ACLS Acute Coronary Syndromes 5 — Questions and Answers
Question 1: A patient develops acute pulmonary edema 2 days after STEMI. Echocardiography reveals a new holosystolic murmur at the cardiac apex with radiation to the axilla. What is the most likely complication?
- Ventricular septal rupture
- Free wall rupture
- Acute mitral regurgitation due to papillary muscle rupture (Correct answer)
- Pericardial tamponade
Correct answer: Acute mitral regurgitation due to papillary muscle rupture
Papillary muscle rupture causing acute mitral regurgitation typically presents 2–7 days post-STEMI with pulmonary edema and an apical holosystolic murmur radiating to the axilla.
Question 2: Which of the following ECG findings would indicate de Winter T-wave pattern, a STEMI-equivalent requiring emergent catheterization?
- Diffuse ST elevation with saddle shape
- Upsloping ST depression at J-point with tall, symmetric T waves in precordial leads (Correct answer)
- Biphasic T waves in V1–V2 with preserved R waves
- ST elevation in aVR with diffuse ST depression
Correct answer: Upsloping ST depression at J-point with tall, symmetric T waves in precordial leads
De Winter T-wave pattern is characterized by upsloping ST depression at the J-point with tall, prominent T waves in precordial leads, indicating proximal LAD occlusion.
Question 3: A patient stabilized after NSTEMI is being discharged. Which long-term medication has been proven to reduce recurrent MI and cardiovascular mortality regardless of LDL level?
- Fibrate therapy
- High-intensity statin therapy (Correct answer)
- Niacin supplementation
- Bile acid sequestrant
Correct answer: High-intensity statin therapy
High-intensity statin therapy (atorvastatin 40–80 mg or rosuvastatin 20–40 mg) is recommended for all ACS patients regardless of baseline LDL level.
Question 4: Which of the following correctly describes the difference between unstable angina and NSTEMI?
- Unstable angina has ST elevation; NSTEMI does not
- Unstable angina has elevated troponin; NSTEMI does not
- NSTEMI has elevated troponin; unstable angina does not (Correct answer)
- NSTEMI always requires fibrinolysis; unstable angina does not
Correct answer: NSTEMI has elevated troponin; unstable angina does not
NSTEMI is distinguished from unstable angina by the presence of elevated cardiac biomarkers (troponin), indicating myocardial necrosis has occurred.
Question 5: A patient presents with STEMI and is in Killip Class IV. Which Killip class does this represent?
- No heart failure signs
- Mild-to-moderate heart failure with rales
- Severe heart failure with pulmonary edema
- Cardiogenic shock (Correct answer)
Correct answer: Cardiogenic shock
Killip Class IV is defined as cardiogenic shock with systolic BP <90 mmHg, oliguria, and peripheral vasoconstriction, carrying the highest mortality.
Question 6: Which arrhythmia most commonly occurs within the first hour of STEMI and is the leading cause of out-of-hospital cardiac arrest in this setting?
- Atrial fibrillation
- Ventricular fibrillation (Correct answer)
- Complete heart block
- Accelerated idioventricular rhythm
Correct answer: Ventricular fibrillation
Ventricular fibrillation is the most common cause of death in the first hour of STEMI, primarily occurring before hospital arrival.
Question 7: ACE inhibitors are recommended post-STEMI in which group of patients?
- All STEMI patients regardless of EF, started within 24 hours
- Only patients with an EF > 55% and no symptoms
- Patients with anterior STEMI, reduced EF < 40%, or signs of heart failure (Correct answer)
- Only patients who are intolerant of beta-blockers
Correct answer: Patients with anterior STEMI, reduced EF < 40%, or signs of heart failure
ACE inhibitors are strongly indicated in STEMI patients with anterior wall MI, EF <40%, or clinical signs of heart failure to reduce remodeling and mortality.
ACLS Acute Coronary Syndromes 5
A patient develops acute pulmonary edema 2 days after STEMI.
Echocardiography reveals a new holosystolic murmur at the cardiac apex with radiation to the axilla.
What is the most likely complication?