Cardiology BCPS – Questions With Solutions
Define acute coronary syndrome ✔️Ans - A spectrum of conditions
compatible with acute myocardial ischemia or infarction caused by an
abrupt reduction in coronary blood flow
Describe the pathophysiology of ACS ✔️Ans - Atherogenic plaque rupture
is the underlying pathophysiology for ACS, causing several prothrombotic
substances to be released, which results in platelet activation and
aggregation and eventual thrombus formation leading to partial or total
occlusion of the coronary artery.
Define STEMI ✔️Ans - Defined by characteristic symptoms of myocardial
ischemia in association with persistent ST-segment elevation on ECG with
positive troponins
Define NSTEMI ✔️Ans - Suggested by the absence of persistent ST-
segment elevation on ECG
NSTE-ACS can be divided into unstable angina (UA) and NSTEMI according
to whether cardiac biomarkers of necrosis are present. UA and NSTEMI are
closely related conditions whose pathogenesis and clinical presentation are
similar but vary in risk and severity.
When should 12-lead ECG be obtained in ACS? ✔️Ans - 10 minutes of
presentation
When should cardiac troponins be obtained in ACS? ✔️Ans - At
presentation and 3-6 hrs after symptom onset
Thrombolysis in Myocardial Infarction (TIMI) ✔️Ans - Useful in predicting
30-day and 1-year mortality in patients with NSTE-ACS.
Global Registry of Acute Coronary Events (GRACE) risk model ✔️Ans -
Predicts in-hospital and post discharge mortality or MI. Patients with high
GRACE risk model scores (i.e., GRACE score greater than 40 can be
identified for early invasive strategies.
,What is the goal of therapy in STEMI? ✔️Ans - The goal of therapy is to
restore the patency of the infarct-related artery and minimize the infarct
size. Secondary goals include preventing complications such as
arrhythmias or death as well as controlling chest pain and associated
symptoms.
What is the preferred intervention for STEMI? ✔️Ans - Primary PCI >>
lytic therapy
When should a PCI be completed in STEMI? ✔️Ans - 90 minutes of first
medical contact
If PCI cannot be done, when should lytic therapy be administered? ✔️Ans -
If PCI cannot be done within 120 minutes, performance measure for lytic
administration includes a door-to-needle time of 30 minutes.
What is the goal of therapy for NSTE-ACS? ✔️Ans - The goal of therapy is
to prevent total occlusion of the related artery and to control chest pain
and associated symptoms.
Patients with NSTE-ACS are treated on the basis of risk (TIMI, GRACE) with
either an early invasive strategy (interventional approach) or an ischemia-
guided strategy (a conservative management strategy using medications
rather than an interventional approach).
What is the early invasive strategy in ACS? ✔️Ans - A diagnostic
angiography with the intent to do revascularization, if appropriate,
depending on coronary anatomy.
When is routine invasive therapy superior to ischemia-guided strategy?
✔️Ans - Patients with one or more of the following risk features: Advanced
age (older than 70)
Previous MI or revascularization
ST deviation
HF
Depressed resting left ventricle (LV) function (i.e., LVEF less than 40%)
Noninvasive stress findings
High TlMl or RACE scores,
Markedly elevated troponins
Diabetes.
,What medications should be given early in care for ACS? ✔️Ans -
Morphine
Oxygen
Nitroglycerin
Aspirin
Beta blocker
Which antiplatelet agents are preferred in patients with NSTE-ACS who
undergo the ischemia guided strategy? ✔️Ans - Aspirin
+
Clopidogrel OR ticagrelor
Which antiplatelet agents are preferred in patients with NSTE-ACS who
undergo the invasive strategy? ✔️Ans - Aspirin
+
Clopidogrel OR Prasugrel OR Ticagrelor
Which antiplatelet agents are preferred in patients with STEMI who
undergo primary PCI? ✔️Ans - Aspirin
+
Clopidogrel OR Prasugrel OR ticagrelor
Which antiplatelet agents are preferred in patients with STEMI who receive
lytic therapy? ✔️Ans - Aspirin
+
Clopidogrel
What is the mechanism of action in aspirin? ✔️Ans - An irreversible
cyclooxygenase-1 inhibitor blocking the formation of thromboxane A2- and
thromboxane A2-mediated platelet activation
What is the benefit of aspirin in ACS? ✔️Ans - Reduces the incidence of
recurrent MI and death
What is the loading dose for aspirin in ACS? ✔️Ans - Dosing is 162-325
mg for patients at initial presentation of ACS
Dosing is 81-325 mg for those who are undergoing PCI, depending on
chronic aspirin therapy regimen
, What is the maintenance dose of aspirin in ACS? ✔️Ans - Aspirin is given
indefinitely at a preferred dose of 81 mg after ACS with or without PCI
(class I).
High dose (greater than 160 mg) is associated with more bleeding than
lower dose (less than 160 mg).
High doses (greater than 160 mg) have not been shown to improve
outcomes after ACS more effectively than lower doses (less than 160 mg).
How long should patients with ACS receive dual therapy? ✔️Ans - Dual
antiplatelet therapy (DAPT) with aspirin plus a P2Y12 receptor inhibitor is
indicated for all patients after ACS for at least 12 months
What is the mechanism of action of P2Y12 inhibitors? ✔️Ans - Inhibit the
effect of adenosine diphosphate on the platelet, a key mediator resulting in
amplification of platelet activation
What are contraindications to prasugrel? ✔️Ans - history of stroke or
transient ischemic attack
Why should higher doses of aspirin be avoided with ticagrelor? ✔️Ans -
The efficacy of ticagrelor is decreased in patients treated with higher doses
of aspirin (greater than 300 mg daily) compared with lower doses (less
than 100 mg daily).
What is the loading dose of clopidogrel? ✔️Ans - Clopidogrel 600 mg
followed by 75 mg daily
What is the loading dose of prasugrel? ✔️Ans - PRA 60 mg followed by 10
mg daily
What is the loading dose of ticagrelor? ✔️Ans - TIC 180 mg followed by 90
mg BID
What is the role for cangrelor in ACS? ✔️Ans - Primarily studied in the
setting of PCI only and may be considered in those who are not candidates
for oral agents. Cangrelor has potential use as a bridge therapy after
Define acute coronary syndrome ✔️Ans - A spectrum of conditions
compatible with acute myocardial ischemia or infarction caused by an
abrupt reduction in coronary blood flow
Describe the pathophysiology of ACS ✔️Ans - Atherogenic plaque rupture
is the underlying pathophysiology for ACS, causing several prothrombotic
substances to be released, which results in platelet activation and
aggregation and eventual thrombus formation leading to partial or total
occlusion of the coronary artery.
Define STEMI ✔️Ans - Defined by characteristic symptoms of myocardial
ischemia in association with persistent ST-segment elevation on ECG with
positive troponins
Define NSTEMI ✔️Ans - Suggested by the absence of persistent ST-
segment elevation on ECG
NSTE-ACS can be divided into unstable angina (UA) and NSTEMI according
to whether cardiac biomarkers of necrosis are present. UA and NSTEMI are
closely related conditions whose pathogenesis and clinical presentation are
similar but vary in risk and severity.
When should 12-lead ECG be obtained in ACS? ✔️Ans - 10 minutes of
presentation
When should cardiac troponins be obtained in ACS? ✔️Ans - At
presentation and 3-6 hrs after symptom onset
Thrombolysis in Myocardial Infarction (TIMI) ✔️Ans - Useful in predicting
30-day and 1-year mortality in patients with NSTE-ACS.
Global Registry of Acute Coronary Events (GRACE) risk model ✔️Ans -
Predicts in-hospital and post discharge mortality or MI. Patients with high
GRACE risk model scores (i.e., GRACE score greater than 40 can be
identified for early invasive strategies.
,What is the goal of therapy in STEMI? ✔️Ans - The goal of therapy is to
restore the patency of the infarct-related artery and minimize the infarct
size. Secondary goals include preventing complications such as
arrhythmias or death as well as controlling chest pain and associated
symptoms.
What is the preferred intervention for STEMI? ✔️Ans - Primary PCI >>
lytic therapy
When should a PCI be completed in STEMI? ✔️Ans - 90 minutes of first
medical contact
If PCI cannot be done, when should lytic therapy be administered? ✔️Ans -
If PCI cannot be done within 120 minutes, performance measure for lytic
administration includes a door-to-needle time of 30 minutes.
What is the goal of therapy for NSTE-ACS? ✔️Ans - The goal of therapy is
to prevent total occlusion of the related artery and to control chest pain
and associated symptoms.
Patients with NSTE-ACS are treated on the basis of risk (TIMI, GRACE) with
either an early invasive strategy (interventional approach) or an ischemia-
guided strategy (a conservative management strategy using medications
rather than an interventional approach).
What is the early invasive strategy in ACS? ✔️Ans - A diagnostic
angiography with the intent to do revascularization, if appropriate,
depending on coronary anatomy.
When is routine invasive therapy superior to ischemia-guided strategy?
✔️Ans - Patients with one or more of the following risk features: Advanced
age (older than 70)
Previous MI or revascularization
ST deviation
HF
Depressed resting left ventricle (LV) function (i.e., LVEF less than 40%)
Noninvasive stress findings
High TlMl or RACE scores,
Markedly elevated troponins
Diabetes.
,What medications should be given early in care for ACS? ✔️Ans -
Morphine
Oxygen
Nitroglycerin
Aspirin
Beta blocker
Which antiplatelet agents are preferred in patients with NSTE-ACS who
undergo the ischemia guided strategy? ✔️Ans - Aspirin
+
Clopidogrel OR ticagrelor
Which antiplatelet agents are preferred in patients with NSTE-ACS who
undergo the invasive strategy? ✔️Ans - Aspirin
+
Clopidogrel OR Prasugrel OR Ticagrelor
Which antiplatelet agents are preferred in patients with STEMI who
undergo primary PCI? ✔️Ans - Aspirin
+
Clopidogrel OR Prasugrel OR ticagrelor
Which antiplatelet agents are preferred in patients with STEMI who receive
lytic therapy? ✔️Ans - Aspirin
+
Clopidogrel
What is the mechanism of action in aspirin? ✔️Ans - An irreversible
cyclooxygenase-1 inhibitor blocking the formation of thromboxane A2- and
thromboxane A2-mediated platelet activation
What is the benefit of aspirin in ACS? ✔️Ans - Reduces the incidence of
recurrent MI and death
What is the loading dose for aspirin in ACS? ✔️Ans - Dosing is 162-325
mg for patients at initial presentation of ACS
Dosing is 81-325 mg for those who are undergoing PCI, depending on
chronic aspirin therapy regimen
, What is the maintenance dose of aspirin in ACS? ✔️Ans - Aspirin is given
indefinitely at a preferred dose of 81 mg after ACS with or without PCI
(class I).
High dose (greater than 160 mg) is associated with more bleeding than
lower dose (less than 160 mg).
High doses (greater than 160 mg) have not been shown to improve
outcomes after ACS more effectively than lower doses (less than 160 mg).
How long should patients with ACS receive dual therapy? ✔️Ans - Dual
antiplatelet therapy (DAPT) with aspirin plus a P2Y12 receptor inhibitor is
indicated for all patients after ACS for at least 12 months
What is the mechanism of action of P2Y12 inhibitors? ✔️Ans - Inhibit the
effect of adenosine diphosphate on the platelet, a key mediator resulting in
amplification of platelet activation
What are contraindications to prasugrel? ✔️Ans - history of stroke or
transient ischemic attack
Why should higher doses of aspirin be avoided with ticagrelor? ✔️Ans -
The efficacy of ticagrelor is decreased in patients treated with higher doses
of aspirin (greater than 300 mg daily) compared with lower doses (less
than 100 mg daily).
What is the loading dose of clopidogrel? ✔️Ans - Clopidogrel 600 mg
followed by 75 mg daily
What is the loading dose of prasugrel? ✔️Ans - PRA 60 mg followed by 10
mg daily
What is the loading dose of ticagrelor? ✔️Ans - TIC 180 mg followed by 90
mg BID
What is the role for cangrelor in ACS? ✔️Ans - Primarily studied in the
setting of PCI only and may be considered in those who are not candidates
for oral agents. Cangrelor has potential use as a bridge therapy after
