypersensitivity
Pregnancy

Question 146

Patients were randomized to valsartan monotherapy (20 mg; n=4,909), valsartan (20 mg) plus captopril (6.25 mg; n=4,885), or captopril monotherapy (6.25 mg; n=4,909).

Among patients with MI complicated by LV systolic dysfunction, heart failure, or both, treatment with valsartan, an ARB, alone or in combination with captopril, an ACE inhibitor, did not meet the primary endpoint of all-cause mortality compared with captopril monotherapy for superiority, but did meet the criteria for noninferiority.

Answer 146

VALIANT trial (Valsartan in Acute Myocardial Infarction Trial Investigators)

The comparison of the valsartan group with the captopril group did meet the criteria for noninferiority for the composite endpoint of fatal and nonfatal cardiovascular events (p<0.001). Adverse events resulting in dose changes occurred most frequently in the valsartan/captopril arm (34.8%) versus the valsartan group (29.4%) or the captopril arm (28.4%). In the valsartan group, hypotension and renal dysfunction occurred more frequently, while in the captopril group, cough, rash, and taste disturbance occurred more frequently.

Question 147

Randomly assigned 6642 patients with acute MI complicated by left ventricular dysfunction and heart failure to the selective aldosterone-blocking agent eplerenone or placebo in conjunction with contemporary postinfarction pharmacotherapy.76 , 77 During a mean follow-up of 16 months, a 15% reduction occurred in the RR for mortality in favor of eplerenone. Eplerenone also reduced CV mortality or hospitalization for CV events

Answer 147

EPHESUS (Eplerenone Post-AMI Heart F ure Efficacy and Survival)

Question 148

Assessed the benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction.

Randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone.

The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI.

Answer 148

ALBATROSS (Early Aldosterone Blockade in Acute Myocardial Infarction)

Question 149

High-risk STEMI patients who should receive lifelong ACEi

Answer 149

Elderly
Anterior infarction
Previous infarction
Killip class II or greater
Asymptomatic patients with evidence of depressed global ventricular function on imaging

Question 150

Longterm aldosterone blockade should be instituted in high-risk patients following STEMI ______________ who are already receiving an ACE inhibitor and beta blocker and do not have contraindications.

Answer 150

EF <40%
Clinical HF
Diabetes mellitus

Question 151

Tolerance to IV nitroglycerin (as manifested by increasing nitrate requirements) develops in many patients, often as soon as _____ hours after beginning the infusion.

Answer 151

12 hours

Question 152

_______________ have no clear beneefit in asymptomatic patients, and we therefore do not prescribe them beyond the first 48 hours in patients without angina or LV failure

Answer 152

Long-term nitrates

Question 153

_______________ have not been helpful in the acute phase of STEMI, and several systematic overviews have raised concern about an increased risk for mortality when these agents, particularly short-acting dihydropyridines, are prescribed on a routine basis

Answer 153

Calcium antagonists

Question 154

Maintain a serum magnesium level of ______________

Answer 154

2 mEq/L or greater

Question 155

Among 4745 patients within 30 days of an acute MI enrolled in _____, colchicine reduced the composite of CV death, resuscitated cardiac arrest, MI, stroke, or urgent coronary revascularization (HR 0.77; 0.61–0.96, p= 0.02) compared with placebo.86 The primary endpoint of all-cause mortality, ACS, ischemia-driven urgent revascularization or ischemic stroke (6.1% vs 9.5%, p= 0.09) was not met in a smaller trial of colchicine in 795 patients with ACS

Answer 155

COLCOT (Colchicine Cardiovascular Outcomes Trial)

Question 156

In the presence of hypokalemia, the serum _____ level should be rechecked and repleted if necessary because it is often difficult to correct a potassium deficit in the presence of a concurrent deficit

Answer 156

Magnesium

Question 157

Routine ___________ does not improve outcomes in STEMI

Answer 157

Invasive hemodynamic monitoring

Question 158

Demonstrated no d ence in death or hospitalization at 6 months, but increased rates of adverse events (21.9% versus 11.5%; P = 0.04) in 433 patients with HF not accompanied by shock randomly assigned to placement of a PA catheter or to noninvasive standard care

Answer 158

ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness)

Question 159

Indications for Hemodynamic Monitoring in Patients with ST-Elevation Myocardial Infarction

Answer 159

Management of complicated acute myocardial infarction

Shock with unclear clinical assessment of hemodynamics (e.g., filling pressures, vascular tone)

Ventricular septal rupture versus acute mitral regurgitation

Severe cardiogenic shock caused by right or left ventricular failure with a need for escalating vasopressor, inotropic, or mechanical circulatory support

Refractory ventricular tachycardia Difficulty differentiating severe pulmonary disease from left ventricular failure with available noninvasive data

Assessment of cardiac tamponade

Question 160

Identify the Forrester classification

Patients with normal perfusion and pulmonary congestion (normal cardiac output and elevated wedge pressure)

Answer 160

Class II

Question 161

Hemodynamic Classification of Patients with Acute Myocardial Infarction

BASED ON INVASIVE MONITORING

Answer 161

I - Normal hemodynamics
PCWP < 18, CI > 2.2

II - Pulmonary congestion
PCWP > 18, CI > 2.2

III - Peripheral hypoperfusion
PCWP < 18, CI < 2.2

IV - Pulmonary congestion and peripheral hypoperfusion
PCWP > 18, CI < 2.2

Question 162

Hemodynamic Classification of Patients with Acute Myocardial Infarction

BASED ON CLINICAL EXAMINATION

Answer 162

I - Rales and S3 absent

II - Crackles, S3 gallop, elevated JVP

III - Frank pulmonary edema

IV - Shock

Question 163

LV Failure in STEMI

HF, in the presence of elevated PCWP, is managed most effectively first by reducing _______________ and then, if possible, by lowering ___________

Answer 163

Ventricular preload

Afterload

Question 164

Mild HF in patients with STEMI frequently responds well to diuretics such as furosemide administered intravenously in doses of _____ intervals if necessary.The resultant lowering of LV wall tension that accompanies the reduction in LV diastolic volume diminishes myocardial oxygen requirements and may lead to improvement in contractility and augmentation of EF, stroke volume, and cardiac output

Answer 164

10 to 40 mg, repeated at 3- to 4-hour

Question 165

Management of hypotension in the prehospital phase

Answer 165

(1) In the absence of HF, when hypotension is suspected to result from excessive vagotonia, patients should be placed in the reverse Trendelenburg position.

(2) In patients with sinus bradycardia and hypotension, atropine should be administered (1 mg IV, repeated at 3- to 5-minute intervals, for a total dose of up to 3 mg). If these measures do not correct the hypotension, normal saline should be administered intravenously while monitoring for signs of HF. Because of the poor correlation between LV filling pressure and mean RA pressure, assessment of CVP can be of limited value as a guide to fluid therapy.

(3) Administration of positive inotropic or vasopressor agents is indicated during the prehospital phase if systemic hypotension persists despite correction of hypovolemia.

Question 166

Patients with low to normal wedge pressure and hypoperfusion may benefit from an infusion of fluids because the peak stroke volume value is not usually attained until LV filling pressure reaches _____ mm Hg

Answer 166

18-24 mm Hg

Question 167

IV furosemide reduces pulmonary vascular congestion and pulmonary venous pressure ________________ before renal excretion of sodium and water has occurred

Answer 167

Within 15 minutes

The resultant lowering of LV wall tension that accompanies the reduction in LV diastolic volume diminishes myocardial oxygen requirements and may lead to improvement in contractility and augmentation of EF, stroke volume, and cardiac output; enhance myocardial oxygen delivery by diminishing the impedance to coronary perfusion; improve arterial oxygenation and dyspnea by reducing p monary vascular congestion.

Question 168

IV vasodilator therapy should be considered in patients with STEMI complicated by

Answer 168

(1) HF unresponsive to treatment with diuretics
(2) hypertension
(3) mitral regurgitation (MR)
(4) ventricular septal defect (VSD)

Question 169

______________ produces a more prominent reduction in LV filling pressure because of its relatively greater effect than nitroprusside on venous capacitance vessels

Answer 169

Nitroglycerin

Less likely than nitroprusside to produce “coronary steal” (i.e., diversion of blood flow from the ischemic to the nonischemic zone).

Question 170

Dosage of NTG inSTEMI with HF

Answer 170

A dosage of 10 to 15 μg/min is infused, and the dose is increased by 10 μg/min every 5 minutes until the desired effect (improvement in hemodynamics or relief of ischemic chest pain) is achieved or a decline in systolic arterial pressure to 90 mm Hg or by more than 15 mm Hg has occurred.

Question 171

True or False

Benefits of both SGLT2 and GLP1 RA of agents are not proven in the acute setting after MI.

Answer 171

True

Question 172

_________________reserved for the management of supraventricular tachyarrhythmias, such as atrial flutter and fibrillation with rapid ventricular response despite standard therapies, in the setting of poor LV function and HF persisting despite treatment with diuretics or vasodilators.

Answer 172

Digitalis

Question 173

In this trial, compared with norepinephrine, treatment with dopamine at doses up to 20 μg/kg/min was associated with a higher rate of tachyarrhythmias (24.1% versus 12.4%) among 1679 patients with shock; subgroup analysis of patients with cardiogenic shock (280, 17% of total trial population), dopamine was not only associated with more arrhythmic events but also with increased mortality

Answer 173

SOAP (Sepsis Occurrence in Acutely Ill Patients) II trial

Question 174

An activator of alpha- and beta-adrenergic receptors, resulting in increased HR, cardiac output, and vascular tone. It is generally reserved for refractory shock as a second- or thirdline agent for cardiogenic shock or in the setting of anaphylaxis

Answer 174

Epinephrine

Question 175

___________________ has a positive inotropic action comparable to that of dopamine, but a slightly less positive chronotropic effect, and vasodilatory rather than vasoconstrictor activity

Answer 175

Dobutamine

Question 176

_____________ noncatecholamine, nonglycoside, phosphodiesterase inhibitor with inotropic and vasodilating actions (see Table 38.10).100 Similar to dobutamine, it is useful in patients with cardiogenic shock without significant hypotension.

Answer 176

Milrinone

Question 177

__________________ antidiuretic hormone (ADH), results in arterial smooth muscle contraction through V1 receptor agonism on the systemic vasculature; is typically used for refractory vasodilatory shock, particularly septic shock.

Answer 177

Vasopressin

Question 178

Cardiogenic shock complicating MI most often results from _________________ (approximately 80%); the remainder have a mechanical defect (e.g.,VSD, papillary muscle rupture) or predominant RV infarction

Answer 178

LV dysfunction

Question 179

Patients with cardiogenic shock complicating STEMI are more likely to be _____.

Answer 179

Older
History of diabetes mellitus, prevous MI, or HF Sustained an anterior infarction at the time of development of shock

Question 180

At autopsy, more than two-thirds of patients with cardiogenic shock demonstrate _____.

Almost all patients with cardiogenic shock exhibit thrombotic occlusion of the artery supplying the major region of recent infarction, with a loss of ___% or more of LV mass

Answer 180

Multivessel coronary disease, usually including the left anterior descending coronary artery (LAD)

40%

Question 181

Patients who die of cardiogenic shock often have _____ necrosis, that is, progressive myocardial necrosis from marginal extension of the infarct into an ischemic zone bordering the infarction. Such extensions and focal lesions probably result in part from the shock state itself.

Answer 181

Piece- meal

Question 182

Criteria for cardiogenic shock

Answer 182

(1) Frank or relative hypotension, defined by a systolic BP below 80 or 90 mm Hg or a reduction in mean arterial pressure (MAP) of 30 mm Hg

(2) Inadequate cardiac index, defined as less than 1.8 liters/min/m 2 without mechanical or pharmacologic support, or less than 2.2 liters/min/ m 2 with support

(3) Elevated end-diastolic pressures on the right (>10 to 15 mm Hg) and/or left (>18 mm Hg) side of the heart

(4) Evidence of end-organ hypoperfusion

Question 183

When SVR is lower than expected (e.g., <1200 dynes/sec/cm5) in patients with cardiogenic shock, _____, can be useful to maintain perfusion through preservation of MAP and augmentation of cardiac output.

Answer 183

Inopressors, or agents with inotropic and vaso- pressor properties (e.g. dopamine, norepinephrine, or epinephrine)

Question 184

The theoretical benefits of mechanical circulatory support (MCS) include the ability to:

Answer 184

(1) maintain end-organ perfusion and prevent progressive shock
(2) reduce intracardiac filling pressures and con- gestion
(3) reduce LV volumes, wall stress, and myocardial oxygen consumption
(4) augment coronary perfusion
(5) support the circulation during complex coronary interventions
(6) allow time for recovery of stunned or hibernating myocardium
(7) limit infarct size

Question 185

The 2017 European Society of Cardiology (ESC) guideline for STEMI recommends that IAB counterpulsation be considered in patients with _____

Answer 185

Cardiogenic shock due to mechanical complications (class IIa)

Not routinely for in patients with STEMI and shock (class III)

Question 186

Epidemiological studies demonstrate that IAB counterpulsation continues to be used for the treatment of STEMI in three groups of patients:

Answer 186

(1) Refractory ischemia that is not alleviated by other treatments, or who await definitive revascularization

(2) Cardiogenic shock that does not respond to medical management

(3) Hemodynamic instability who require circulatory support for the performance of coronary angiography to assess lesions that are potentially correctable surgically or by PCI

Question 187

The most commonly used percutaneous advanced MCS is a ____- that is placed across the aortic valve and delivers continuous non-pulsatile flow of blood (3 to 5 liters/min, depending on the system) from the left ventricle into the aorta, providing a larger increase in cardiac output and reduction in PCWP than IAB counterpulsation

Answer 187

Micro-axial pump

Question 188

The _____ study evaluated early revascularization for the treatment of patients with MI complicated by cardiogenic shock.

Patients with shock caused by LV failure complicating STEMI were randomly assigned to emergency revascularization (n = 152), accomplished by either CABG or angioplasty, or to initial medical stabilization (n = 150).

In 86% of patients in both groups, IAB counterpulsation was performed. The primary endpoint was all-cause mortality at 30 days; a secondary end- point was mortality at 6 months.

At 30 days, the overall mortality rate was 46.7% in the revascularization group, not significantly different from the 56% mortality observed in the medical therapy group (P = 0.11).Although the primary analysis was neutral, long- term survival improved significantly in patients with cardiogenic shock who underwent early revascularization.

Answer 188

SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock?)

_____

Subgroups of patients in the SHOCK study who showed benefit from the early revascularization strategy (i.e., reduced 6-month mortality) were those:

Younger than 75 years
Previous MI
Assigned less than 6 hours from the onset of infarction

Question 189

However, in the pivotal randomized _____ trial among 706 patients with cardiogenic shock onset within 12 hours in the setting of acute MI (ST- and non-ST-elevation MI), patients randomized to infarct artery-only compared with acute multivessel revascularization at index catheterization had a lower 30-day rate of death or severe renal failure leading to renal replacement therapy (RR 0.83; 95% CI 0.71 to 0.96; P = 0.01). Moreover, the risk of death was lower in patients randomized to culprit-only PCI at the initial catheterization (P = 0.03).

Answer 189

CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock)

Question 190

Clinically significant RV infarction, which accompanies approximately _______ of inferior LV infarctions

Answer 190

1/3

Question 191

The hemodynamic picture In RV infarction may superficially resemble that seen in patients with pericardial disease and includes:

Answer 191

(1) Elevated RV filling pressure:
a steep, RA y descent; and an early diastolic drop and plateau (resembling the square root sign) in the RV pressure tracing.

(2) Kussmaul sign (increase in jugular venous pressure with inspiration)
**In fact, the Kussmaul sign in the setting of inferior STEMI is highly predictive of RV involvement.

(3) Pulsus paradoxus (decrease in systolic BP >10 mm Hg with inspiration)

Question 192

Increase in jugular venous pressure with inspiration

Answer 192

Kussmaul’a sign

Question 193

Decrease in systolic BP >10 mm Hg with inspiration

Answer 193

Pulsus paradoxus

Question 194

The presence of ST-segment elevation of 0.1 mV or greater in any one or a combination of leads V4 R, V5 R, and V6 R in patients with the clinical picture of acute MI points to the diagnosis of ____________________.

Answer 194

RV MI

Question 195

Identify the location of occlusion in RV MI

No ST-segment elevation and positive T wave

Answer 195

Distal RCA

Question 196

_______________ should be avoided in RV MI

Answer 196

Nitrates, morphine, and diuretics

Question 197

In patients with hypotension caused by RV MI, hemodynamics can improve with a combination of ________________ to augment RV preload and cardiac output and, when LV failure is present, _______________

Answer 197

Expansion of plasma volume

Arterial vasodilators

Arterial vasodilators reduce the impedance to LV outflow and, in turn, LV diastolic, left atrial, and pulmonary (arterial) pressure, thereby lowerin

Question 198

The clinical course of rupture varies from _____.

Answer 198

Catastrophic, with an acute tear leading to tamponade and immediate death

Subacute, with nausea, hypotension, and pericardial discomfort the major clinical clues to its presence

Question 199

Free wall rupture is more common in the left ventricle ( specifically, the __________________) than in the right ventricle and seldom occurs in the atria.

Answer 199

Anterior or lateral wall

The tear is usually preceded by a large infarct with subsequent expansion, sometimes with a dissecting hematoma, and occurs near the junction of the infarct and normal muscle.

Features associated with rupture include reperfusion with a fibrinolytic agent versus PCI, older age, female sex, hypertension, single-vessel disease without collateral circulation, and an anterior or first MI.

Question 200

Incomplete rupture of the heart may occur when organizing thrombus and hematoma, together with pericardium, seal a rupture of the left ventricle and thus prevent the development of _____.

Answer 200

Hemopericardium

Question 201

Walls of pseudoaneurysms are composed of _____ and lack any elements of the original myocardial wall.

Answer 201

Organized hematoma
Pericardium

Question 202

Characteristics of a pseudoaneurysm

Answer 202

Narrow base
Walls composed of thrombus and pericardium
High risk of free rupture

Question 203

Characteristics of a true LV aneurysm

Answer 203

Wide base
Walls composed of myocardium
Low risk of free rupture

Question 204

Treatment of LV pseudoaneurysm

Answer 204

Surgery

In patients with critically compromised hemodynamics, establishment of the diagnosis should be followed immediately by surgical resection of the necrotic and ruptured myocardium with primary reconstruction.

When the rupture is subacute and a pseudoaneurysm is suspected or present, prompt elective surgery is indicated because the risk of rupture approaches 50% in untreated cases

Question 205

Rupture of the septum with an anterior infarction tends to be ____________ in location, whereas inferior infarctions are associated with perforation of the ____________

Answer 205

Apical

Basal septum

Question 206

Rupture of IVS with worse prognosis is seen in

Answer 206

Inferior infarctions

Question 207

Clinical features associated with increased risk for rupture of the interventricular septum

Answer 207

Lack of development of a collateral network
Advanced age
Female sex
Chronic kidney disease

Question 208

Rupture of the interventricular septum after STEMI carries a poor prognosis, with mortality of _______________

Answer 208

40% to 75%

Question 209

_________________ of an LV papillary muscle is incompatible with life because the sudden massive MR that develops cannot be tolerated.

Answer 209

Complete transection

Question 210

Inferior wall infarction can lead to rupture of the _________________, which because of its singular blood supply, occurs more frequently than r ture of the anterolateral muscle, a consequence of anterolateral MI

Answer 210

Posteromedial papillary muscle

Question 211

Identify the mechanical complication

A new, harsh, loud holosystolic murmur heard best at the lower left sternal border, usually accompanied by a thrill

“Step-up” in Sao in blood samples from the right ventricle and PA compared with those from the right atrium

Answer 211

Ventricular Septal Rupture

Question 212

Unimpressive or absent holosystolic murmur

Tall c-v waves in both the pulmonary capillary and pulmonary arterial pressure tracings

Answer 212

Acute MR from Papillary Muscle Rupture

Question 213

For acute MR and VSDs, unless systolic BP is below 90 mm Hg, ________________ should be instituted as soon as possible once hemodynamic monitoring is available.

Answer 213

Vasodilator therapy, usually nitroglycerin or nitroprusside

Question 214

In a subset of patients whose hemodynamic status remains stable, the operation may be postponed for ________________ to allow some healing of the infarct.

Answer 214

2 to 4 weeks

Question 215

Studies of patients without STEMI have d strated that loss of atrial transport decreases LV output by _____________

Answer 215

15% to 20%

Question 216

In patients with STEMI, atrial systole boosts end-diastolic volume by approximately ____%, end-diastolic pressure by ___%, and stroke volume by ___%.

Answer 216

EDV: 15%
EDP: 30%
SV: 35%

Question 217

__________________ rhythm often follows successful reperfusion with fibrinolytic therapy.

This rhythm typically occurs during the first _____ days with about equal frequency in anterior and inferior infarctions.

Answer 217

Accelerated idioventricular rhythm

First 2 days

In contrast to rapid VT, accelerated idioventricular rhythm is thought not to affect prognosis, and we do not routinely treat accelerated idioventricular rhythms.

Question 218

A leading hypothesis for a major mechanism of ventricular arrhythmias in the acute phase of coronary occlusion is _____ caused by inhomogeneity of the electrical characteristics of ischemic myocardium.

The cellular electrophysiologic mechanisms for reperfusion arrhythmias appear to include washout of various ions such as _____ that have accumulated in the ischemic zone

Answer 218

Reentry

Lactate
Potassium
Toxic substance

Question 219

In patients in whom sustained VT/ VF develops later in the course after STEMI (e.g., >48 hours) without evidence of a reversible cause, _______________ should be considered before discharge.

Answer 219

ICD therapy for secondary prevention

Question 220

VT/VF before reperfusion therapy, in whom antiarrhythmic therapy other than a ___________ is not indicated.

Answer 220

Beta blocker

Question 221

Sinus bradycardia frequently occurs during the early phases of STEMI, particularly in patients with _____ infarctions.

Answer 221

Inferior and posterior

Question 222

Isolated sinus bradycardia, unaccompanied by hypotension or ventricular ectopy, should be _____ rather than treated.

In the first 4 to 6 hours after infarction, if the sinus rate is extremely low (<40 to 50 beats/min) and associated with hypotension, IV _____ in doses of 1 mg every 3 to 5 minutes (maximum of 3 mg) can be administered to bring the heart rate up to approximately 60 beats/min.

Answer 222

Observed

Atropine

Question 223

A first-degree AV block does not generally require specific treatment. Beta blockers and calcium antagonists (other than dihydropyridines) prolong AV conduction and may be responsible for first-degree AV block as well, but discontinuation of the use of these drugs in the setting of STEMI could increase ischemia and ischemic injury.

Therefore, we generally do not decrease the dosage of these drugs unless the PR interval is longer than _____ seconds

Answer 223

> 0.24s

Question 224

First-degree and type I second-degree AV blocks do not appear to affect survival, are most often associated with occlusion of the _____.

Answer 224

RCA and result from ischemia of the AV node

Question 225

Specific therapy is not required in patients with type I second- degree AV block when the ventricular rate exceeds 50 beats/min and PVCs, HF, and bundle branch block are absent. If these complications develop, however, or if HR falls below approximately 50 beats/min and the patient is symptomatic, immediate treatment with _____ is indicated

Answer 225

Atropine (1 mg)

Question 226

Temporary pacing systems are almost never needed in the management of what type of arrhythmias?

Answer 226

First-degree and type I second-degree AV blocks

Question 227

What arrhythmia should be treated with a temporary external or transvenous demand pacemaker.

Answer 227

Type II second-degree AV block

Complete AV block if with symptoms or hemodynamic instability

Question 228

Type II second-degree AV block in the setting of _____ STEMI is usually temporary and is manifested as a narrow-complex, junctional escape rhythm. These arrhythmias can typically be managed conservatively.

Answer 228

Inferior and Posterior

Question 229

Only when a complete heart block develops in _____________ after the onset of symptoms is atropine likely to abolish the AV block or cause acceleration of the escape rhythm.

Answer 229

Less than 6 hours

Question 230

With anterior or lateral STEMI, a type II second- degree AV block usually originates from a lesion in the conduction system below the bundle of His. Because of its potential for progression to complete heart block, patients with type II second-degree AV block in this setting should be treated with a _____.

Answer 230

Temporary external or transvenous demand pacemaker

Question 231

Complete AV block can occur in patients with either inferior or anterior infarction, although it is more common in _____ MI.

Answer 231

Inferior

Question 232

Complete heart block in patients with inferior infarction usually develops gradually, often progressing from a first-degree or type I second-degree block.

The escape rhythm is typically stable without asystole and often junctional, with a rate exceeding _____ beats/min and a narrow QRS complex in 70% of cases and a slower rate and wide QRS complex in the others.

This form of complete AV block is often transient, may respond to pharmacologic antagonism of adenosine with methylxanthines, and resolves in most patients within a few days

Answer 232

> 40 bpm

Question 233

Mortality is markedly higher in patients who present with _____ fascicular block.

Answer 233

Posterior

An isolated left anterior divisional block seldom progresses to complete AV block. Mortality is increased in these patients, although not as much as in those with other forms of conduction block.The posterior fascicle is larger than the anterior fascicle, and in general, a larger infarct is required to block it

Question 234

Isolated _____ associates with increased mortality risk in patients with anterior STEMI, even if complete AV block does not occur, but this appears to be the case only if accompanied by HF.

Answer 234

RBBB

Right bundle branch block (RBBB) alone can lead to AV block because it is often a new lesion associated with anteroseptal infarction

Question 235

In patients with _______________, third-degree AV block can occur suddenly 12 to 24 hours after the onset of infarction, although it is usually preceded by intraventricular block and often a type II (not first-degree or type I) second-degree AV block.

Such patients typically have unstable escape rhythms with wide QRS complexes and rates less than 40 beats/min, and ventricular asystole may occur

Answer 235

Anterior infarction

Question 236

Temporary pacing is advisable in _______________ however, because of the high risk for complete AV block. This category includes patients with new bilateral (bifascicular) bundle branch block (i.e., RBBB with left anterior or posterior divisional block and alternating right and left BBB); first-degree AV block adds to this risk.

Answer 236

Intraventricular conduction defects.

As with complete AV block, transvenous ventricular pacing has not resulted in a statistically demonstrable improvement in prognosis in STEMI patients who develop intraventricular conduction defects.

Question 237

Long-term pacing may be indicated in STEMI when

Answer 237

Complete heart block persists throughout the hospital phase in a patient with STEMI
Sinus node function is greatly impaired
Type II second-degree, high-grade atrioventricular block, alternating bundle branch block, or third-degree block persists or occurs intermittently after a waiting period.

Question 238

Ischemic causes after STEMI includes

Answer 238

Acute reocclusion of an initially recanalized or stented vessel
Mechanical or thrombotic occlusion of a side branch or distal vessel during an initial PCI
New ischemia in a non-infarct related coronary artery that was also stenosed but not occluded
Coronary spasm

Question 239

Although diminished in its incidence in the era of primary PCI, pericarditis can produce pain as early as the _____ after STEMI

Answer 239

First day and as late as 8 weeks

Question 240

An important distinguishing feature of pericarditis is radiation of the pain to __________________, a finding that is almost pathognomonic of pericarditis and rarely seen with ischemic discomfort

Answer 240

Either trapezius ridge

Question 241

_________________ pericarditis occurs frequently after transmural infarction, but most patients do not report any symptoms from this process.

Answer 241

Acute fibrinous pericarditis, pericarditis epistenocardica

Transmural MI, by definition, extends to the epicardial surface and can cause local pericardial inflammation.

Although transient pericardial friction rubs are relatively common within the first 48 hours in patients with transmural infarction, pain or electrocardiographic changes occur much less often.The development of a pericardial rub, however, appears to correlate with a larger infarct and greater hemodynamic compromise.

Question 242

Although anticoagulation clearly increases the risk for hemorrhagic pericarditis early after STEMI, this complication does not occur with sufficient frequency during heparinization or after fibrinolytic therapy to warrant absolute prohibition of such agents when a rub is present. Nevertheless, detection of at least ____ cm on echocardiography or enlarging pericardial effusion usually should result in discontinuation of anticoagulation

Answer 242

1 cm

Question 243

Treatment of pericaridits post MI

Answer 243

Aspirin 650 mg orally as often as every 4 hours, together with a proton pump inhibitor.

Question 244

Also known as post-myocardial infarction syndrome, usually occurs 1 to 8 weeks after infarction.

Answer 244

Dressler syndrome

Question 245

Treatment of Dressler syndrome

Answer 245

Aspirin, 650 mg as often as every 4 hours, and colchicine may be effective.

Question 246

_____ are best avoided in patients with Dressler syndrome within 4 weeks of STEMI because of their potential to impair infarct healing, cause ventricular rupture, and increase coronary vascular resistance

Answer 246

Glucocorticosteroids and NSAIDs

Question 247

_________________ generally reserved for a discrete, dyskinetic area of the LV wall with a broad neck

Answer 247

Left ventricular aneurysm

Dyskinetic or akinetic areas of the left ventricle are much more common than true aneurysms after STEMI. True LV aneurysms probably develop in less than 5% of all patients with STEMI. 1 The wall of a true aneurysm is thinner than that of the rest of the left ventricle, and it is usually composed of fibrous tissue, as well as necrotic muscle occasionally mixed with viable myocardium

Question 248

_____ is associated with aneurysm formation after anterior STEMI

Answer 248

Total occlusion of a poorly collateralized LAD

Question 249

Aneurysms occur approximately four times more often at the _______ and in the anterior wall than in the inferoposterior wall.

Answer 249

Apex

Total occlusion of a poorly collateralized LAD is associated with aneurysm formation after anterior STEMI. An aneurysm rarely occurs with multivessel disease with either extensive collaterals or a patent LAD.

Question 250

Echocardiographic risk factors for thrombus embolization include

Answer 250

Increased mobility and protrusion into the ventricular chamber
Visualization on multiple views
Contiguous zones of akinesis and hyperkinesis.

Question 251

A meta-analysis of multiple small studies suggested that anticoagulation reduces the development of LV thrombi by more than ___%

Answer 251

> 50%

Question 252

Anticoagulation for _____________ is reasonable for many patients with demonstrable mural thrombi.

Answer 252

3 to 6 months

Recommendations for anticoagulation vary considerably; nevertheless, patients with STEMI and anterior apical akinesis or severe dyskinesis may merit a limited course of anticoagulant therapy

Question 253

Risk indicators for mortality in the hospital include

Answer 253

Clinical HF
Recurrent VT and VF
New AF or atrial flutter
Intraventricular conduction delays or heart block
Anterior location of infarctio
Recurrent episodes of angina with marked ST-segment abnormalities at low activity levels

Question 254

In patients with apparently successful reperfusion, absence of early sustained ventricular tachyarrhythmias, hypotension, or HF, coupled with a well-preserved LVEF, predicts a low risk for late complications in the hospital. Such patients appear to be suitable candidates for hospital discharge _______________

Answer 254

Less than 5 days

Question 255

Most complications that would preclude early discharge occur within the first _____ days of admission, permitting identification of patients suitable for expedited discharge early during the hospitalization

Answer 255

3 days

Question 256

Initially, this should consist of walking at home but avoidance of __________________

Answer 256

Isometric exercise such as lifting

Question 257

Both short-term and long-term survival after STEMI depend on three major factors:

Answer 257

Resting LV function
Residual potentially ischemic myocardium Susceptibility to serious ventricular arrhythmias.

The most important of these factors is the state of LV function

Question 258

Mortality is greater in patients experiencing __________ STEMI than in those with inferior STEMI

Answer 258

Anterior wall

Question 259

Both short-term and long-term survival after STEMI depend on three major factors: resting LV function, residual potentially ischemic myocardium, and susceptibility to serious ventricular arrhythmias.

The most important of these factors is the _________________

Answer 259

State of LV function

The second most important factor is how the severity and extent of the obstructive lesions in the coronary vascular bed perfusing residual viable myocardium affect the risk for recurrent infarction and serious ventricular arrhythmias. Thus, survival is related to the quantity of myocardium that has become necrotic and the portion remaining in ischemic jeopardy.

The third risk factor, susceptibility to serious arrhythmias, is reflected in ventricular ectopic activity and other indicators of electrical instability, such as reduced HR variability or baroreflex sensitivity and abnormal findings on a signal-averaged ECG. 143 All these factors identify patients at increased risk for death.

Question 260

After STEMI, patients have the greatest risk for development of sudden cardiac death (SCD) from malignant ventricular arrhythmias in the first _______________

Answer 260

1 to 2 years

Question 261

Routine use of prophylactic antiarrhythmic drug therapy, with the exception of ______________, does not improve outcome

Answer 261

Beta blockers

Question 262

Evaluated the sppression of asymptomatic or mildly symptomatic ventricular arrhythmias after acute myocardial infarction with encainide, flecainide, or moricizine, would decrease mortality during long-term follow-up.

Population - post ACS, EF <40%

Encainide and flecainide caused increased cardiovascular mortality with a relative risk of 2.5 (confidence interval 1.7-8.5; p < .001).

Answer 262

CAST (The Cardiac Arrhythmia Suppression Trial)

Neither Encainide nor Flecainide should be used in the treatment of patients with asymptomatic or minimally symptomatic ventricular arrhythmia after myocardial infarction, even though these drugs may be effective initially in suppressing ventricular arrhythmia. The suppression of asymptomatic or mildly symptomatic ventricular arrhythmias after myocardial infarction does not improve survival and can increase mortality. Treatment strategies designed solely to suppress these arrhythmias should no longer be followed.

Question 263

Evaluated that All cause mortality is reduced in patients with ischemic heart disease, acute myocardial infarction, and left ventricular dysfunction or symptomatic heart failure when D-Sotolol is administered.

Among patients evaluated and treated with D-Sotolol there was an increased mortality which was presumed principally secondary to arrhythmias. The investigators indicate that prophylactic use of this potent antiarrhythmic agent does not reduce mortality in this patient population and may be associated with increased death risk in patients with left ventricular systolic dysfunction after myocardial infarction.

Answer 263

SWORD (Survival with Oral D-Sotalol Trial)

Question 264

Evaluated antiarrhythmic drug therapy with amiodarone vs placebo might reduce mortality in patients identified to be at high risk of sudden death from VPDs post ACS patient

Amiodarone reduces the incidence of ventricular fibrillation or arrhythmic death among survivors of acute myocardial infarction with frequent or repetitive VPDs. Amiodarone, in moderate loading and maintenance dosages with adjustments in response to plasma levels, VPD suppressions, and side effects, results in effective VPD suppression and acceptable levels of toxicity.

Answer 264

CAMIAT (Canadian Amiodarone Myocardial Infarction Arrhythmia)

Question 265

Evaluated an individualized approach to optimized therapy for patients with persisting asymptomatic complex arrhythmias after MI could improve survival in comparison to a standardized treatment using low-dose amiodarone.

Reduction in arrhythmic death after MI in patients with depressed LV function, but total mortality and other CVrelated mortality did not decrease.

Low-dose amiodarone decreases mortality the first year after MI in patients at high risk of sudden death. Survival curves appear to remain parallel thereafter.

Answer 265

EMIAT (European Myocardial Infarction Amiodarone Trial)

Question 266

ICD post MI is recommended among

Answer 266

Patients with LVEF less than 35% at least 40 days after STEMI are referred for insertion of an ICD if they are in New York Heart Association (NYHA) Class II or III.

Patients with LVEF less than 30% are referred for ICD implantation even if they are NYHA Class I

Question 267

Patients were randomized to ICD therapy (n=332) versus no ICD therapy (n=342) in addition to best medical treatment in survivors of AMI

Popultation: Age 18-80 years, recent MI (6-40 days), left ventricular ejection fraction (EF) ≤35%, and evidence of impaired cardiac autonomic modulation (i.e., depressed heart rate variability or increased mean 24-hour heart rate

Among recent post-MI patients, prophylactic implantable defibrillator therapy was not associated with a reduction in the primary endpoint of all-cause mortality compared with optimal medical therapy. As would be expected, the frequency of arrhythmia deaths was lower in the prophylactic ICD therapy arm. However, nonarrhythmia deaths were higher in the ICD arm.

Answer 267

DINAMIT (Defibrillator in Acute Myocardial Infarction Trial)

Question 268

Efforts to improve survival and quality of life after MI are related to lifestyle modification of known risk factors.Of these, _____ are probably the most important

Answer 268

Cessation of smoking and control of hypertension

Question 269

All patients with STEMI without contraindications should receive 75 to 325 mg of aspirin daily indefinitely, with _________ being the preferred maintenance dose.

Answer 269

81 mg tab

Question 270

In the absence of contraindications, all patients after STEMI should receive a platelet inhibitor in addition to aspirin for _____________

Answer 270

12 months

Question 271

DAPT Regimens in STEMI:

________________ in patients with STEMI treated with medical therapy alone, lytic therapy, or PCI
________________ in patients treated with PCI
________________ in patients treated with medical therapy alone or PCI 1,7

Answer 271

Clopidogrel (75 mg/day)

Prasugrel (10 mg/day)

Ticagrelor (90 mg twice daily)

Aspirin therapy should be maintained indefinitely.

Question 272

In the absence of significant overt bleeding or risk factors for bleeding, it is reasonable to continue dual-antiplatelet therapy for more than 12 months based on the ____________ and ______________

Answer 272

Dual-antiplatelet therapy (DAPT) and PEGASUS-TIMI 54

Question 273

Three theoretical reasons exist for a pating that anticoagulants might be beneficial in the long-term management of patients after STEMI

Answer 273

First, because the coronary occlusion responsible for STEMI is often caused by a thrombus, anticoagulants might be expected to halt progression, slow progression, or prevent the development of new thrombi elsewhere in the coronary arterial tree.

Second, anticoagulants might be expected to diminish the formation of mural thrombi and resultant systemic embolization.

Third, anticoagulants might reduce the incidence of the incidence of venous thrombosis and pulmonary embolization.

Question 274

Investigated if 30 months of DAPT was superior to 12 months in patients undergoing DES and bare-metal stent (BMS) PCI.
Population - patients post PCI with stent deployment within the past 24 hours

Patients were enrolled 72 hours after stent placement and were given open-label aspirin and thienopyridine for 12 months, per current practice norms. At 12 months, patients without an ischemic or bleeding complication and with documented compliance, were randomized in a 1:1 fashion to receive an additional 18 months of DAPT or matching placebo

The results of the DAPT trial indicate that prolonged duration of DAPT up to 30 months following index PCI with a DES results in lower stent thrombosis and recurrent MIs compared with a 12-month duration of DAPT, although bleeding and all-cause mortality were higher with prolonged therapy.

Answer 274

DAPT (Dual Antiplatelet Therapy)

Question 275

Evaluated treatment with ticagrelor compared with placebo among subjects with a prior myocardial infarction (MI) on a background of aspirin therapy

Subjects with a history of MI (1-3 years prior) on aspirin therapy were randomized to ticagrelor 90 mg bid (n = 7,050) or ticagrelor 60 mg bid (n = 7,045) versus placebo (n = 7,067).

All the patients were to receive low-dose aspirin and were followed for a median of 33 months.

Among patients with prior MI on aspirin therapy, the addition of ticagrelor was beneficial. Ticagrelor compared with placebo reduced the risk of cardiovascular death, MI, or stroke. All-cause and cardiovascular mortality were similar between the groups. Ticagrelor was also associated with an increase in TIMI major bleeding, but was not associated with an increase in intracranial hemorrhage.

Answer 275

PEGASUS TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin–Thrombolysis in Myocardial Infarction 54)

Efficacy and safety were similar among those with multivessel coronary artery disease and history of coronary stent vs. no coronary stent. The two doses of ticagrelor resulted in a similar degree of efficacy (adverse cardiovascular events) and safety (bleeding). Ticagrelor 60 mg twice daily was associated with a reduction in stroke (ischemic stroke) compared with placebo. Cost-effectiveness for ticagrelor could be enhanced if certain high-risk characteristics were present.

Question 276

Indefinite therapy with an _________________ in patients with HF, a moderate decrease in global EF, or a large regional wall motion abnormality,

Answer 276

ACE inhibitor

Question 277

Randomized 15,526 patients with a recent acute coronary syndrome to receive twice-daily doses of either 2.5 mg or 5 mg of rivaroxaban or placebo for a mean of 13 months and up to 31 months.

Rivaroxaban both 2.5mg BID or 5mg BID significantly reduced the primary efficacy end point, as compared with placebo, with respective rates of 8.9% and 10.7%. The twice-daily 2.5-mg dose of rivaroxaban reduced the rates of death from cardiovascular causes (2.7% vs. 4.1%, P=0.002) and from any cause (2.9% vs. 4.5%, P=0.002), a survival benefit that was not seen with the twice-daily 5-mg dose.

As compared with placebo, rivaroxaban increased the rates of major bleeding not related to coronary-artery bypass grafting (2.1% vs. 0.6%, P<0.001) and intracranial hemorrhage (0.6% vs. 0.2%, P=0.009), without a significant increase in fatal bleeding (0.3% vs. 0.2%, P=0.66) or other adverse events. The twice-daily 2.5-mg dose resulted in fewer fatal bleeding events than the twice-daily 5-mg dose (0.1% vs. 0.4%, P=0.04).

Answer 277

ATLAS ACS TIMI 51 (Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with Acute Coronary Syndrome–Thrombolysis in Myocardial Infarction 51)

Question 278

Patients with stable atherosclerosis were randomized to rivaroxaban 2.5 mg twice daily plus aspirin (n = 9,152) vs. rivaroxaban 5 mg twice daily alone (n = 9,117) vs. aspirin alone (n = 9,126).

Among patients with stable atherosclerosis, rivaroxaban plus aspirin was associated with fewer adverse cardiovascular events, but more major bleeding events compared with aspirin alone. Net clinical benefit favored the use of rivaroxaban plus aspirin, especially for high-risk groups.

Rivaroxaban alone was not more effective than aspirin alone. Rivaroxaban plus aspirin compared with aspirin alone was associated with a reduction in all strokes and ischemic strokes. Rivaroxaban alone compared with aspirin alone was not associated with a reduction in all strokes. Hemorrhagic strokes were very low in all treatment groups; however, there was a nonsignificant increase in this outcome for rivaroxaban plus aspirin compared with aspirin alone, and a significant increase in this outcome for rivaroxaban alone compared with aspirin alone. Findings were the same among those with PAD, lower extremity PAD, CAD, heart failure, diabetes, women, and obesity.

Answer 278

COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies)

Rivaroxaban plus aspirin was effective at preventing both MACE and MALE among those with PAD. Bleeding is an important outcome; therefore, net clinical benefit will need to be carefully considered with this strategy. GI and GU bleeding should stimulate a search for a new cancer diagnosis in the same organ. Rivaroxaban plus aspirin (or rivaroxaban alone) was ineffective at improving bypass graft patency rates.

Question 279

At present, we recommend that hormone therapy with _____should not be started after STEMI and should be discontinued in post- menopausal women after STEMI.

Answer 279

Estrogen plus progestin

Question 280

We do not recommend the routine use of calcium antagonists for the secondary prevention of MI.A possible exception is a patient who cannot tolerate a beta blocker because of adverse effects on _____.Such patients may be candidates for a rate-slowing calcium antagonist such as diltiazem or verapamil.

Answer 280

bBonchospastic lung disease but who has well-preserved LV function