Internal Medicine Exam Acute Coronary Syndromes 3 — Questions and Answers
Question 1: A 70-year-old man with anterior STEMI develops cardiogenic shock. His BP is 75/50 mmHg and he is on maximum vasopressors. What is the most appropriate next step?
- Add IV diuretics to reduce preload
- Insert an intra-aortic balloon pump (IABP) and proceed to PCI (Correct answer)
- Administer thrombolytics given inability to reach cath lab
- Transfer for emergent surgical revascularization without PCI
Correct answer: Insert an intra-aortic balloon pump (IABP) and proceed to PCI
Cardiogenic shock complicating STEMI requires mechanical circulatory support (IABP or more advanced devices) along with emergent PCI, which is the definitive treatment to restore perfusion.
Question 2: Which troponin characteristic best distinguishes Type 2 MI (supply-demand mismatch) from Type 1 MI (plaque rupture)?
- Higher absolute troponin level in Type 2 MI
- Clinical context and absence of obstructive coronary disease on angiography in Type 2 MI (Correct answer)
- Faster troponin rise in Type 2 MI
- Troponin I elevation only in Type 1 MI
Correct answer: Clinical context and absence of obstructive coronary disease on angiography in Type 2 MI
Type 2 MI is distinguished by clinical context (e.g., sepsis, tachyarrhythmia, anemia) causing supply-demand mismatch, often without obstructive CAD on angiography, rather than by troponin kinetics.
Question 3: A post-STEMI patient is started on an ACE inhibitor. What is the PRIMARY evidence-based indication for this therapy?
- Prevention of in-stent thrombosis
- Reduction of LV remodeling and mortality, especially with reduced EF (Correct answer)
- Lowering LDL cholesterol
- Prevention of ventricular arrhythmias
Correct answer: Reduction of LV remodeling and mortality, especially with reduced EF
ACE inhibitors reduce LV remodeling, HF, and mortality after MI, with greatest benefit in patients with anterior STEMI or reduced ejection fraction (EF ≤40%).
Question 4: Spontaneous coronary artery dissection (SCAD) causing ACS most commonly occurs in which patient population?
- Elderly men with longstanding hypertension
- Young women in the peripartum period or with fibromuscular dysplasia (Correct answer)
- Diabetic patients with multivessel CAD
- Patients with prior cocaine use
Correct answer: Young women in the peripartum period or with fibromuscular dysplasia
SCAD predominantly affects young women, especially peripartum or those with fibromuscular dysplasia, and presents with ACS without typical atherosclerotic risk factors.
Question 5: A patient with STEMI undergoes primary PCI. Post-procedure, the culprit vessel is patent but the patient has no ST resolution and persistent symptoms. What phenomenon best explains this?
- Stent thrombosis
- No-reflow phenomenon (Correct answer)
- Coronary vasospasm
- Aortic dissection extension
Correct answer: No-reflow phenomenon
No-reflow occurs when myocardial perfusion is inadequate despite a patent epicardial artery, caused by microvascular obstruction from embolization of debris and reperfusion injury.
Question 6: Which statin regimen is recommended for all ACS patients regardless of baseline LDL level?
- Low-intensity statin (e.g., pravastatin 10 mg)
- Moderate-intensity statin (e.g., atorvastatin 20 mg)
- High-intensity statin (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg) (Correct answer)
- Statin therapy only if LDL >130 mg/dL
Correct answer: High-intensity statin (e.g., atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
Guidelines recommend high-intensity statin therapy for all ACS patients to achieve LDL <70 mg/dL and reduce cardiovascular events, regardless of baseline LDL.
Question 7: In a STEMI patient presenting 3 hours after symptom onset at a non-PCI-capable hospital, what is the recommended door-to-device (DTD) time if transfer for primary PCI is chosen?
- Within 90 minutes
- Within 120 minutes (Correct answer)
- Within 180 minutes
- Within 240 minutes
Correct answer: Within 120 minutes
If primary PCI is chosen at a non-PCI-capable hospital, the total first-medical-contact-to-device time should be ≤120 minutes; otherwise, fibrinolysis should be administered first.
Internal Medicine Exam Acute Coronary Syndromes 3
A 70-year-old man with anterior STEMI develops cardiogenic shock.
His BP is 75/50 mmHg and he is on maximum vasopressors.
What is the most appropriate next step?