Cardiology Intensive Board Review, 3th Edition

Chapter 4 - Coronary Artery Disease

Baris Gencer, Debabrata Mukherjee, Marco Roffi

QUESTIONS

1.A 67-year-old man presents to the emergency room with increasing frequency of chest pain on exertion and one episode of rest pain lasting 15 minutes the day of admission. Other than for hypertension and hyperlipidemia his medical history is unremarkable. He quit smoking (1 pack a year for 20 years) 11 years ago. On physical examination he is afebrile, his pulse is 78 bpm, and his blood pressure is 138/76 mmHg. Cardiac and pulmonary auscultations are unremarkable. His current medications include aspirin, metoprolol, ramipril, and atorvastatin. The electrocardiogram (ECG) at admission reveals deep T-wave inversion in the precordial leads and no pathologic Q waves. You admit the patient to the hospital and start intravenous (IV) unfractionated heparin (UFH) and nitroglycerine. The first available serum troponin I level is 1.4 μg/L (upper limit of normal, 0.09 μg/L). Cardiac echocardiography shows an anterior and apical hypokinesia with mildly depressed left ventricular function. The next step in his management would be

a.low-level exercise stress ECG next morning.

b.to continue IV heparin and nitroglycerin, increase β-blocker, and add a calcium antagonist until completely free of chest pain for 24 hours, then discharge home.

c.coronary angiography within 48 hours followed by percutaneous intervention/surgical revascularization if indicated.

d.dobutamine echocardiogram or myocardial perfusion scan within 48 hours.

e.continue IV heparin and nitroglycerin, increase β-blocker, and add a calcium antagonist until completely free of chest pain for 24 hours, then transfer to a cardiac rehabilitation program.

2.A 57-year-old man presenting with unstable angina (UA) was successfully treated with percutaneous coronary intervention (PCI) of a significant lesion of the right coronary artery (RCA) in the presence of a normal left ventricular ejection fraction (LVEF). He is referred for cardiac rehabilitation program. What is the expected benefit?

a.Reduced risk of stent restenosis

b.Lower rate of hospital readmission

c.Reduction in maximal O2

d.Higher event rate related to exercise

e.Reduced risk of stent thrombosis

3.A 66-year-old man with stable angina at low exertion level was investigated with coronary angiography that showed an isolated significant lesion (70%) of the ostium and mid-portion of the left main coronary artery in the presence of a normal left ventricular function. What is the correct statement regarding the recommended approach?

a.Heart team discussion between the interventional cardiologist and the cardiac surgeon to select the best treatment option is the recommended approach.

b.Coronary artery bypass grafting (CABG) is the recommended approach for all patients with left main disease.

c.PCI is the recommended approach for all patients with left main disease.

d.A calculation of the Society of Thoracic Surgeons (STS) and SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) scores is not recommended at this stage.

e.The choice of treatment is independent of the clinical presentations (stable angina or acute coronary syndromes [ACSs]).

4.A 58-year-old man with coronary artery disease (CAD) and severe chronic obstructive pulmonary disease (COPD) with forced expiratory volume in the first second of expiration (FEV1)/forced vital capacity <0.74 with FEV1<40% predicted had stenting of the mid-left anterior descending artery (LAD) 10 months prior to admission with a 3.0 mm × 24 mm bare metal stent (BMS). He presents now with recurrent angina despite intensified medical treatment, and coronary angiography reveals a severe and diffuse in-stent restenosis (ISR). A reasonable next therapeutic option would be

a.plain balloon angioplasty.

b.coronary artery bypass surgery.

c.drug-eluting stent (DES) implantation (stent-in-stent).

d.medical therapy.

e.brachytherapy.

5.A 66-year-old man had in the last few months sporadic episodes of chest pain on exertion. His cardiovascular (CV) risk factors included diabetes, hypertension, and hypercholesterolemia. He had no other comorbidity. Coronary angiography revealed a lesion of 60% of the RCA in addition to multiple nonsignificant plaques affecting the three coronary arteries. The fractional flow reserve (FFR) of the RCA (0.0.85) and LVEF were normal. What is the recommended treatment for this patient?

a.CABG is the first recommended approach as the risk of surgical procedure is low.

b.PCI is the first recommended approach as the SYNTAX score is low.

c.Perform an additional imaging (myocardial perfusion scan or magnetic resonance [MR] perfusion scan) in addition to optimal medical management.

d.Guideline-directed medical therapy is the first recommended approach.

e.Repeat coronary angiography after 6 months to exclude disease progression in addition to optimal medical management.

6.A 58-year-old male smoker treated for hypertension complained about chest pain on exertion in the preceding 4 weeks. To investigate the clinical symptoms, you performed a stress perfusion cardiac magnetic resonance showing hypoperfusion during IV administration of adenosine. Which area of the myocardium is more vulnerable to hypoperfusion?

a.Subepicardium

b.Mid-myocardium

c.Subendocardium

d.Pericardium

e.All of the above

7.A 73-year-old man presents to the emergency room with severe mid-sternal chest discomfort. He appears anxious and in distress. His heart rate is 66 bpm, blood pressure is 92/68 mmHg, and respiratory rate is 14. There is marked jugular venous distention. Cardiac auscultation is unremarkable and the lungs are clear. ECG reveals 2-mm ST-segment elevation in leads II, III, and aVF. The most likely diagnosis is

a.acute pericarditis.

b.acute aortic dissection.

c.pneumothorax.

d.inferior wall myocardial infarction (MI) with right ventricular infarction.

e.pneumonia.

8.A 65-year-old hypertensive man was hospitalized for non-ST-segment-elevation myocardial infarction (NSTEMI). The clinical examination shows a fourth heart sound (S4). What is expected to be found at the echocardiography?

a.Reduction in left ventricular compliance

b.Rapid deceleration of transmitral flow during protodiastolic filling of the left ventricle

c.Increased inflow into the left ventricle

d.Reduced left ventricular systolic function

e.Aortic sclerosis

9.A 66-year-old man known for diabetes mellitus treated with oral glucose lowering medications presents with UA. Coronary angiography reveals a three-vessel disease: 70% mid-LAD lesion, complex, long, and calcified; 70% focal proximal left circumflex artery (LCX) stenosis; and 70% focal mid-RCA lesion. A hybrid coronary revascularization was proposed. All the following statements are correct regarding hybrid coronary revascularization, with the exception of one.

a.Hybrid revascularization is defined as the planned combination of surgical and percutaneous revascularization (typically left internal mammary artery [LIMA]-to-LAD and PCI of ≥1 additional vessel).

b.Hybrid revascularization is reasonable in patients with limitations to traditional CABG, such as heavily calcified proximal aorta.

c.Hybrid revascularization is reasonable in patients with lack of suitable graft conduit.

d.Hybrid revascularization is reasonable in patients with unfavorable LAD artery for PCI.

e.Hybrid revascularization mandates surgical and percutaneous revascularization during the same procedure.

10.A 57-year-old female smoker presents to the emergency department for an ongoing new typical chest pain lasting 30 minutes. The physical examination is unremarkable and she is hemodynamically stable. The ECG reveals T inversion in II, III, and aVF leads. Which of the following biomarker elevation has been associated with an improved benefit of ticagrelor therapy over clopidogrel in patients hospitalized with ACS?

a.Ultrasensible C-reactive protein

b.Interleukin-6

c.High-sensitive troponin T (Hs-TnT)

d.D-dimers

e.Lactate dehydrogenase

11.A 58-year-old man known for a metabolic syndrome shows increasing frequency of chest pain on exertion in the preceding 2 weeks. Resting ECG did not show significant abnormalities. Which of the exercise parameters are associated with adverse prognosis?

a.Duration of symptom-limiting exercise <5 METs (metabolic equivalents)

b.Failure to increase systolic blood pressure ≥120 mmHg, or a sustained decrease ≥10 mmHg, or below rest levels, during progressive exercise

c.ST-segment depressions ≥2 mm

d.Angina pectoris at low exercise workloads

e.All of the above

12.A 58-year-old man presented stable chest pain on moderate effort exertion in the preceding 12 months. The medical history is relevant for hypertension and hyperlipidemia. His current treatment includes lisinopril, atorvastatin, metoprolol, and aspirin. He is addressed for coronary angiography that showed a 70% to 90% lesion of the LCX successfully treated with PCI with a placement of a DES. The LVEF was normal. What was the expected benefit of a PCI over a medical therapy?

a.Decrease of total mortality

b.Decrease of CV mortality

c.Decrease of MI

d.Decrease of heart failure events

e.No improvement of any of the mentioned endpoints

13.The same patient was investigated with stress imaging before and after PCI to assess the extension of myocardial ischemia. Which of the following statements is correct regarding the benefit of PCI over medical therapy in this setting?

a.A greater reduction in the extension of residual myocardial ischemia

b.A greater resolution of angina episodes

c.An increased benefit of ischemia reduction in patients with extensive ischemic areas at baseline

d.A greater improvement in symptoms

e.All of the above

14.A 63-year-old man has been successfully treated with percutaneous coronary revascularization for a stable angina pectoris. His low-density lipoprotein cholesterol (LDL-C) value was 143 mg/dL. Which of the following statement is incorrect regarding the impact of prescribing intensive lipid-lowering therapy (e.g., 80 mg atorvastatin daily) compared with less intensive therapy (e.g., 10 mg atorvastatin daily)?

a.Higher LDL-C level reduction

b.Significant absolute risk reduction of major adverse cardiovascular events (MACE) of ~2% over 5 years

c.Significant relative risk reduction of MACE of ~20% over 5 years

d.Increased incidence of persistent liver aminotransferase levels of 1%

e.Significant reduction of overall mortality

15.A 67-year-old man is treated with PCI. Which of the following statement is not correct regarding periprocedural anticoagulation?

a.An anticoagulant should be administered to all patients undergoing PCI.

b.Administration of IV UFH is useful in patients undergoing PCI.

c.An additional dosage of IV enoxaparin should be administered at the time of PCI to patients who received the last subcutaneous dose of enoxaparin 12 hours or more prior to PCI.

d.The appropriate diagnostic test to check for the level of anticoagulation with UFH during PCI is the activated clotting time.

e.Fondaparinux might be used as the sole anticoagulant to support PCI.

16.A 65-year-old male hypertensive smoker benefited from primary PCI of the RCA for inferior STEMI. Which of the following statements is not correct regarding secondary prevention in this patient?

a.Medically supervised cardiac rehabilitation programs are recommended.

b.Blood pressure should be controlled with a goal of <140/90 mmHg.

c.Statin therapy should be uptitrated to achieve an LDL-C <70 mg/dL

d.Smoking cessation program should be proposed.

e.Even in the absence of symptoms, routine periodic stress testing is indicated.

17.A 60-year-old male patient was treated 2 years earlier with PCI and the implantation of BMS in the LAD for NSTEMI. He complains about recurrent worsening exertional chest pain in the last week. Coronary angiography reveals ISR. What are the predisposing factors for BMS restenosis?

a.Diabetes

b.Increasing stent length

c.Increasing stent number

d.Decreasing stent diameter

e.All of the above

18.A 60-year-old healthy colleague on no medication with an LDL-C level of 123 mg/dL and High-sensitivity C-reactive protein (hs-CRP) level >2.0 mg/L asked to you whether he should take rosuvastatin 20 mg a day. Which of the following statements is incorrect regarding JUPITER trial?

a.Rosuvastatin 20 mg/day reduced LDL-C levels by 50%.

b.Rosuvastatin 20 mg/day significantly decreased the incidence of MI.

c.Rosuvastatin 20 mg/day reduced hs-CRP by 37%.

d.Rosuvastatin 20 mg/day did not significantly decrease the incidence of stroke.

e.Rosuvastatin 20 mg/day significantly increased the incidence of physician-reported diabetes.

19.A 65-year-old man with diabetes presented typical chest pain on exertion in the previous 2 months. Coronary angiography revealed significant complex multivessel coronary disease (SYNTAX score, 34). What is the expected benefit of a revascularization with CABG versus PCI?

a.CABG is associated with a reduction of death only.

b.CABG is associated with a reduction of stroke only.

c.CABG is associated with a reduction of death and of MI, but not of stroke.

d.CABG is associated with a reduction of all following individual endpoints: stroke, myocardial infraction, and death.

e.CABG is associated with a reduction of MI only.

20.A 41-year-old male smoker was admitted for STEMI and quitted smoking after hospitalization. Which of the following statements is incorrect regarding smoking cessation?

a.Smoking cessation reduces the relative risk of total mortality by >30% over a mean follow-up of 5 years.

b.Smoking cessation reduces the relative risk of nonfatal MI by >30% over a mean follow-up of 5 years.

c.More than 70% of patients quit smoking after ACS.

d.Smoking cessation counseling program is effective to help smokers to quit smoking.

e.Smoking cessation counseling program should be proposed during hospital stay and continued after discharge.

21.Six hours after the start of chest pain, a 55-year-old diabetic man was admitted to the emergency department for anterior STEMI with hemodynamic instability (cold extremities, heart rate of 110 bpm and blood pressure of 85/50 mmHg) and severe reduced LVEF (25% to 30%) estimated by echocardiography. What is the correct statement regarding the decision to perform an emergent revascularization versus an initial medical stabilization according to the SHOCK trial?

a.Significant reduction of mortality with early revascularization compared with intensive medical therapy at 30 days

b.No significant difference of mortality with early revascularization compared with intensive medical therapy at 30 days

c.Significant reduction with intensive medical therapy compared with early revascularization at 30 days

d.Significant reduction of mortality with early revascularization compared with intensive medical therapy at 6 months

e.Answers b and d are correct

22.A 63-year-old man known for chronic kidney disease (CKD) due to long-term uncontrolled hypertension is hospitalized for elective coronary angiography. Which of the following statements is not correct?

a.Patients with CKD undergoing cardiac catheterization should receive adequate preparatory hydration.

b.In patients with CKD, the volume of contrast should be minimized.

c.Administration of N-acetyl-cysteine is useful for the prevention of contrast-induced acute kidney injury (AKI).

d.Contrast-induced AKI is one of the leading causes of hospital-acquired AKI.

e.In elective cases, patients should be assessed for risk of contrast-induced AKI before coronary angiography.

23.A 45-year-old man benefited from primary PCI for STEMI. The adjunctive antithrombotic therapy consisted of aspirin, heparin, and abciximab. The addition of abciximab is associated with

a.no significant difference in the risk of stroke.

b.a significant increase in the risk of stroke.

c.a significant decrease in the risk of stroke.

d.a significant decrease of nonhemorrhagic stroke only.

e.a significant increase of hemorrhagic stroke only.

24.A 65-year-old diabetic man known for a multivessel coronary disease underwent revascularization with CABG. What is the target LDL-C that should be aimed?

a.160 mg/dL

b.130 mg/dL

c.100 mg/dL

d.70 mg/dL

e.50 mg/dL

25.A 62-year-old man was hospitalized for an NSTEMI and underwent invasive strategy with DES-based PCI. Which of the following statements about antiplatelet therapy is wrong?

a.Patients not on aspirin should be given nonenteric aspirin 325 mg before PCI.

b.After PCI, use of aspirin should be continued indefinitely.

c.Additional aspirin (81 to 325 mg) is recommended in all patients on chronic aspirin therapy before PCI.

d.A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting at the latest after completion of PCI (e.g., clopidogrel 600 mg, prasugrel 60 mg, and ticagrelor 180 mg).

e.In patients receiving a stent (BMS or DES) during PCI for ACS, P2Y12 receptor inhibitor should be given for 12 months.

26.A 50-year-old white female nonsmoker without history of cardiovascular disease (CVD) and treated only with ramipril for hypertension was hospitalized for UA. The ECG revealed T inversion in the lateral leads. The medical student who admitted the patient asks you what is the proportion of patients that undergo coronary angiography for ACS who have nonsignificant CAD.

a.<5%

b.10% to 15%

c.20% to 30%

d.25% to 35%

e.30% to 40%

27.A 59-year-old man was successfully treated with PCI for NSTEMI. During the procedure, the patient received bivalirudin. Due to closure device failure, the patient suffered a major bleeding at the access site difficult to control with manual compression and you are in need of reversing the anticoagulation. Your treatment of choice is

a.fresh frozen plasma.

b.prothrombin complex.

c.epsilon aminocaproic acid.

d.protamine.

e.vitamin K.

28.A 63-year-old man presents typical chest pain at moderate exertion in the preceding month and he is admitted to the hospital for coronary angiography. While considering the best access for the procedure, which of the following statements is not correct regarding a radial vascular access?

a.The radial vascular access may be useful to decrease access site complications.

b.The radial vascular access is preferred in patients with coagulopathy.

c.The radial vascular access is preferred in patients with morbid obesity.

d.The radial vascular access is preferred in patients with an elevated INR.

e.The radial vascular access is more frequently performed in the United States than in Europe.

29.Which of the following conditions does not justify immediate coronary angiography and, if needed, revascularization?

a.A 57-year-old man presenting with typical chest pain lasting 60 minutes up to emergency department arrival. As cardiologist on call you are called in immediately and when you see the patient, his pain has virtually disappeared while ECG shows 2-mm ST-segment elevation in the inferior leads.

b.A 60-year-old diabetic man known for previous coronary disease presenting with not better defined chest discomfort lasting for 10 hours and currently decreasing in intensity, pulmonary edema, and 3-mm ST-segment elevation in the anterior leads on ECG in the absence of Q waves.

c.A 65-year-old man known for CAD complaining of progressive shortness of breath since 1 week. At admission, no ongoing chest pain with stable hemodynamic status but bibasilar rales at lung auscultation. The ECG revealed ST-segment elevation as well as Q waves in the anterior leads.

d.A 70-year-old man presenting to the emerging department with on–off chest pain in the preceding 20 hours. Upon your arrival he has mild chest pain and on ECG 2-mm ST elevation in the lateral leads in the absence of Q waves.

e.A 68-year-old diabetic man presenting to the emerging department with chest pain lasting 4 hours, hypotension, and tachycardia and on ECG 3-mm ST-segment elevation in the anterior and lateral leads.

30.A 76-year-old man with no prior cardiac history presents to the emergency department with acute retrosternal chest pain. He had a single episode of chest pain lasting 4 hours 5 days ago. At that time he did not seek medical attention. Physical examination reveals a slightly confused diaphoretic patient, with heart rate of 95 bpm, blood pressure of 76/42 mmHg, and cold extremities. He is able to lie flat, the lungs are clear, and the jugular veins are distended even if the upper part of the body is raised at 45°. On cardiac auscultation a loud systolic murmur is audible, while on ECG Q waves associated with ST-segment elevation are detected in the inferior leads. The most likely diagnosis is

a.severe left ventricular failure.

b.ventricular septal defect.

c.acute mitral regurgitation.

d.right ventricular infarction.

e.cardiac rupture.

31.Considering the suspected diagnosis for the patient described in the previous question, what is the next diagnostic step?

a.Cardiac enzymes

b.Chest X-ray

c.Transesophageal echocardiography

d.Immediate coronary angiography

e.Transthoracic echocardiography

32.While considering surgery for the patient described in the previous two questions, the most effective cardiac unloading treatment for him is

a.fluid resuscitation.

b.β-blockers.

c.mechanical ventilation with positive end-expiratory pressure.

d.vasopressors.

e.intra-aortic balloon pump.

33.A 66-year-old man with a history of diabetes was referred for coronary angiography. The procedure showed complex multivessel disease. Which of the following statements justify the use of DES over BMS?

a.Patient with diabetes mellitus

b.Long coronary lesions

c.Multifocal coronary lesions

d.Small vessel disease

e.All of the above

34.A 63-year-old male smoker with no history of CVD and a treatment for hypertension complains of typical chest pain on exertion the preceding 2 months without any aggravation. He is scheduled for coronary angiography in 7 days. In the meantime, you should start the following antiplatelet treatment(s):

a.Low-dose aspirin daily

b.Clopidogrel 75 mg daily without loading dose

c.A loading dose of clopidogrel 300 mg followed by 75 mg daily should be given

d.A loading dose of ticagrelor 180 mg followed by 2 × 90 mg/day should be given

e.No antiplatelet therapy needed prior to coronary angiography

35.A 66-year-old man with intermediate probability of ischemic heart disease is scheduled for stress testing. Which of the following strategies is not recommended?

a.Exercise ECG if able to exercise and ECG interpretable

b.Exercise echocardiography if able to exercise but uninterpretable ECG

c.Pharmacologic stress with nuclear myocardial perfusion imaging if able to exercise and ECG interpretable

d.Exercise stress with nuclear myocardial perfusion imaging if able to exercise but uninterpretable ECG

e.Pharmacologic stress with cardiac MR imaging if unable to exercise and interpretable ECG

36.A 65-year-old man with hypercholesterolemia, diabetes, and hypertension presents new, worsening, typical angina symptoms. The angiogram (Fig. 4.1) shows

a.occluded LAD.

b.occluded left circumflex coronary artery.

c.severe ostial and moderate distal left main trunk stenosis.

d.normal coronary arteries.

e.normal RCA.

Figure 4.1

37.A 64-year-old man with stable ischemic heart disease (SIHD) wants to know whether he is at high risk for mortality. Which of the following clinical and exercise testing data are useful to predict the risk?

a.Typical angina symptoms

b.Diabetes

c.ST-segment depression during exercise

d.Proportion of predicted METs achieved

e.All of the above

38.A 48-year-old woman presents with congestive heart failure. The etiology of her heart failure based on the coronary angiogram (Fig. 4.2) is

a.severe CAD.

b.arteriovenous fistula.

c.aortic regurgitation.

d.absent RCA.

e.coronary perforation.

Figure 4.2

39.A 72-year-old man known with a history of coronary heart disease presents typical chest pain. During the transport to the PCI center, the patient had two episodes of ventricular fibrillation requiring electrical reanimation. ECG shows inferolateral ST depression. What does the angiography show (Fig. 4.3)?

a.Lesions at bifurcation

b.Stenosis of the ostium of the LCX

c.Stenosis of the ostium of the LAD

d.Stenosis of the distal left main trunk

e.All of the above

Figure 4.3

40.During coronary angioplasty of the RCA, this 72-year-old patient developed sharp chest pain with rapid development of hypotension and tachycardia. The etiology based on Figure 4.4 is

a.abrupt closure of the RCA.

b.dissection of the RCA.

c.perforation of the RCA.

d.allergic reaction.

e.distal embolization of an atherosclerotic plaque.

Figure 4.4

41.For which clinical situation is coronary angiography not recommended in patients with SIHD?

a.Risk assessment in patients with SIHD not candidates for revascularization because of comorbidities

b.Risk assessment in patients with SIHD who have preserved LV function and low-risk criteria on noninvasive testing

c.Risk assessment in patients who are at low risk according to clinical criteria and have not undergone noninvasive risk testing

d.Risk assessment in asymptomatic patients with no evidence of ischemia on noninvasive testing

e.All the mentioned clinical situations do not justify coronary angiography in the initial phase of patient management

42.A 66-year-old man with diabetes with no hypertension but end-stage renal failure treated with hemodialysis in the last 15 years presents with worsening dyspnea and suspicion of ischemia at the stress imaging. What are the most characteristic findings relating to the coronary arteries to be found at angiography?

a.Tortuous coronary vessels

b.Calcified coronary arteries

c.Ectatic coronary arteries

d.Coronary arteries with anomalous origins

e.Normal coronary arteries (symptoms caused by small vessel disease)

43.A 65-year-old man with SIHD wants to optimize secondary prevention. Which of the following statements does not apply?

a.Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged.

b.Patients should be screened for depression and treated when indicated.

c.Treatment with clopidogrel is reasonable when aspirin is contraindicated.

d.Dipyridamole is not recommended as antiplatelet therapy for patients with SIHD.

e.Acupuncture might be used for the purpose of improving symptoms of patients with SIHD.

44.A 74-year-old man was hospitalized for a subacute MI. He presented 1 week prior to admission one episode of chest pain lasting 3 hours but he did not seek medical attention. The ECG at admission revealed deep Q waves and persisting ST-segment elevation in the anterior leads. The angiography showed a total occlusion of the proximal left anterior ascending coronary artery. Which statement about the benefit of revascularization in this particular patient does apply?

a.PCI reduces the occurrence of death.

b.PCI reduces the occurrence of reinfarction.

c.PCI reduces the occurrence of heart failure.

d.CABG should be preferred to PCI.

e.PCI does not reduce the occurrence of death, reinfarction, or heart failure.

45.A 60-year-old man with a history of PCI 3 years previously asks for your advice with respect to his pharmacologic treatment. He is asymptomatic and his CV risk factors include smoking, hypertension, hypercholesterolemia, and impaired glucose tolerance. His medications include aspirin, atorvastatin, metoprolol, metformin, and lisinopril. His friend told him that clopidogrel should be added to his regimen. What is the correct statement about that suggestion in this particular patient?

a.There is no significant benefit associated with clopidogrel plus aspirin as compared with placebo plus aspirin in reducing the incidence of the primary endpoint of MI, stroke, or death from CV causes.

b.There is a significant benefit associated with clopidogrel plus aspirin as compared with placebo plus aspirin in reducing the incidence of the primary endpoint of MI, stroke, or death from CV causes.

c.The rate of severe or moderate bleeding is not significantly greater with clopidogrel and aspirin compared with aspirin alone.

d.The rate of severe or moderate bleeding is significantly greater with clopidogrel and aspirin compared with aspirin alone.

e.Answers a and d are correct.

46.A 60-year-old woman was discharged after an MI. Pharmacologic secondary prevention with antiplatelet agents, statins, β-blockers, and angiotensin-converting enzyme inhibitors is associated with

a.significant reduction in recurrent angina but no mortality benefit.

b.significant survival advantage.

c.no significant clinical benefit.

d.significant reduction in recurrent hospitalization but no mortality benefit.

e.significant survival advantage only in patients treated with PCI.

47.A 55-year-old man presents since 3 months typical chest pain at moderate exertion. The angiography revealed single-vessel disease. An optimal therapy has been started; what is the benefit of a treatment with PCI of the culprit lesion?

a.PCI would reduce the risk of death, MI, or other major CV events when added to optimal medical therapy (OMT).

b.PCI may reduce the episodes of angina in the presence of moderate-to-severe ischemia at stress single-photon emission computed tomography (SPECT) but not the risk of death, MI, or other major CV events when added to OMT.

c.PCI would not reduce the risk of death, MI, angina episodes, or other CV events when added to OMT.

d.The benefit of revascularization in patients with stable angina and ischemia detected on SPECT is independent of the extent of ischemia.

e.Selective ischemia-driven PCI approach should be avoided, as thus not improved clinical outcomes.

48.A 67-year-old man known for hypertension and hypercholesterolemia presented significant ST elevation in inferoposterior leads during the treadmill test. The angiogram shows (Fig. 4.5)

a.severe LCX stenosis.

b.severe left main trunk stenosis.

c.severe LAD stenosis.

d.severe RCA stenosis.

e.no significant coronary artery stenosis.

Figure 4.5

49.A 66-year-old man hospitalized for an NSTEMI was successfully treated with DES for a subtotal lesion of the proximal LAD. What is the recommended minimal duration of dual antiplatelet therapy according to the 2011 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on PCI?

a.1 month

b.3 months

c.6 months

d.12 months

e.24 months

50.A 54-year-old man known for smoking and hypertension is admitted to the emergency department with an NSTEMI. Echocardiography reveals abnormalities in the acute lateral wall motion. The angiogram (Fig. 4.6) shows

a.severe LCX stenosis.

b.severe left main trunk stenosis.

c.severe LAD stenosis.

d.severe RCA stenosis.

e.no significant coronary artery stenosis.

Figure 4.6

51.A 75-year-old man has been treated 1 month ago with a DES in the proximal LAD for ACS. At that time he did not mention that he was supposed to require surgery for debilitating knee arthritis. Which of the following statements is correct?

a.The recent implantation of a DES is not problematic as long as aspirin can be continued during surgery.

b.The recent implantation of DES is not problematic as long as clopidogrel can be continued during surgery.

c.The recent implantation of DES is not problematic as long as aspirin and clopidogrel can be continued during surgery.

d.Discontinuation of dual antiplatelet therapy followed by noncardiac surgery in the first few weeks following stent implantation is associated with increased ischemic cardiac events with both DES and BMS.

e.Discontinuation of dual antiplatelet therapy followed by surgery in the first few weeks following stent implantation is problematic with DES but not BMS.

52.A 66-year-old woman had a second-generation DES implantation after an acute MI. What is the correct statement?

a.To prevent DES late thrombosis, dual antiplatelet therapy with aspirin and clopidogrel is recommended for 3 years.

b.Based on the results of the CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization Management, and Avoidance) trial, aspirin and clopidogrel should be administered for at least 2 years in patients with an acute coronary event, independently of the implantation of a DES.

c.At 1 year, clopidogrel may be discontinued but if the patient is on low-dose aspirin, the dose of aspirin has to be increased to 325 mg/day.

d.In patients who have already suffered a stent thrombosis dual antiplatelet therapy may be extended long term, although currently there are no data to support this strategy.

e.Following DES implantation, aspirin should be discontinued at 12 months and clopidogrel administered indefinitely.

53.A 60-year-old man known for current smoking is admitted to the emergency department for prolonged typical chest pain. The 12-lead ECG is shown in Figure 4.7. What is the most likely finding at the coronary angiography?

a.Occlusion of the first marginal branch of the left circumflex coronary artery

b.Occlusion of the proximal left anterior descending coronary artery

c.Occlusion of the dominant RCA

d.Occlusion of the left main trunk

e.Occlusion of the first diagonal branch

Figure 4.7

54.A 37-year-old man known for obesity felt typical chest pain while playing tennis accompanied by nausea, dyspnea, and sudations. The ECG shows ST-segment elevation. He is immediately admitted to the catheterization laboratory (Fig. 4.8). What is the underlying pathology?

a.Thrombotic occlusion of the left main trunk

b.Anomalous origin of the left main trunk

c.Dissection of the left main trunk

d.Vasospasm of the left main trunk

e.None of the above

55.A 58-year-old man known for hypertension and smoking suffered chest pain and dyspnea in the previous 48 hours. He consulted emergency department for persisting symptoms. The rest 12-lead ECG at admissions is shown in Figure 4.9. What is the diagnosis?

a.Takotsubo cardiomyopathy

b.Pericarditis

c.Anterior subacute MI

d.Cardiomyopathy hypertrophic obstructive

e.Hypertensive heart disease

Figure 4.8

Figure 4.9

56.A 28-year-old male smoker presented after wakeup typical inaugural chest pain. The 12-rest ECG at admission is shown in Figure 4.10. He is transferred immediately to the catheterization laboratory. What is the most likely finding?

a.Occlusion of a large diagonal branch

b.Occlusion of the left anterior descending coronary artery

c.Occlusion of the left circumflex coronary artery

d.Occlusion of the RCA

e.Normal coronary angiogram

57.A 69-year-old man known for hypertension and diabetes consulted emergency department for typical chest pain. The ECG did not show significant changes. Troponins were elevated (1.4 μg/L). Coronary angiography (Fig. 4.11) shows

a.no significant lesion of the RCA.

b.perforation of the mid-portion of the RCA.

c.anomalous origin of the RCA.

d.visible thrombus in the mid-portion of the RCA.

e.dissection of the mid-portion of the RCA.

Figure 4.10

Figure 4.11

58.A 41-year-old overweight heavy-smoker construction worker presented with chest pain while on the job associated with diaphoresis and dyspnea. In the field, no ECG could be obtained due to the extreme diaphoresis. In the ambulance, the patient developed hypotension, bradycardia, and subsequently asystole. Under cardiopulmonary resuscitation he was transferred to the cardiac catheterization laboratory and circulation was reestablished using extracorporeal membrane oxygenation. Subsequently, coronary angiography (Fig. 4.12) shows

a.subtotal occlusion of the left main trunk.

b.aortic dissection.

c.anomalous origin of the left main trunk.

d.left main trunk stenosis equivalent (i.e., severe stenosis of the left anterior descending coronary artery and left circumflex).

e.severe aortic stenosis.

Figure 4.12

59.A 61-year-old man known for diabetes, hypercholesterolemia, hypertension, and a history of PCI with stenting of the mid-left anterior descending coronary artery 10 years earlier presents with worsening typical angina on exertion and a positive stress test. Coronary angiography (Fig. 4.13) shows

a.ISR of the left descending coronary artery.

b.significant stenosis of LCX.

c.stenosis of the ostium of the left main trunk.

d.normal coronary arteries.

e.none of the above.

Figure 4.13

ANSWERS

1.c. Coronary angiography within 48 hours followed by percutaneous intervention/surgical revascularization if indicated. There is continued debate as to whether a routine, early invasive strategy is superior to a conservative strategy for the management of UA and NSTEMI. A pooled analysis of randomized controlled trials with 5,467 patients compared the impact of routine invasive (RI) strategy with selective invasive (SI) strategy: Over 5 years, 14.7% of patients randomized to an RI strategy experienced CV health or nonfatal MI versus 17.9% in the SI strategy (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.71 to 0.93; P = 0.002). However, the largest absolute effect was mainly observed in higher-risk patients (11.1%).1 Another meta-analysis using data from eight trials (3,075 women and 7,075 men) compared early invasive versus conservative treatment strategies in women and men with UA and NSTEMI and reported comparable odds ratio (OR) for reducing MACE (death, MI, and rehospitalization for ACS) of 0.81 (95% CI: 0.65 to 1.01) in women and 0.73 (95% CI: 0.55 to 0.98) in men. In contrast, an invasive strategy was not associated with a significant reduction in low-risk (biomarker-negative) women.2 The 2012 ACC/AHA guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction recommend an early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) in patients who have refractory angina or hemodynamic or electrical instability, and in those initially stabilized who have an elevated risk of clinical events.3 Table 4.1 lists patients at elevated risk and in whom invasive strategy is preferred based on the ACC/AHA 2011 guidelines. Our patient has several high-risk criteria (ongoing angina, elevated biomarkers, and echocardiographic abnormalities). TIMI (Thrombolysis in Myocardial Infarction) risk score revealed 5 points (26% risk at 14 days of MACE) and GRACE (Global Registry of Acute Cardiac Events) risk score showed a high risk of mortality.

2.b. Lower rate of hospital readmission. Belardinelli et al. addressed the effects of exercise training (ET) on functional capacity and quality of life (QOL) in patients who received percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting (CS). The authors studied 118 consecutive patients with CAD (mean age 57 ± 10 years) who underwent PTCA or CS on one (69%) or two (31%) native epicardial coronary arteries. Patients were randomized into two matched groups. Group T (n = 59) was exercised three times a week for 6 months at 60% of peak VO2. Group C (n = 59) was the control group. Only patients in the active group had significant improvements in peak VO2 (26%, P <0.001) and QOL (26.8%, P = 0.001 versus C). The angiographic restenosis rate was unaffected by ET (T: 29%; C: 33%, P = not significant). However, residual diameter stenosis was lower in trained patients (–29.7%, P = 0.045). In patients with angiographic restenosis, thallium uptake improved only in group T (19%, P <0.001). During the follow-up (33 ± 7 months), trained patients had a significantly lower event rate than controls (11.9% versus 32.2%; risk ratio [RR]: 0.71; 95% CI: 0.60 to 0.91; P = 0.008) and a lower rate of hospital readmission (18.6% versus 46%; RR: 0.69; 95% CI: 0.55 to 0.93; P <0.001). Moderate ET improved functional capacity and QOL after PTCA or CS. During the follow-up, trained patients had fewer events and a lower hospital readmission rate than controls, despite an unchanged restenosis rate.4 The 2011 ACC/AHA guidelines for PCI recommend (class I, evidence A) medically supervised exercise programs to patients after PCI, particularly for moderate- to high-risk patients for whom supervised ET is warranted.5 Participation in cardiac rehabilitation is associated with significant reductions in all-cause mortality (OR 0.80; 95% CI: 0.68 to 0.93)6 in several community-based surveys and meta-analyses.6-8

3.a. Heart team discussion between the interventional cardiologist and the cardiac surgeon to select the best treatment option is the recommended approach. The 2011 AHA/ACC guidelines for PCI recommend the heart team approach (class I, evidence C) for the revascularization of patients with unprotected left main trunk disease.5 Several trials used protocols that involve a multidisciplinary approach.9,10 The heart team is composed of an interventional cardiologist and a cardiac surgeon and aims at (1) reviewing patients’ medical history, (2) determining the approach of revascularization (PCI versus CABG), and (3) discussing with the patient the options of revascularization. The guidelines endorse a heart team approach in patients with unprotected left main CAD and/or complex CAD in whom the optional strategy is not straightforward. Because the STS score and the SYNTAX score predict clinical outcomes, their use is often useful in making revascularization decisions.11,12

4.c. Drug-eluting stent (DES) implantation (stent-in-stent). In the randomized trial TAXUS V ISR (treatment of De Novo Coronary Disease Using a Single Paclitaxel-Eluting Stent trial), the slow-release, polymer-based, paclitaxel-eluting stent was found to be not only noninferior to β-source vascular brachytherapy but also superior in terms of reducing clinical and angiographic restenosis at 9 months after treatment of bare-metal ISR lesions. Because of both greater acute gain and less late loss, luminal dimensions were significantly larger with paclitaxel-eluting stents compared with brachytherapy in the injury zone, at the distal edge, and over the entire analysis segment. Proximal edge luminal dimensions were also numerically larger with the paclitaxel-eluting stent.13 Similarly, the Sirolimus-Eluting Stent with Vascular Brachytherapy for the Treatment of In-Stent Restenosis (SISR) trial demonstrated a marked reduction in target vessel failure with the sirolimus-eluting stent, driven predominantly by a reduction in the rate of target vessel revascularization.14 Based on available data and the severity of the patient’s COPD, DES implantation is the best option for this patient with BMS restenosis. Brachytherapy is no longer available except in a few research centers.15

5.d. Guideline-directed medical therapy is the first recommended approach. In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 2,287 patients with stable CAD were randomized to undergo PCI and medical therapy or to medical therapy alone. The primary outcome was death from any cause and nonfatal MI during a follow-up of 2.5 to 7.0 years. The cumulative event rates were 19.0% in the PCI group and 18.5% in the medical therapy group (P = 0.62). As an initial management strategy, PCI did not reduce the risk of death, MI, or other MACE in the COURAGE trial.16 About 314 patients were enrolled in the nuclear substudy of the COURAGE study to perform serial stress imaging. The addition of PCI to medical therapy improved ischemia reduction in patients with significant ischemia at baseline.17 A recent meta-analysis of 10 randomized controlled trials (6,752 patients) comparing PCI with medical therapy in stable CAD did not detect significant differences in PCI versus CABG; the relative risk (RR) for all-cause mortality was 0.97 (95% CI: 0.84 to 1.12), CV mortality RR 0.91 (95% CI: 0.70 to 1.12), MI RR 1.09 (95% CI: 0.92 to 1.29), or angina relief RR 1.10 (95% CI: 0.97 to 1.26).18 According to the AHA/ACC guidelines CABG or PCI should not be performed to improve symptoms or survival in patients with CAD with one or more coronary stenoses who do not meet anatomic (≥70% non-left main stenosis diameter), physiologic (FFR >0.80, no or mild ischemia on noninvasive testing) criteria for revascularization and involve only LCX or RCA, or subtend only a small area of viable myocardium.5 The multiple meta-analyses comparing PCI versus medical therapy in patients with SIHD showed that PCI reduced the incidence of angina, but has not been demonstrated to improve survival or lower the long-term risk of MI in stable patients.17,19 Our patient does not have criteria for coronary revascularization, and the first-line therapy should be an aggressive medical therapy.

6.c. Subendocardium. The subendocardium is most susceptible to ischemic damage. Although the mechanisms of subendocardial ischemia remain to be fully defined, they are clearly associated with the transmural distribution of intramyocardial systolic pressures. Even though almost all the myocardium is perfused in diastole, a reduction of diastolic perfusion pressure or duration will result in subendocardial ischemia.11 The abnormal subendocardial perfusion in patients with cardiac syndrome X (typical angina, abnormal exercise test results, and normal coronary arteries) has been described with CV MR imaging during the IV administration of adenosine.20

7.d. Inferior wall myocardial infarction (MI) with right ventricular infarction. The association of inferior wall MI on ECG and elevated jugular venous pressure with clear lungs is suggestive of additional right ventricular infarction. Tall c–v waves of tricuspid regurgitation may be evident in patients with necrosis or ischemia of the right ventricular papillary muscles.

8.a. Reduction in left ventricular compliance. An S4 is frequently present in patients with acute MI and is related to auricular contraction and ventricular compliance reduction during ventricular filling.21 Rapid deceleration of transmitral flow during protodiastolic filling of the left ventricle and increased inflow into the left ventricle are responsible for the third heart sound (S3). A systolic ejection murmur is suggesting for aortic sclerosis.

9.e. Hybrid revascularization mandates surgical and percutaneous revascularization during the same procedure. According to the ACC/AHA PCI guidelines, hybrid coronary revascularization is defined as the planned combination of LIMA-to-LAD artery grafting and PCI of ≥1 non-LAD coronary arteries and intended to combine the advantages of CABG (i.e., durability of the LIMA graft) and PCI. Hybrid revascularization is particularly suitable in patients with limitations to traditional CABG (e.g., heavily calcified proximal aorta, lack of graft conduits, or a non-LAD coronary artery unsuitable for bypass but amenable to PCI) and situations in which PCI of the LAD artery is not feasible (e.g., excessive tortuosity or calcification, complex bifurcation lesion, and very long lesion). The procedure may be performed in one operative setting or as a staged procedure. CABG before PCI is preferred.5Preliminary reports suggest that this approach is feasible and safe,22 but randomized data are lacking.

10.c. High-sensitive troponin T (Hs-TnT). In the PLATO (Platelet Inhibition and Patient Outcomes) trial, 9,946 patients presented with non-ST-elevation ACS: 5,357 were revascularized and 4,589 managed conservatively. High-sensitive elevated Hs-TnT (>14.0 ng/L) have been described to predict substantial benefit (reduction rate of CV death, MI, and stroke) of ticagrelor over clopidogrel in patients who were revascularized or treated conservatively, while no apparent was observed in those who had normal Hs-TnT.23

11.e. All of the above. Patients with extensive and severe CAD are more likely to present abnormal exercise ECG results.24 Early onset of angina, ischemic ST depression ≥2 mm, downsloping ST segment starting at <5 METs, involving ≥5 leads and persisting ≥5 minutes into recovery, and fall in blood pressure at low exercise are all associated with adverse prognosis.

12.e. No improvement of any of the mentioned endpoints. The COURAGE trial enrolled 2,287 patients with significant CAD to an initial strategy: (1) PCI and OMT or (2) OMT only. There were no significant differences between the PCI group and the medical therapy group in the composite of death, MI, and stroke (HR: 1.05; 95% CI: 0.87 to 1.27), and hospitalization for ACS (HR: 1.07; 95% CI: 0.84 to 1.37) or MI (HR: 1.13; 95% CI: 0.89 to 1.43). The authors concluded that as initial management strategy in patients with stable CAD, PCI did not reduce the risk of death, MI, or other MACE when added to OMT.16 According to the 2011 ACC/AHA PCI guidelines, revascularization should not be performed to improve survival in patients with SIHD with one or more coronary artery stenoses that are not anatomically significant, or involve only the LCX or RCA, or subtend only a small area of viable myocardium.5

13.e. All of the above. In the COURAGE patients, 314 were enrolled in the substudy of myocardial perfusion SPECT performed before treatment and 6 to 18 months after randomization. At follow-up, the reduction in ischemic myocardium was greater with PCI + OMT than with OMT (–2.7% versus –0.5%, P <0.0001). The patients with PCI + OMT exhibited significant ischemia reduction (33% versus 19%, P = 0.0004), especially those patients with moderate-to-severe myocardial ischemia at baseline (78% versus 52%, P = 0.007).17 The 2012 AHA/ACC guidelines for PCI mentioned in patients with stable ischemic coronary heart disease a benefit of angina reduction and symptom improvement with PCI versus OMT; however, PCI has not been demonstrated to improve survival in stable patients.5

14.b. Significant absolute risk reduction of major adverse cardiovascular events (MACE) of ~2% over 5 years. The 2012 ACC/AHA guidelines for the management of SIHD recommend the prescription of moderate or high dose of a statin therapy in addition to lifestyle changes (class I, evidence A).25 The Treating to New Targets (TNT) study randomized 10,001 patients with stable coronary heart disease and LDL >130 mg/dL to receive atorvastatin 10 or 80 mg daily. The mean LDL-C was 2.0 mmol/L during the treatment with 80 mg of atorvastatin, whereas it was 2.6 mmol/L during the treatment with 10 mg of atorvastatin. About 8.7% of patients in the group with intensive lipid-lowering therapy and 10.9% in the group with moderate lipid-lowering therapy presented MACE during a median follow-up of 4.9 years, representing a significant absolute reduction in the rate of MACE of 2.2% and a 22% relative reduction in risk. There was no difference between both treatment groups in the overall mortality.26

15.e. Fondaparinux might be used as the sole anticoagulant to support PCI. The 2011 ACCF/AHA PCI guidelines made the following recommendations regarding anticoagulant therapy during the procedure. Following recommendations are class I: (1) All patients undergoing PCI should receive an anticoagulant to prevent thrombus formation during the procedure; (2) the administration of IV UFH is a useful standard therapy in patients undergoing PCI; (3) an additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of PCI to patients who have received fewer than two therapeutic subcutaneous doses (e.g., 1 mg/kg) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI; and (4) for patients undergoing PCI, bivaluridin is useful as an anticoagulant with or without prior treatment with UFH. In contrast, fondaparinux should not be used as the sole anticoagulant to support PCI.5 An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis. Fondaparinux is an indirect factor Xa inhibitor, but no effect on thrombin (IIa). The use of fondaparinux alone was associated with thrombus catheter formation and therefore the anticoagulant with anti-IIa should be used during PCI.27

16.e. Even in the absence of symptoms, routine periodic stress testing is indicated. According to the 2011 AHA/ACC PCI and 2011 AHA/ACC secondary prevention guidelines, the following interventions and targets are strongly recommended in patients with CHD to reduce morbidity and mortality: (1) to refer to a medically supervised cardiac rehabilitation program post discharge, (2) to manage lipid-lowering treatment for an LDL-C target <70 mg/dL, (3) to control blood pressure with the goal of <140/90 mmHg, and (4) to advise patients for complete smoking cessation. Conversely, there is no proven benefit or indication for routine periodic stress testing in patients after PCI, and thus, it is not indicated.24

17.e. All of the above. The clinical situations associated with higher risk of BMS restenosis have been defined by the 2011 AHA/ACC PCI guidelines as follows: (1) left main disease, (2) small vessels, (3) ISR, (4) bifurcations, (5) diabetes, (6) long lesions, (7) multiple lesions, and (8) saphenous vein grafts. The ISR of BMS presented by the patient should be treated with DES,5 as sirolimus- or paclitaxel-eluting stents are superior to balloon angioplasty.28The use of DES over BMS had decreased the incidence of ISR by over 70%.13,28

18.b. Rosuvastatin 20 mg/day significantly decreased the incidence of MI. The JUPITER trial randomized 17,802 men and women without CVD presenting an LDL-C lower than 130 mg/dL, but high levels of hs-CRP, to rosuvastatin, 20 mg daily, or to placebo. Rosuvastatin reduced LDL-C levels by 50% and hs-CRP levels by 37%. The primary endpoint outcome was a composite of MI, stroke, arterial revascularization, hospitalization for UA, or death from CVD. The study was interrupted after 1.9 years at interim analyses because of a significant decrease for primary outcome (HR: 0.56; 95% CI: 0.46 to 0.69). HR for MI was 0.46, 95% CI (0.30 to 0.70), and HR for stroke was 0.52, 95% CI (0.34 to 0.79). In the adverse events section, the physician-reported diabetes was more frequent in the rosuvastatin group (n = 270) than in the placebo group (n = 216, P = 0.01); the difference in the median glycated hemoglobin value was minimal (5.9% versus 5.8%, respectively, P = 0.001).29

19.c. CABG is associated with a reduction of death and of MI, but not of stroke. The future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial randomized 1,900 patients with diabetes and multivessel CAD to a revascularization strategy with (1) CABG or (2) PCI. The primary outcome was defined as death from any cause, nonfatal MI, or nonfatal stroke. The primary outcome rate at 5 years was 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was observed in reduction of death (P = 0.049) and MI (P <0.001) rates, but stroke was more frequent in the CABG group than the PCI group (5.2% versus 2.4%, P = 0.03).30

20.c. More than 70% of patients quit smoking after ACS. About 50% to 70% of smokers continue to smoke after an ACS,31 despite the fact that smokers who quit smoking have a 36% reduction in the risk of mortality and 32% in the risk of recurrent nonfatal MI in comparison with continuing smokers over a mean follow-up of 5 years.32 Smoking cessation intervention is a major target of secondary prevention of CVD and should be one of the priorities of clinicians providing care to such patients. Given the large benefits of smoking cessation, promotion of smoking cessation is the most effective intervention to reduce morbidity and mortality in smokers with CHD.32Unfortunately smoking receives less attention from cardiologists than other CV risk factors,33 and many smokers with CHD are unable to quit smoking without assistance. Based on a systemic review, several studies found a beneficial effect on smoking cessation rates through a smoking cessation intervention that started in hospital and continued in the ambulatory setting.31

21.e. Answers b and d are correct. The leading cause of death in patients hospitalized for acute MI is cardiogenic shock. The SHOCK investigators conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock. Patients with shock caused by left ventricular failure complicating MI were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either CABG or angioplasty. Intra-aortic balloon counterpulsation was performed in 86% of the patients in both groups. The primary endpoint was mortality from all causes at 30 days. Six-month survival was a secondary endpoint. The mean age of the patients was 66 ± 10 years; 32% were women and 55% were transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87% underwent revascularization; only 2.7% of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days (primary endpoint) did not differ significantly between the revascularization and medical therapy groups (46.7% and 56.0%, respectively; difference, –9.3%; 95% CI for the difference, –20.5% to 1.9%; = 0.11). However, at 6 months mortality was lower in the revascularization group than in the medical therapy group (50.3% versus 63.1%, P = 0.027).34

22.a. Patients with CKD undergoing cardiac catheterization should receive adequate preparatory hydration. The 2011 ACC/AHA PCI guidelines made recommendations regarding contrast-induced AKI. Contrast-induced AKI is considered one of the most frequent causes of iatrogenic AKI. Risk factors for developing contrast-induced AKI are hypotension, intra-aortic balloon pump, congestive heart failure, CKD, diabetes, age >75 years, anemia, and volume of contrast.35 The following recommendations are of class I for the prevention of AKI: (1) Patients should be assessed for risk of contrast-induced AKI before PCI; (2) patients undergoing catheterization with contrast media should receive adequate preparatory hydration; and (3) in patients with CKD (creatinine clearance <60 mL/min), the volume of contrast media should be minimized. However, the administration of N-acetyl-cysteine is not useful for the prevention of contrast-induced AKI and is not recommended based on the results of several randomized controlled trials.36

23.a. No significant difference in the risk of stroke. Abciximab, a potent inhibitor of the platelet glycoprotein IIb/IIIa receptor, reduces thrombotic complications in high-risk patients undergoing PCI in the setting of ACS compared with a regimen of aspirin and UFH. Akkerhuis et al. combined analysis of data from 8,555 patients undergoing PCI assigned to receive a bolus and infusion of abciximab (n = 5,476) or matching placebo (n = 3,079). No significant difference in stroke rate was observed between patients assigned abciximab (n = 22 [0.40%]) and those assigned placebo (n = 9 [0.29%]; P = 0.46). The rate of nonhemorrhagic stroke was 0.17% in patients treated with abciximab and 0.20% in patients treated with placebo (difference: –0.03%; 95% CI: –0.23% to 0.17%), and the rates of hemorrhagic stroke were 0.15% and 0.10%, respectively (difference: 0.05%; 95% CI: –0.11% to 0.21%). Abciximab in addition to aspirin and heparin does not increase the risk of stroke in patients undergoing PCI.39

24.d. 70 mg/dL. For patients with established CAD, LDL-lowering therapies significantly reduce the risk of MACE and yield highly favorable cost-effectiveness ratios. In high-risk persons, the recommended LDL-C goal is <100 mg/dL. An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available clinical trial evidence, especially for patients at very high risk. Diabetic patients with established advanced CAD, like the mentioned patient, should be considered at very high risk for MACE and qualify for the ambitious target of LDL <70 mg/dL.42

25.c. Additional aspirin (81 to 325 mg) is recommended in all patients on chronic aspirin therapy before PCI. The 2011 AHA/ACC PCI guidelines recommend the use of antiplatelet therapy before PCI.5 Aspirin reduced ischemic CV events after PCI37,38 and should be given at least 2 hours before PCI after which aspirin has to be continued indefinitely.39 In addition to aspirin, a loading dose of P2Y12 receptor inhibitor might be given to patients undergoing PCI with stenting.40-42 Options include clopidogrel 600 mg, prasugrel 60 mg, or ticagrelor 180 mg. The duration of P2Y12 receptor inhibitor after stent implantation (BMS or DES) for ACS should be of at least 12 months.43,44 Options include clopidogrel 75 mg daily, prasugrel 10 mg daily, and ticagrelor 90 mg twice daily. In patients receiving DES for a non-ACS indication, clopidogrel 75 mg daily should be given for 12 months if patients are not at high risk for bleeding.45 In patients receiving BMS for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months.44 A benefit of additional aspirin in patients on chronic aspirin undergoing PCI has never been demonstrated.

26.c. 20% to 30%. A proportion of patients who present with suspected ACS are found to have insignificant CAD during coronary angiography. Of the 5,767 patients with non-ST-segment-elevation ACS who were enrolled in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin (Eptifibatide) Therapy (PURSUIT) trial and who underwent inhospital angiography, 88% had significant CAD (any stenosis >50%), 6% had mild CAD (any stenosis >0% to ≤50%), and 6% had no CAD (no stenosis identified). Overall, 12% of the patients had nonsignificant CAD.44 Patients with nonsignificant CAD were more likely to be women, non-white, younger, nondiabetic, nonhypercholesterolemic, without history of CVD, without ST-segment changes, but with more T-wave inversion compared with patients with significant CAD. Based on the profile of the patient admitted, her probability of having nonsignificant CAD is >12%.

27.b. Prothrombin complex. Bivaluridin is a naturally occurring anticoagulant secreted by the salivary glands of the leech Hirudo medicinalis. It is a potent and specific anticoagulant and exerts its action by binding directly to the active catalytic site of thrombin. Unlike heparin, it does not require a cofactor (antithrombin) and does not appear to cause immune-mediated thrombocytopenia. It is also a more potent inhibitor of platelet function than heparin, probably because of a direct inhibitory effect on thrombin. Unlike heparin, which is readily neutralized by protamine or platelet factor 4, a specific agent useful in reversing the effects of bivalirudin is unavailable. Irani et al. demonstrated the first clinical experience, suggesting benefit from prothrombin complex concentrate in neutralizing the effect of r-hirudin. Although the specific mechanism of action remains unclear, the generation of additional thrombin probably plays a role. Also, epinephrine-induced platelet aggregation in hirudinized platelet-rich plasma is restored by addition of prothrombin complex concentrate, most probably by additional thrombin generation. Adverse effects of prothrombin complex concentrate include intravascular thrombosis, particularly in patients with liver disease and possible viral hepatitis. As the product contains some activated clotting factors (II, VII, IX, and X) and has thrombogenic potential, it should be used as a last resort, especially in patients with liver disease. Clinical experience suggests that prothrombin complex concentrate in a dose of 25 to 30 UI/kg can be considered for patients with life-threatening hemorrhage caused by bivalirudin.45

28.e. The radial vascular access is more frequently performed in the United States than in Europe. Radial site access is used more frequently in Europe and Canada than in the United States.46 The 2011 AHA/ACC PCI guidelines recommend radial artery access to decrease access site complications.5 In fact, it has been demonstrated that radial access, compared with femoral access, decreases the rate of access-related bleeding and complications.47 Its utility is more pronounced in patients at higher risk for bleeding or vascular access complications such as in patients with coagulopathy, anticoagulated, or morbid obesity.

29.c. A 65-year-old man known for CAD complaining of progressive shortness of breath since 1 week. At admission, no ongoing chest pain with stable hemodynamic status but bibasilar rales at lung auscultation. The ECG revealed ST-segment elevation as well as Q waves in the anterior leads. The 2011 AHA/ACC PCI guidelines elaborated indication of PCI in patients with STEMI.5 Primary PCI should be performed in patients within 12 hours of onset of STEMI, within 90 minutes of the first medical contact in patients presenting to a hospital with PCI capabilities and within 120 minutes of the first medical contact in patients presenting to a hospital without PCI capabilities (“systems goal”).4850 Primary PCI should be performed in patients with STEMI who are candidates for primary PCI, who develop severe heart failure or cardiogenic shock irrespective of time delay,34,51 and who had clinical and/or ECG evidence for ongoing ischemia between 12 and 24 hours after symptom onset.52 Delayed PCI in patients with STEMI is reasonable in patients with infarct artery reocclusion or demonstrating ischemia on invasive testing.53 PCI of hemodynamically significant stenosis in patent infarct artery greater than 24 hours after STEMI might be considered as part of an invasive strategy (class of recommendations IIb).54,55 PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with one- or two-vessel disease if patients are hemodynamically stable and do not present evidence of severe ischemia (class III).56

30.d. Right ventricular infarction. Rupture of the interventricular septum is one of the mechanical complications of MI, less frequent than left free wall rupture.57 It occurs in general 3 to 5 days after acute MI. An increase in risk is observed in patients with occlusion of LAD wrapping the distal inferior wall and inferior septum (inferior MI with large anterior MI). The ECG findings of the interventricular septum rupture are typical for ST elevation and Q waves in the inferior leads II, III, and aVF.58 Clinically, the patients present a rapid onset of hemodynamic compromise characterized by hypotension, biventricular failure, and a new harsh, loud, holosystolic murmur best heard at the lower left sternal border.59

31.d. Immediate coronary angiography. The septal defect and the associated turbulent transseptal flow can be visualized by a transthoracic echocardiography using color flow Doppler imaging.60 The addition of Doppler to echocardiography improves significantly the sensitivity of the examination demonstrating the transseptal turbulent flow and diastolic–systolic turbulences in the right ventricle.

32.c. Mechanical ventilation with positive end-expiratory pressure. The timing of surgical repair with post-MI ventricular septal rupture is controversial. In patients with cardiogenic shock, a fatal prognosis is inevitable in the absence of urgent surgical treatment. First, stabilization with an intra-aortic balloon pump counterpulsation, inotropic agents, diuretics, and, if tolerated, vasodilators is attempted.61 This is followed by cardiac catheterization to define the coronary anatomy and then surgical repair.

33.e. All of the above. The 2011 ACC/AHA PCI guidelines assessed the risk–benefit profile for the use of BMS versus DES. DES is preferred to BMS when high risk of stent restenosis is present with BMS. The clinical situations associated with higher risk of restenosis are (1) left main disease, (2) small vessels, (3) ISR, (4) bifurcations, (5) diabetes, (6) long lesions, (7) multiple lesions, and (8) saphenous vein grafts. All the criteria mentioned above increased the risk of restenosis, suggesting the use of DES over BMS.5

34.a. Low-dose aspirin daily. The patient will have coronary angiography for a high suspicion of SIHD. Until the angiogram is performed, he should be treated with optimal medical treatment including aspirin, statins, control of blood pressure (β-blockers/angiotensin converting), and additional medical therapy for the relief of symptoms (β-blockers, calcium channel blockers, long-acting nitrates, or sublingual nitroglycerin).25 The efficacy of clopidogrel pretreatment compared with the administration in the catheterization laboratory is controversial.62 There is no evidence to give prasugrel or ticagrelor in patients with SIHD.

35.c. Pharmacologic stress with nuclear myocardial perfusion imaging if able to exercise and interpretable ECG. Patients with intermediate pretest probability of CAD are those who most benefit from stress testing to improved diagnostic accuracy. The choice of stress test depends on two questions: Is the patient able to exercise? Is the resting ECG interpretable?25 The ACC/AHA SIHD guidelines recommend standard exercise ECG testing for interpretable ECG and at least moderate physical functioning or no disabling comorbidity (level of evidence A, class I).63 Exercise with nuclear myocardial perfusion imaging or echocardiography is recommended for patients with an intermediate to high pretest probability of ischemic heart disease who have an uninterpretable ECG and at least moderate physical activity functioning or no disabling comorbidity.64,65 Pharmacologic stress with cardiac MR can be useful for patients with an intermediate to high pretest probability who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity.66 Pharmacologic stress with nuclear myocardial perfusion imaging, echocardiography, or cardiac MR is not recommended for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidities.67

36.c. Severe ostial and moderate distal left main trunk stenosis. The coronary angiography shows severe ostial and moderate distal left main trunk stenosis.

37.e. All of the above. The 2012 AHA/ACC guidelines on SIHD25 recommend using a nomogram to predict the risk of death in patients with SIHD.68 This score is based on following clinical and exercise testing variables: age, male gender, typical angina, diabetes, cigarette smoking, hypertension, proportion of predicted METs achieved, ST-segment depression, test-induced angina, abnormal heart rate recovery, and frequent ventricular ectopy during recovery.

38.b. Arteriovenous fistula. The coronary angiography reveals large coronary AV fistula involving the RCA. Patient underwent surgical ligation of the fistula with resolution of her symptoms.

39.e. All of the above. The coronary angiography shows a bifurcation lesion involving the distal left main trunk as well as the ostium of the left anterior descending and left circumflex coronary arteries.

40.c. Perforation of the RCA. The coronary angiography demonstrates extravasation of contrast caused by perforation of the RCA.

41.e. All the mentioned clinical situations do not justify coronary angiography in the initial phase of patient management. According to 2012 AHA/ACC SIHD guidelines,25 coronary angiography is not recommended as an initial testing strategy to assess risk in the following clinical situations (class III, no benefit): (1) patients with SIHD who elect not to undergo revascularization or who are not candidates for revascularization because of comorbidities or individual preferences; (2) patients with SIHD who have preserved left ventricular function and low-risk criteria on noninvasive testing; (3) low risk according to clinical criteria and who have not undergone noninvasive risk testing; and (4) asymptomatic patients with no evidence of ischemia on noninvasive testing.

42.b. Calcified coronary arteries. Patients with long-standing terminal nephropathy have frequently severely calcified vessels including the coronary arteries.69 Qualitative analysis of the coronary arteries showed significantly more calcified plaques of coronary arteries in patients with end-stage renal failure. Plaques of nonuremic patients were mostly fibroatheromatous, while coronary plaques in patients with end-stage renal failure were characterized by increased media thickness and marked calcification. Deposition of calcium within the plaques may contribute to the high event rate in uremic patients.

43.e. Acupuncture might be used for the purpose of improving symptoms of patients with SIHD. According to 2012 AHA/ACC SIHD guidelines,25 acupuncture should not be used for the purpose of improving symptoms or reducing CV risk in patients with SIHD (class III, no benefit). Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home should be encouraged (class I), dipyridamole is not recommended as antiplatelet therapy for patients with SIHD (class III, no benefit), treatment with clopidogrel is reasonable when aspirin is contraindicated in patients with SIHD (class I), and it is reasonable to consider screening SIHD patients for depression and to refer or treat when indicated (class IIa).

44.e. PCI does not reduce the occurrence of death, reinfarction, or heart failure. The Occluded Artery Trial (OAT) study showed high rates of procedural success with PCI and sustained patency but no clinical benefit during an average 3-year follow-up with respect to death, reinfarction, or heart failure.56 There was, in fact, a trend toward excess nonfatal reinfarction when routine PCI was performed in stable patients who were found to have occlusion of the infarct-related artery 3 to 28 days after MI. A strategy of CABG was not tested in the OAT.

45.e. Answers a and d are correct. In the CHARISMA trial of 15,603 patients with established stable atherothrombotic disease or at high risk for such disease, there was no significant benefit associated with clopidogrel plus aspirin as compared with placebo plus aspirin in reducing the incidence of the primary endpoint of MI, stroke, or death from CV causes. Clopidogrel was associated with a significant increase in the rate of moderate bleeding.70

46.b. Significant survival advantage. A cohort study of approximately 1,400 patients demonstrated that the use of combination evidence-based medical therapies was independently and strongly associated with lower 6-month mortality in patients with ACSs.71 Furthermore, there was a gradient of benefit across the different TIMI risk groups with higher-risk patients obtaining higher absolute benefit.72 The 2013 AHA/ACCA STEMI guidelines73recommend (1) indefinitely aspirin 81 to 325 mg daily maintenance dose after PCI (class I), (2) β-blockers should be continued after hospitalization for all patients with STEMI and with no contraindications to their use (class I), (3) angiotensin-converting enzyme inhibitors are reasonable for all patients with STEMI and no contraindications to their use (class IIa and class I if presence of reduced LVEF), and (4) high-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use.

47.b. PCI may reduce the episodes of angina in the presence of moderate-to-severe ischemia at stress single-photon emission computed tomography (SPECT) but not the risk of death, MI, or other major CV events when added to optimal medical therapy. The COURAGE trial compared OMT alone or in combination with PCI as an initial management strategy in patients with stable CAD. Although the addition of PCI to OMT reduced the prevalence of angina, especially in case of moderate-to-severe ischemia detected by SPECT, it did not reduce long-term rates of death, nonfatal MI, and hospitalization for ACSs.16

48.d. Severe RCA stenosis. Coronary angiography shows severe mid-RCA stenosis explaining the inferior ischemia.

49.d. 12 months. The 2011 AHA/ACC PCI guidelines recommend the continuation of aspirin indefinitely (class I) and the duration of P2Y12 inhibitor after stent implantation as follows: (1) BMS or DES during PCI for ACS, at least 12 months; (2) DES for a non-ACS indication, at least 12 months if patients are not at high risk for bleeding; and (3) BMS for a non-ACS indication, a minimum of 1 month, and ideally up to 12 months (unless the patient is at increased risk for bleeding).5

50.a. Severe LCX stenosis. The coronary angiography of the left circulation shows severe mid-left circumflex coronary artery stenosis.

51.e. Discontinuation of dual antiplatelet therapy followed by surgery in the first few weeks following stent implantation is problematic with DES but not BMS. In patients scheduled for noncardiac surgery in the year following PCI, the implantation of DESs should be avoided. Accordingly, one of the most frequent predisposing conditions to DES thrombosis is the (partial or complete) discontinuation of dual antiplatelet therapy because of urgent or elective noncardiac surgery.74 Although preliminary data suggest that continuation of dual antiplatelet therapy during surgery, if feasible, may be protective of DES thrombosis, no recommendation can be made at this time. Conceptually, the potential for stent thrombosis remains because of the intrinsic prothrombotic state related to surgery. Perioperative thrombosis of BMS implanted shortly prior to noncardiac surgery have been described and associated with prohibitive morbidity and mortality. Therefore, whenever possible, noncardiac surgery should be postponed for at least 6 weeks following implantation of a BMS and 6 to 12 months following DES implantation.

52.d. In patients who have already suffered a stent thrombosis dual antiplatelet therapy may be extended long term, although currently there are no data to support this strategy. Currently, there are no data to support an extension of dual antiplatelet therapy beyond 12 months. Nevertheless, in selected patients at high risk for stent thrombosis, aspirin and clopidogrel may be administered for a longer period of time. The CHARISMA trial70 did show a benefit of prolonged aspirin and clopidogrel therapy over aspirin only in the secondary prevention setting, but did not specifically address the PCI population. According to the 2011 AHA/ACC PCI, continuation of P2Y12 inhibitor after stent implantation for ACS should be at least 12 months.5

53.e. Occlusion of the first diagonal branch. The ECG showed inferoposterolateral STEMI. Coronary angiography showed a thrombotic occlusion of mid-portion of the dominant RCA.

54.a. Thrombotic occlusion of the left main trunk. The coronary angiography shows thrombotic occlusion of the left main trunk artery. This lesion has been treated with thromboaspiration and implantation of a DES.

55.c. Anterior subacute MI. ECG reveals ST elevation of anterolateral fields. Due to persisting chest pain, the patient has been investigated with angiography. The ventriculography showed occlusion of the mid-portion of the left anterior descending coronary artery treated with thromboaspiration and implantation of a BMS. The image of the thrombus extracted is shown in Figure 4.14.

Figure 4.14

56.b. Occlusion of the left anterior descending coronary artery. The coronary angiography showed an occlusion of the proximal left anterior descending coronary artery. The fact that the vessel perfused the apex including the inferoapical portion of the left ventricles explains the ST elevations in the anterior and inferior leads.

57.d. Visible thrombus in the mid-portion of the RCA. The coronary angiography showed a subtotal stenosis of the mid-RCA followed by a filling defect compatible with a large thrombus. The thromboaspiration was successfully performed and the lesion was subsequently treated with stenting.

58.a. Subtotal occlusion of the left main trunk. Coronary angiography showed subtotal occlusion of the left main trunk and the lesion was treated with stenting. Ventriculography showed a severely reduced LVEF (15%) under a mechanical chest compression system. The patient did not recover and subsequently died.

59.a. ISR of the left descending coronary artery. Coronary angiography shows a ISR of the mid-left anterior descending coronary artery.

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