CSC Risk Assessment & Management 4 — Questions and Answers
Question 1: A patient on dual antiplatelet therapy (DAPT) after drug-eluting stent placement requires urgent non-cardiac surgery at 2 months post-stent. What is the recommended management?
- Discontinue both agents 5-7 days before surgery
- Continue aspirin alone and hold the P2Y12 inhibitor perioperatively (Correct answer)
- Continue full DAPT through the perioperative period
- Substitute IV heparin bridging for oral DAPT
Correct answer: Continue aspirin alone and hold the P2Y12 inhibitor perioperatively
When surgery cannot be deferred beyond 30 days post-DES, continuing aspirin while holding the P2Y12 inhibitor minimizes both bleeding and stent thrombosis risk.
Question 2: Which non-invasive stress test has the highest sensitivity for detecting significant coronary artery disease in patients with known left bundle branch block (LBBB)?
- Exercise treadmill test (ETT)
- Dobutamine stress echocardiography
- Adenosine stress myocardial perfusion imaging (MPI) (Correct answer)
- Exercise stress echocardiography
Correct answer: Adenosine stress myocardial perfusion imaging (MPI)
Vasodilator pharmacologic stress (adenosine or regadenoson) MPI is preferred in LBBB because exercise and dobutamine can cause false-positive septal defects.
Question 3: The EuroSCORE II is primarily designed to predict which outcome in cardiac surgical patients?
- 30-day stroke risk
- In-hospital or 30-day operative mortality (Correct answer)
- 5-year cardiovascular mortality
- Perioperative atrial fibrillation
Correct answer: In-hospital or 30-day operative mortality
EuroSCORE II predicts in-hospital or 30-day operative mortality risk in patients undergoing cardiac surgery.
Question 4: In a patient with stable ischemic heart disease, which finding on coronary CT angiography (CCTA) most increases the risk of future MACE beyond luminal stenosis assessment?
- Positive remodeling with low-attenuation plaque (vulnerable plaque features) (Correct answer)
- Calcified plaque burden >100 Agatston units
- Non-dominant right coronary artery
- Mild luminal irregularity without stenosis
Correct answer: Positive remodeling with low-attenuation plaque (vulnerable plaque features)
Positive arterial remodeling combined with low-attenuation (lipid-rich) plaque on CCTA identifies high-risk 'vulnerable' plaques associated with future acute coronary events.
Question 5: Which variable is NOT included in the MAGGIC risk calculator for heart failure prognosis?
- Age
- Ejection fraction
- Serum sodium
- 6-minute walk distance (Correct answer)
Correct answer: 6-minute walk distance
The MAGGIC score incorporates clinical and laboratory variables including age, EF, BMI, creatinine, NYHA class, and serum sodium, but not 6-minute walk distance.
Question 6: A 58-year-old diabetic woman presents with atypical chest pain. Her pretest probability of obstructive CAD is intermediate. Which initial diagnostic strategy is most appropriate?
- Immediate coronary angiography
- Exercise ECG alone
- Stress imaging (nuclear MPI or stress echo) (Correct answer)
- CT coronary angiography
Correct answer: Stress imaging (nuclear MPI or stress echo)
In patients with intermediate pretest probability and interpretable ECG but suboptimal exercise capacity, or atypical symptoms, stress imaging provides higher sensitivity and specificity than exercise ECG alone.
Question 7: Which scoring system stratifies risk of contrast-induced nephropathy following PCI based on pre-procedure clinical variables?
- GRACE score
- Mehran risk score (Correct answer)
- TIMI risk index
- SYNTAX score
Correct answer: Mehran risk score
The Mehran risk score uses variables such as age, contrast volume, eGFR, hemodynamic status, and diabetes to stratify the risk of contrast-induced nephropathy after PCI.
CSC Risk Assessment & Management 4
A patient on dual antiplatelet therapy (DAPT) after drug-eluting stent placement requires urgent non-cardiac surgery at 2 months post-stent.
What is the recommended management?