ACLS Acute Coronary Syndromes 3 — Questions and Answers
Question 1: A patient in the ED is diagnosed with STEMI. The nearest PCI-capable hospital is 3 hours away. What is the most appropriate reperfusion strategy?
- Transfer immediately for primary PCI
- Administer fibrinolytic therapy if no contraindications (Correct answer)
- Perform emergency CABG at the current facility
- Administer high-dose aspirin only and observe
Correct answer: Administer fibrinolytic therapy if no contraindications
When PCI cannot be performed within 120 minutes of first medical contact, fibrinolytic therapy should be administered if there are no contraindications.
Question 2: Which of the following is an absolute contraindication to fibrinolytic therapy in STEMI?
- Age over 75 years
- Prior ischemic stroke more than 3 months ago
- Active internal bleeding or bleeding diathesis (Correct answer)
- Uncontrolled hypertension treated with medication
Correct answer: Active internal bleeding or bleeding diathesis
Active internal bleeding or bleeding diathesis is an absolute contraindication to fibrinolytic therapy due to the risk of life-threatening hemorrhage.
Question 3: After successful fibrinolysis for STEMI, what is the recommended time frame for transfer to a PCI-capable facility?
- Immediately post-lysis if stable
- 3 to 24 hours after fibrinolysis (Correct answer)
- Only if the patient develops recurrent symptoms
- After 48 hours of monitoring
Correct answer: 3 to 24 hours after fibrinolysis
Guidelines recommend pharmacoinvasive strategy with transfer for angiography 3–24 hours after successful fibrinolysis.
Question 4: Which ECG change most reliably indicates complete reperfusion after fibrinolytic therapy?
- Development of new Q waves
- Greater than 50% reduction in ST elevation at 90 minutes (Correct answer)
- Resolution of sinus tachycardia
- Appearance of new left bundle branch block
Correct answer: Greater than 50% reduction in ST elevation at 90 minutes
A >50% reduction in ST elevation in the worst lead at 90 minutes post-fibrinolysis is a reliable marker of successful reperfusion.
Question 5: A patient with STEMI develops cardiogenic shock. Which intervention has the strongest evidence for improving mortality?
- Intra-aortic balloon pump placement
- Emergency primary PCI (Correct answer)
- High-dose vasopressor infusion alone
- Immediate surgical revascularization
Correct answer: Emergency primary PCI
Emergency revascularization with primary PCI is the only intervention shown to reduce mortality in STEMI complicated by cardiogenic shock.
Question 6: In an ACS patient, which medication has been shown to reduce mortality when initiated within 24 hours and continued long-term?
- Calcium channel blockers
- Beta-blockers (Correct answer)
- Loop diuretics
- Antiarrhythmic class IC agents
Correct answer: Beta-blockers
Beta-blockers reduce mortality in ACS by decreasing myocardial oxygen demand, limiting infarct size, and reducing arrhythmia risk.
Question 7: Which of the following patients is at highest risk for a STEMI-equivalent condition requiring emergent reperfusion despite no classic ST elevation?
- Patient with Wellens syndrome pattern on ECG (Correct answer)
- Patient with sinus bradycardia and chest tightness
- Patient with new right bundle branch block only
- Patient with peaked T waves and hypokalemia
Correct answer: Patient with Wellens syndrome pattern on ECG
Wellens syndrome ECG pattern (biphasic or deeply inverted T waves in V2–V3) indicates critical LAD stenosis and requires urgent angiography.
ACLS Acute Coronary Syndromes 3
A patient in the ED is diagnosed with STEMI.
The nearest PCI-capable hospital is 3 hours away.
What is the most appropriate reperfusion strategy?