Of the following statements regarding a patient with multiple cardiac risk factors and angina-like chest pain lasting 30 min, which is the incorrect one?

1. A normal echocardiogram (ECG) in the emergency room (ER) rules out myocardial infarction (MI)
   
2. Ischemia in circumflex area is more often electrically silent
   
3. Negative first set of cardiac markers does not rules out MI
   
4. ECG changes could be dynamic, and it is useful to repeat every 15 min in the first hour of chest pain or when chest pain recurs

The components of thrombolysis in MI (TIMI) risk score on initial patient evaluation for suspected acute coronary syndrome (ACS) include which of the following?

1. Age >65 years
   
2. More than three coronary artery disease (CAD) risk factors
   
3. Prior CAD with >50% lesion
   
4. More than two anginal events in 24 h
   
5. Use of aspirin in last 7 days
   
6. ST deviation on ECG
   
7. Elevated cardiac markers
   
8. All of the above
   
9. Some of the above

Which of the following types of chest pain rule out ACS?

1. Sharp stabbing chest pain
   
2. Pleuritic chest pain
   
3. Chest pain reproduced by palpation
   
4. None of the above

Guideline recommendation for ECG for patients presenting with chest pain to the ER is performance of ECG within how much time of arrival?

1. 5 min
   
2. 10 min
   
3. 30 min
   
4. 60 min

The GRACE risk model predicts in hospital mortality in ACS patients and includes Killip class, systolic blood pressure (BP), heart rate, age, and serum creatinine level. Which one of the following may be negatively correlated with mortality?

1. Heart rate
   
2. Systolic BP
   
3. Killip class
   
4. None of the above

Which of the following are contraindications for NTG in patients with ACS and continuing chest pain?

1. Systolic BP <90 mmHg
   
2. Inferior MI with positive Kussmaul
   
3. Sildenafil or vardenafil within 24 h
   
4. Tadalafil within 48 h
   
5. All of the above
   
6. None of the above

Regarding use of traditional nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors in the setting of ACS, which of the following statements is correct?

1. Traditional NSAIDs, but not COX-2 inhibitors can be used
   
2. Traditional NSAIDs should be used, but COX-2 inhibitors can be used
   
3. Neither traditional NSAIDs nor COX-2 inhibitors should be used
   
4. Either can be used with no risk of harm

Which calcium channel blockers are contraindicated in ACS?

1. Diltiazem
   
2. Verapamil
   
3. Short-acting nifedipine without a beta blocker
   
4. None of the above

The first dose and route of aspirin use in suspected ACS is which of the following?

1. 162 or 325 mg enteric coated
   
2. 162 or 325 mg nonenteric coated chewed
   
3. 81 mg orally
   
4. None of the above

Aspirin in suspected ACS is avoided in which of the following patients?

1. Aspirin allergy
   
2. Recent gastrointestinal bleed
   
3. Neither A nor B
   
4. Both A and B

For patients with ACS, what is the recommended duration of double antiplatelet therapy (DAPT)?

1. 1 month
   
2. 6 months
   
3. 1 year
   
4. Forever, unless at high risk of bleeding

After NSTEMI, in addition to ASA, Plavix, beta blocker, and high-intensity statin therapy, which other agents are recommended for those with ejection fraction (EF) <40%?

1. Angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs) in those who are ACEI intolerant
   
2. Aldosterone blocking agent, provided creatinine is <2 mg/dL and K is <5 meq/L
   
3. Diltiazem to prevent reinfarction
   
4. A and B
   
5. A and C

In a patient with non-ST elevation ACS, early coronary angiography is appropriate in which of the following situations?

1. TIMI score of 5
   
2. Continuing chest pain
   
3. EF <40%
   
4. Anterior wall motion abnormality
   
5. Dynamic mitral regurgitation (MR) murmur
   
6. All of the above

Based on current data, which of the following statements are correct in the setting of ACS?

1. In the setting of ST elevation MI (STEMI), nonculprit vessels should not be stented
   
2. In the setting of NSTEMI, it is reasonable to perform percutaneous coronary intervention (PCI) on critically stenosed nonculprit vessels as well
   
3. Both A and B are correct
   
4. Neither A or B are correct

Which of the following statements are correct re prasugrel use?

1. It is used 10 mg once a day.
   
2. It reduces risk of stent thrombosis compared with clopidogrel
   
3. It has a higher risk of bleeding in those above 75 years of age or weigh <60 kg
   
4. It is contraindicated in those with prior stroke or transient ischemic attack (TIA)
   
5. All of the above
   
6. None of the above

Which of the following should not be used as the sole anticoagulant during PCI?

1. Fondaparinux
   
2. Enoxaparin
   
3. Bivalirudin
   
4. None of the above

Which of the following statements are accurate re the duration of stoppage of antiplatelet drugs before elective coronary artery bypass grafting?

1. Clopidogrel for 5 days
   
2. Prasugrel for 7 days
   
3. Eptifibatide and tirofiban for 2–4 h
   
4. Abciximab for 12 h
   
5. All of the above

Before coronary artery bypass grafting, which of the following statements is correct?

1. Aspirin should be stopped a week earlier
   
2. Aspirin should not be stopped
   
3. Aspirin should be stopped 24 h before
   
4. None of the above

Which of the following statements are accurate regarding triple antithrombotic therapy after MI?

1. The duration should be minimized
   
2. Concomitant proton pump inhibitors should be used
   
3. Triple therapy should not be used
   
4. A and B are correct

Which of the following agents are useful for secondary prevention post MI?

1. Vitamin E
   
2. Folic acid
   
3. Beta carotene
   
4. Fish oil
   
5. None of the above

Which of the following statements are true for older patients with non-ST elevation ACS?

1. They may have atypical symptoms
   
2. Benefit with medical and catheter-based therapies is similar to younger patients
   
3. They get less guideline-directed medical therapy
   
4. None of the above
   
5. All of the above

Compared with men, women presenting with ACS have which of the following?

1. More atypical symptoms
   
2. Greater chance of getting discharge from the ER
   
3. Higher risk of long-term complications such as heart failure (HF), shock, renal failure, stroke, readmission
   
4. All of the above
   
5. None of the above

Compared with men, women presenting with ACS have which of the following?

1. Greater incidence of normal coronary arteries
   
2. Higher percentage of normal EF
   
3. Fewer high-risk lesions
   
4. Same benefit with medicines
   
5. All of the above
   
6. None of the above

In ACS due to cocaine use, it is preferable to avoid which of these agents?

1. Heparin
   
2. Beta blocker
   
3. ACEI
   
4. None of the above

Which of the following are true re use of early glycoprotein (GP) IIb/IIIa inhibitor in the setting of acute STEMI receiving DAPT?

1. There is no clear benefit in terms of MI or death during follow-up
   
2. No clear evidence for a decrease in target vessel revascularization
   
3. There is evidence for rapidity of ST segment resolution, but not for improvement in TIMI grade 3 flow
   
4. All of the above

Adjunctive GP IIb/IIIa inhibitors are recommended in addition to DAPT and heparin in acute STEMI setting in which of the following situations?

1. At time of primary PCI
   
2. Routinely in the ER
   
3. Those with large thrombus burden
   
4. All of the above
   
5. At time of primary PCI or those with large thrombus burden

For a patient presenting with STEMI to a non-PCI facility, which of the following factors support immediate thrombolytic therapy?

1. Presentation within 4 h of chest pain
   
2. Low-risk STEMI
   
3. Low bleeding risk with thrombolysis
   
4. PCI facility is far away
   
5. All of the above
   
6. There is no indication for thrombolysis; transfer to PCI facility

A 68-year-old man presents to a non-PCI facility with anterior STEMI with ST elevation from V2 to V5. He is short of breath with bilateral rales. Chest pain started 4 h earlier. He had a TIA 6 weeks earlier and is on clopidogrel and statin. Estimated transport time to nearest catheterization laboratory is 75 min. After giving O₂, nitroglycerin (NTG), ASA, and heparin, what is the best next strategy?

1. Immediate transfer to the PCI facility
   
2. Give half-dose thrombolytic and then transfer
   
3. Patient is too high risk to transfer; give full-dose thrombolytic
   
4. None of the above

A 64-year-old man presents to a non-PCI facility with anterior STEMI with ST elevation from V2 to V4. He is short of breath with bilateral rales. Chest pain started 3 h earlier. He is on aspirin and statin. Estimated transport time to nearest catheterization laboratory is 4 h. There are no contraindications for thrombolytic therapy. After giving O₂, NTG, ASA chewed, and heparin, what is the best next strategy?

1. Full-dose thrombolytic and transfer to PCI facility
   
2. Half-dose thrombolytic and transfer to PCI facility
   
3. Immediately transfer to PCI facility
   
4. Treat medically as the patient is high risk to transfer

In patients presenting with acute MI, which of the following plasma glucose targets are desirable?

1. Tight control with glucose <110 mg/dL
   
2. Liberal control with glucose <300 mg/dL
   
3. Glucose <180 mg/dL
   
4. None of the above

A 65-year-old patient with diabetes mellitus and hypertension had an acute anterior MI treated within 4 h of chest pain with drug-eluting stent (DES) in left anterior descending (LAD) artery. He is stable. Serum creatinine is 1.3 mg/dL; creatine clearance 60 mL/min. His home medications include aspirin, glybenclamide, metformin, and lisinopril. What would the appropriate actions be?

1. Start on insulin infusion 1 unit per hour and titrate to blood glucose <180 mg/dL
   
2. Continue current medications
   
3. Discontinue metformin
   
4. Discontinue lisinopril

Which of the following statements regarding thrombus aspiration are accurate in patients with acute MI undergoing PCI?

1. It is reasonable to perform in those presenting early and have large thrombus burden
   
2. It may not be useful in those presenting late
   
3. It is not useful in side branches subtending small myocardial territories
   
4. All of the above
   
5. None of the above

A 52-year-old man with no prior cardiac history presented with chest pain of 4 h and found to have acute anterior STEMI. He lost his job and medical insurance recently. He was on lisinopril and simvastatin. After administering aspirin and NTG, an immediate coronary angiography revealed a 90% lesion in the mid LAD artery with a reference diameter of 4 mm. The lesion length was 6 mm and type B. Other vessels were angiographically normal. What would the most appropriate therapy be?

1. A DES
   
2. A bare-metal stent (BMS)
   
3. Either
   
4. Immediate single-vessel bypass using left internal mammary artery on beating heart

In acute STEMI qualifying for reperfusion therapy, which of the following options is correct?

1. Desired door to needle is ≤30 min and door to balloon time is ≤90 min
   
2. Desired door to needle and door to balloon times are ≤90 min
   
3. There is no indication for thrombolysis
   
4. None of the above

Which of the following strategies may reduce time to reperfusion therapy in acute STEMI?

1. Media campaign to educate patients on signs of MI
   
2. Prehospital ECG
   
3. Use of 9-1-1 rather than being driven to the ER by a family member
   
4. An ER MI protocol
   
5. All of the above

In acute STEMI, fibrinolysis is preferred over primary PCI in which of the following situations?

1. Early presentation, ≤3 h
   
2. Catheterization laboratory is not available or expert operator is not available
   
3. Predicted (door to balloon)–(door to needle) time is greater than 60 min
   
4. Medical contact to balloon or door to balloon time is likely to be >90 min
   
5. All of the above

In acute STEMI, primary PCI is preferred over fibrinolysis in which of the following situations?

1. Late presentation, >3 h of chest pain
   
2. Heart failure or cardiogenic shock
   
3. Contraindication to thrombolytics
   
4. Diagnosis of STEMI is in doubt
   
5. All of the above

Absolute contraindications for thrombolytics include which of the following?

1. Prior intracranial hemorrhage
   
2. Ischemic stroke within 3 months (except acute stroke <3 h)
   
3. Closed head or facial trauma in last 3 months
   
4. Cerebral arteriovenous malformation, berry aneurysm, or neoplasms
   
5. All of the above
   
6. Above are only relative contraindications and decision depends upon risk/benefit ratio

Relative contraindication for thrombolytics include which of the following?

1. Systolic BP >180 mmHg or diastolic BP >110 mmHg
   
2. Prolonged cardiopulmonary resuscitation or major surgery in <3 weeks
   
3. Pregnancy
   
4. Current anticoagulant use
   
5. Noncompressible vascular punctures
   
6. All of the above
   
7. Some of the above

Which of the following statements about tissue plasminogen activator (tPA) are true?

1. It acts more rapidly than streptokinase
   
2. It acts better in the presence of fibrin; in its absence it is a weak plasminogen activator
   
3. It is a surface-active agent
   
4. Generally, dose for STEMI is 15 mg bolus + 50 mg over 30 min + 35 min over 60 min
   
5. All of the above
   
6. Some of the above

GUSTO-1 was a landmark trial that compared front-loaded alteplase with streptokinase in acute STEMI within 6 h. What were the findings?

1. Reduced death with alteplase
   
2. Reduced myocardial reinfarction with alteplase
   
3. Trend to increased intracranial bleed with streptokinase
   
4. All of the above

A 48-year-old man with acute inferior MI has a heart rate of 74 bpm, BP of 90/60 mmHg. There are no murmurs. The jugular venous pressure is 16 cmH₂O and the column seems to rise during quiet breathing. The lungs are clear. What would the appropriate treatment for low BP include?

1. Intravenous bolus of normal saline
   
2. Normal saline and dobutamine infusion if BP is still low
   
3. Intravenous Lasix
   
4. Infusion of norepinephrine

A 52-year-old man with reperfused (with PCI with DES) acute anterior MI got recurrent chest pain, more on breathing, associated with an increase in ST elevation leads V2 to V5 on day 3. What may this indicate?

1. Stent thrombosis
   
2. Dressler’s syndrome
   
3. Chemical pericarditis
   
4. Potential for myocardial rupture

In what is left ventricle free wall rupture in the presence of acute MI more common?

1. Elderly
   
2. Women
   
3. Those without prior infarcts
   
4. Large infarcts
   
5. Reperfusion with lytics rather than PCI
   
6. All of the above
   
7. Some of the above

Which of the following are true about left ventricle free wall rupture?

1. It tends to occur at the junction of infarct and normal muscle
   
2. Generally occurs after 1–4 days of infarct, but can occur as late as 3 weeks
   
3. Usually occurs in left ventricle, but may involve right ventricle or atria
   
4. All of the above