Internal Medicine Exam Acute Coronary Syndromes 2 — Questions and Answers
Question 1: A 58-year-old man with NSTEMI has a TIMI risk score of 5. Which management strategy is most appropriate?
- Medical therapy alone with discharge in 24 hours
- Early invasive strategy (cardiac catheterization within 24-48 hours) (Correct answer)
- Immediate thrombolytic therapy
- Emergent surgical revascularization without catheterization
Correct answer: Early invasive strategy (cardiac catheterization within 24-48 hours)
A high TIMI score (≥3) in NSTEMI favors an early invasive strategy with catheterization within 24-48 hours due to higher risk of adverse outcomes.
Question 2: Which ECG finding in a patient with chest pain represents a 'STEMI equivalent' requiring immediate reperfusion?
- Diffuse ST depression in leads V1-V6
- New left bundle branch block (LBBB) with typical ischemic symptoms (Correct answer)
- T-wave inversions in leads III and aVF
- PR interval prolongation with ST changes
Correct answer: New left bundle branch block (LBBB) with typical ischemic symptoms
New LBBB in the context of ischemic symptoms is considered a STEMI equivalent because it obscures ST-segment analysis and warrants immediate reperfusion therapy.
Question 3: A patient with inferior STEMI develops hypotension and elevated JVP without pulmonary congestion. Which diagnosis should be suspected first?
- Cardiogenic shock from LV failure
- Right ventricular infarction (Correct answer)
- Aortic dissection
- Pulmonary embolism
Correct answer: Right ventricular infarction
Right ventricular infarction commonly accompanies inferior STEMI and presents with hypotension, elevated JVP, and clear lungs (Kussmaul's sign may be present).
Question 4: Which antiplatelet agent should be AVOIDED in a patient with ACS who requires urgent coronary artery bypass grafting (CABG)?
- Aspirin
- Ticagrelor
- Prasugrel (Correct answer)
- Low-dose aspirin plus clopidogrel
Correct answer: Prasugrel
Prasugrel is contraindicated when CABG is planned because its irreversible and potent platelet inhibition significantly increases surgical bleeding risk; it should be held at least 7 days before CABG.
Question 5: A 62-year-old woman presents with NSTEMI. Her creatinine is 2.8 mg/dL. Which anticoagulant requires the most careful dose adjustment in this setting?
- Unfractionated heparin (UFH)
- Enoxaparin (LMWH) (Correct answer)
- Bivalirudin
- Fondaparinux
Correct answer: Enoxaparin (LMWH)
Enoxaparin is renally cleared and accumulates in renal failure, significantly increasing bleeding risk; dose reduction is required when CrCl <30 mL/min, and UFH is often preferred in severe renal impairment.
Question 6: Which complication of STEMI typically presents 5-10 days after the initial event with new holosystolic murmur and hemodynamic deterioration?
- Papillary muscle rupture causing acute mitral regurgitation
- Free wall rupture
- Ventricular septal defect (VSD) (Correct answer)
- Pericarditis (Dressler syndrome)
Correct answer: Ventricular septal defect (VSD)
Post-infarction VSD presents 3-7 days after STEMI with a new harsh holosystolic murmur at the left sternal border, step-up in O2 saturation from right atrium to pulmonary artery, and cardiogenic shock.
Question 7: Clopidogrel should be avoided in patients who have recently taken which medication due to reduced antiplatelet efficacy?
- Metoprolol
- Omeprazole (Correct answer)
- Lisinopril
- Atorvastatin
Correct answer: Omeprazole
Omeprazole inhibits CYP2C19, the enzyme responsible for converting clopidogrel (a prodrug) to its active metabolite, thereby significantly reducing its antiplatelet effect.
Internal Medicine Exam Acute Coronary Syndromes 2
A 58-year-old man with NSTEMI has a TIMI risk score of 5.
Which management strategy is most appropriate?