In the setting of primary angioplasty for acute MI, which of the following have stents been convincingly shown to do compared with balloon angioplasty alone?
Decrease subsequent repeat TVR. Stents decrease the rate of subsequent TVR compared with balloon angioplasty alone, but there is no favorable impact on TIMI-3 flow or mortality.
Which of the following is true about reteplase in Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III)?
It had similar rates of mortality compared with alteplase. It had similar rates of mortality to alteplase. This noninferiority trial randomized over 15,000 patients with STEMI to intravenous alteplase or reteplase. The rates of mortality (11.20% and 11.06% at 1 year, respectively) and stroke were similar for reteplase and alteplase. The major advantage of reteplase was that it could be given as two boluses rather than as an infusion.
Which of the following statements is true regarding non–ST-segment elevation (NSTE)-ACS?
All of the above. Results from large TIMI registry indicate that biomarker elevation (NSTEMI) and ST-segment deviation on admission ECG carries poorer prognosis in patients with NSTE-ACS. In addition, one in five patients with NSTE-ACS may have normal or nonspecific changes on ECG.
A 46-year-old man presents to the emergency with complaints of sudden, severe chest pain radiating to his right arm. He admits to snorting crack cocaine 2 hours prior to the development of chest pain. His BP is 180/100 mmHg and heart rate is 96 per minute. An ECG done reveals downsloping ST depression and T-wave inversion in V2 to V4 .
What is the next best step in management?
Administer aspirin, sublingual nitroglycerin, and heparin. The patient has signs and symptoms suggestive of cocaine-induced ACS. The dominant underlying pathophysiologic factor in cocaine-induced ACS can be coronary spasm or thrombus formation caused by α-adrenergic stimulation. Atherosclerosis is also accelerated by cocaine use. This patient should be started on aspirin, sublingual nitroglycerin, and intravenous heparin. β-Blockers are contraindicated as they may allow unopposed β-adrenergic stimulation and have been associated with increased mortality.
A 46-year-old man presents to the emergency with complaints of sudden, severe chest pain radiating to his right arm. He admits to snorting crack cocaine 2 hours prior to the development of chest pain. His BP is 180/100 mmHg and heart rate is 96 per minute. An ECG done reveals downsloping ST depression and T-wave inversion in V2 to V4.
The patient is started on aspirin, nitroglycerin, and intravenous heparin. He continues to have severe substernal chest pain. Repeat ECG is unchanged. Troponin T is borderline elevated to 0.04 ng/mL.
Activate the catheterization laboratory for emergent left heart catheterization. The patient has persistent ischemia after initiation of antianginal therapy. He needs to be sent for emergent left heart catheterization. Intravenous benzodiazepine can temporarily relieve cocaineinduced chest pain but this patient has ischemic symptoms with ECG changes suggestive of ACS. Fibrinolytics have not been shown to be useful in cocaine-induced chest pain without evident thrombosis.
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