Acute Coronary Syndrome Flashcard 2

D. Rationale: In patients with acute MI and cardiogenic shock, multiple studies show that interventional revascularization (both PCI and CABG) is superior to fibrinolytic therapy (such as tPA) in terms of long-term survival. However, multiple vessel disease typically cannot be treated with PCI. CABG is the better management for patients with extensive disease. Clopidogrel is an adjunct therapy shown to improve outcomes when used in conjunction with fibrinolytic or interventional revascularization. It does not replace these treatments.

D. Rationale: Patients with cardiac arrest secondary to coronary artery disease must undergo coronary angiography after resuscitation to identify and address the coronary artery obstruction.

B. Rationale: Clopidogrel has been shown to decrease morbidity and mortality (decreased infarct size and stroke risk) in STEMI patients when combined with PCI. This was combined with a slight increase in major bleeding events. Heparin, both unfractionated and low-molecular-weight, should not be given to patients with thrombocytopenia. Also, patients over age 75 have an increased risk of major bleeding events and intracranial hemorrhage. IV beta-blockers can be useful in STEMI as they reduce mortality and morbidity. However, they are contraindicated in bradycardia and AV block due to their effect on nodal conduction.

D. Rationale: The fibrinolytic checklist provides a list of absolute contraindications to fibrinolysis that increase the risk of the procedure to unacceptable levels or reduce the likelihood of benefit of therapy. Patients who present at > 24 hours after onset of symptoms do not derive a benefit from fibrinolysis and should not receive the therapy. Other contraindications include intracranial hypertension and bleeding diatheses. Allergy to aspirin does not preclude fibrinolytic therapy, the risk of thrombotic events may be increased if aspirin is not given. Delay to PCI access (> 90 minutes) will make fibrinolysis preferred, and age > 75 would make PCI preferred. However, neither are considered absolute contraindications to therapy.

B. Rationale: A negative troponin between 0 and 2 hours and a low TIMI risk score provides a lower than 1% risk of ACS in the next 30 days. All of these men have a negative troponin. However, as troponin levels may elevate several hours after symptom onset, this is not enough to determine low risk. The TIMI score looks at comorbidities, pain symptoms, ECG findings, age, and risk factors. A score > 1 increases the risk of ACS in the next 30 days. Only the man with over three CAD risk factors and ST changes of 0.5 mm or more has a TIMI score > 1. He is at increased risk for short-term ACS. CAD risk factors include family history, hypertension, hyperlipidemia, diabetes, and current smoking status.