CAD (23%)

Question 1

What is the next management step for a patient with NSTEMI and high risk criteria such as elevated biomarkers, ECG abnormalities, elevated TIMI risk score?

Answer 1

Coronary angiography within 48 hours followed by percutaneous intervention/surgical revasc if indicated.

Question 2

What is a Class IA recommendation for post-MI patients done as an outpatient after discharge?

Answer 2

Cardiac rehabilitation

Question 3

What is the genetic classification for familial hypercholesterolemia?

Answer 3

Most common: Monogenic Autosomal Dominant

(defect in gene that encodes the apo B/E (LDL) receptor.

Question 4

What is the most common genetic defect for Familial Hypercholesteralemia?

Answer 4

Defect in the gene that encodes the apo B/E (LDL) receptor.

Question 5

What is the frequency range for myalgia symptoms in statin use?

Answer 5

5-10%

Question 6

Of myalgia/myopathy/rhabdomyolysis: which one:

Muscle symptoms without CPK elevation?

Answer 6

myalgia

Question 7

Of myalgia/myopathy/rhabdomyolysis: which one:

Muscle symptoms with CPK >10x ULN.

Answer 7

myopathy

Question 8

Of myalgia/myopathy/rhabdomyolysis: which one:

Muscle symptoms with marked CPK elevation typically >10 ULN with creatinine elevation and often with urinary myoglobin?

Answer 8

Rhabdomyolysis (<0.1%)

Question 9

What is the reversal agent for bivalirudin?

Answer 9

Prothrombin Complex

Question 10

In ACS with planned PCI, which antiplatelet medication should never be given if there is a history of TIA/CVA?

Answer 10

Prasugrel
Prasugrel cannot be given to patients with a prior history of TIA/CVA as an absolute contraindication (TRITON-TIMI 38 - net harm was demonstrated)

Question 11

In patients with metabolic syndrome, what is the particle size of LDL (normal, larger than normal, smaller than normal) ?

Answer 11

Smaller than normal.
The LDL particle sizes in metabolic syndrome are smaller and denser, and are more atherogenic than normal sized particles.

Lipid characteristics in metabolic syndrome:

1. Small, dense LDL particles
2. Elevated serum endothelin
3. Elevated homcysteine level
4. Low HDL

Question 12

Which of the statins has been seen to reduce the incidence of diabetes?

Answer 12

Pravastatin

Question 13

What is the incidence of heterozygous Familial Hypercholesterolemia?

Answer 13

1 in 500 persons
Also remember FH is autosomal dominant.
(Homozygous FH: 1 in 1 million individuals)

Question 14

What is the recommended minimum duration of DAPT in patient with BMS or DES after NSTEMI?

Answer 14

12 months.

Aspirin indefinitely

Question 15

What is the Duke Treadmill score range for Intermediate Risk?

Answer 15

-10 to +4

Question 16

What is Incidence of Familial combined hyperlipidemia?

Answer 16

1 in 33 to 1 in 100.

• Arcus cornea and xanthelasma can be seen.
• Xanthomas are rarely present (unlike heterozyg FH)
• Think of this with TC 250-350, overweight, hypertension, insulin resistance, TG >140

Question 17

What is the normal coronary artery response to intracoronary acetylcholine?

Answer 17

Vasodilation

Question 18

What is the response to coronary arteries to intracoronary acetylcholine in the setting of endothelial dysfunction?

Answer 18

Vasoconstriction

normal coronary arteries will vasodilate with Ach

Question 19

What is the type of myocardial infarction suggested by elevated JVP, clear lung auscultation, and ECG with ST segment elevation in leads II/III/aVF ?

Answer 19

Inferior wall MI with right ventricular infarction.

Question 20

What is the major result of this study?

PROVE-IT/TIMI-22

Answer 20

Post-MI patients treated with more potent statin atorvastatin vs pravastatin had a 16% relative risk reduction.

Question 21

What is the major result of this study?

JUPITER

Answer 21

Patients without documented CAD and median LDL of 108, rosuvastatin offered a greater benefit in patients with CRP>2

Question 22

What is the major result of this study?

WOSCOPS, AFCAPS/TexCAPS (in general)

Answer 22

Statins reduce CVD events at approximately 1% reduction in CVD events for every 1% reduction in LDL
WOSCOPS and AFCAPS/TexCAPS were primary prevention trials.

Question 23

What is the major result of this study?

4S, CARE, PIPID, HPS (in general)

Answer 23

Statins reduce secondary events.

These are secondary prevention trials.

Question 24

What are the ages in male and female relatives for which cardiac risk factors are calculated?

Answer 24

Male relative less than 55 years old.

Female relatives less than 65 years old.

Question 25

What is the clinical significance of a diagonal crease in the earlobe from tragus to the lobule at a 45 degree angle?

Answer 25

Increased risk of premature coronary artery disease.
This is Frank’s Sign.
It is thought to indicate premature aging and loss of dermal and vascular elastic fibers.

Question 26

Which post-MI mechanical complication is this?
Inferior MI s/p TPA. Dyspnea 12 hrs later, lying supine.
New systolic thrill, large V wave on PCWP tracing.

Answer 26

Acute VSD

“Patient lying flat is acute VSD”

Question 27

In Post-MI mechanical complications, which papillary muscle is more prone to rupture?

Answer 27

Posteromedial papillary muscule.
Because it has a single blood supply (only from PDA)
Easier to knock out the PM pap.

Question 28

Which Post MI mechanical complication:

Flash pulmonary edema occurring between 2 and 7 days after MI

Answer 28

Papillary Muscle Rupture
<1% of infarcts
Can occur with subendocardial infarcts.
Tends to be the PM pap muscle (single blood supply- the PDA)
Causes acute severe torrential MR
May not have a murmur because happens rapidly.

Question 29

What is the urgent treatment needed for acute papillary muscle rupture?

Answer 29

URGENT SURGERY.
The clock is ticking.
(may be able to temporize while waiting for OR with IABP)

Question 30

Which Post MI mechanical complication?
Occurs 3-5 days after infarction, but can be within 1st 24 hours particularly in patients who have been treated with fibrinolytic therapy. Harsh systolic murmur.
“Precordial Thrill”. Patient lying flat.

Answer 30

VSD

Question 31

Which Post-MI mechanical complication:

New Murmur, patient lying flat.

Answer 31

Acute VSD

Question 32

CAD s/p MI, EF 38%, nonsustained VT on holter, Class II CHF. Recs?

Answer 32

EP study for sudden cardiac death risk stratification, ICD if sustained VT is induced
(EF is over 35%, so does not meet implant criteria on own)

Question 33

In patients with established stable CAD, is there a benefit to add clopidogrel to aspirin?

Answer 33

No significant benefit.

CHARISMA trial. Had increase moderate bleeding in asa/clopidogrel

Question 34

What is the reversal agent for hirudin?

Answer 34

Prothrombin Complex