An 85-year-old man presents with increasing intensity of his typical angina pain associated with shortness of breath. His ECG is unchanged from prior tracings. He has a history of established coronary artery disease and has previously refused revascularization. A decision is made to manage him conservatively.
Which of the following interventions would be considered inappropriate?
Treatment with clopidogrel 300 mg followed by 75 mg daily. This patient has UA and will likely rule in for an NSTEMI. Initiation of antiplatelet therapy with a bolus dose of clopidogrel 300 mg followed by 75 mg once daily is indicated based on the results of the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial. The use of prasugrel in the elderly is associated with increased risk of bleeding. In this patient who is not undergoing revascularization, the use of bolus dose prasugrel cannot be supported. In addition to antiplatelet therapy with aspirin, the patient also needs to be started on antithrombotic therapy (with unfractionated heparin, LMWH, or fondaparinux). Lastly, since he has refused revascularization, medical antianginal therapy should be maximized. Increasing β-blocker as tolerated is indicated.
Which of the following is not a direct thrombin inhibitor?
Apixaban. Bivalirudin, argatroban, and hirudin are intravenous direct thrombin inhibitors and dabigatran is an oral direct thrombin inhibitor. Apixaban is an oral factor Xa inhibitor.
Which of the following is true regarding pericarditis in acute MI?
Fibrinolysis reduces the incidence of pericarditis in MI. Several studies, including Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (Italian) (GISSI 1), have examined this issue and found that fibrinolysis reduces the incidence of pericarditis in the setting of acute MI. Indeed, in the era of reperfusion therapy, the rate of both early and late pericarditis has decreased. Probably, by reducing infarct size, reperfusion decreases the incidence of pericarditis, which is more common with large MIs.
Which of the following are potential indications for IABP in the setting of acute MI?
All of the above are acceptable indications for IABP use
A 66-year-old man presents to the emergency with complaints of on–off episodes of chest discomfort for the last 24 hours. Each episode lasts from 15 to 45 minutes and occurs at rest. He denies any history of similar pain in the past. He has a past medical history of hypertension, diabetes mellitus, and peripheral vascular disease. He is an active smoker with 40 pack-year history. An ECG done reveals nonspecific ST-T wave changes. Troponin T is elevated at 0.62. He is taken to the catheterization laboratory and a 90% lesion is noted in first diagonal via a transfemoral approach. He is treated with overlapping BMSs with subsequent TIMI-3 flow. He is transferred to CCU in stable condition. About 4 hours later, the patient develops hypotension with BP of 80/40 mmHg and heart rate of 110 per minute. There is no jugular venous distension. He is pale, diaphoretic, and dizzy. Cardiac auscultation is unchanged. A repeat ECG done is similar to admission ECG. No pericardial effusion is noted on a bedside echocardiogram.
Which of the following is most likely to identify the cause of his current condition?
CT abdomen without contrast. The patient has signs and symptoms suggestive of massive retroperitoneal bleeding after left heart catheterization. Retroperitoneal bleeding is a common complication after left heart catheterization through femoral access. Patients present with anemia that may be hard to detect on clinical examination. CT abdomen without contrast is the test of choice to confirm bleeding. He has no signs of recurrent ischemia on ECG and as such repeat catheterization to look for stent thrombosis (a) is not indicated. Lack of elevated jugular venous pulse makes pulmonary embolism (b) or cardiac tamponade/acute mitral regurgitation (e) unlikely.
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