Question 81#

The same patient was investigated with stress imaging before and after PCI to assess the extension of myocardial ischemia.

Which of the following statements is correct regarding the benefit of PCI over medical therapy in this setting?

A. A greater reduction in the extension of residual myocardial ischemia

All of the above. In the COURAGE patients, 314 were enrolled in the substudy of myocardial perfusion SPECT performed before treatment and 6 to 18 months after randomization. At follow-up, the reduction in ischemic myocardium was greater with PCI + OMT than with OMT (–2.7% versus – 0.5%, P <0.0001). The patients with PCI + OMT exhibited significant ischemia reduction (33% versus 19%, P = 0.0004), especially those patients with moderate-to-severe myocardial ischemia at baseline (78% versus 52%, P = 0.007). The 2012 AHA/ACC guidelines for PCI mentioned in patients with stable ischemic coronary heart disease a benefit of angina reduction and symptom improvement with PCI versus OMT; however, PCI has not been demonstrated to improve survival in stable patients.

Question 82#

A 63-year-old man has been successfully treated with percutaneous coronary revascularization for a stable angina pectoris. His low-density lipoprotein cholesterol (LDL-C) value was 143 mg/dL.

Which of the following statement is incorrect regarding the impact of prescribing intensive lipidlowering therapy (e.g., 80 mg atorvastatin daily) compared with less intensive therapy (e.g., 10 mg atorvastatin daily)?

A. Higher LDL-C level reduction

Significant absolute risk reduction of major adverse cardiovascular events (MACE) of ~2% over 5 years. The 2012 ACC/AHA guidelines for the management of SIHD recommend the prescription of moderate or high dose of a statin therapy in addition to lifestyle changes (class I, evidence A). The Treating to New Targets (TNT) study randomized 10,001 patients with stable coronary heart disease and LDL >130 mg/dL to receive atorvastatin 10 or 80 mg daily. The mean LDL-C was 2.0 mmol/L during the treatment with 80 mg of atorvastatin, whereas it was 2.6 mmol/L during the treatment with 10 mg of atorvastatin. About 8.7% of patients in the group with intensive lipid-lowering therapy and 10.9% in the group with moderate lipid-lowering therapy presented MACE during a median follow-up of 4.9 years, representing a significant absolute reduction in the rate of MACE of 2.2% and a 22% relative reduction in risk. There was no difference between both treatment groups in the overall mortality.

Question 83#

A 67-year-old man is treated with PCI.

Which of the following statement is not correct regarding periprocedural anticoagulation?

A. An anticoagulant should be administered to all patients undergoing PCI

Fondaparinux might be used as the sole anticoagulant to support PCI. The 2011 ACCF/AHA PCI guidelines made the following recommendations regarding anticoagulant therapy during the procedure. Following recommendations are class I:

1. All patients undergoing PCI should receive an anticoagulant to prevent thrombus formation during the procedure.
2. The administration of IV UFH is a useful standard therapy in patients undergoing PCI.
3. An additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of PCI to patients who have received fewer than two therapeutic subcutaneous doses (e.g., 1 mg/kg) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI.
4. For patients undergoing PCI, bivaluridin is useful as an anticoagulant with or without prior treatment with UFH. In contrast, fondaparinux should not be used as the sole anticoagulant to support PCI.

An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis. Fondaparinux is an indirect factor Xa inhibitor, but no effect on thrombin (IIa). The use of fondaparinux alone was associated with thrombus catheter formation and therefore the anticoagulant with anti-IIa should be used during PCI.

Question 84#

A 65-year-old male hypertensive smoker benefited from primary PCI of the RCA for inferior STEMI.

Which of the following statements is not correct regarding secondary prevention in this patient?

A. Medically supervised cardiac rehabilitation programs are recommended

Even in the absence of symptoms, routine periodic stress testing is indicated. According to the 2011 AHA/ACC PCI and 2011 AHA/ACC secondary prevention guidelines, the following interventions and targets are strongly recommended in patients with CHD to reduce morbidity and mortality:

1. To refer to a medically supervised cardiac rehabilitation program post discharge.
2. To manage lipid-lowering treatment for an LDLC target <70 mg/dL.
3. To control blood pressure with the goal of <140/90 mmHg.
4. To advise patients for complete smoking cessation.

Conversely, there is no proven benefit or indication for routine periodic stress testing in patients after PCI, and thus, it is not indicated.

Question 85#

A 60-year-old male patient was treated 2 years earlier with PCI and the implantation of BMS in the LAD for NSTEMI. He complains about recurrent worsening exertional chest pain in the last week.

Coronary angiography reveals ISR. What are the predisposing factors for BMS restenosis?

A. Diabetes

All of the above. The clinical situations associated with higher risk of BMS restenosis have been defined by the 2011 AHA/ACC PCI guidelines as follows:

1. Left main disease.
2. Small vessels.
3. ISR.
4. Bifurcations.
5. Diabetes.
6. Long lesions.
7. Multiple lesions.
8. Saphenous vein grafts.

The ISR of BMS presented by the patient should be treated with DES, as sirolimus- or paclitaxel-eluting stents are superior to balloon angioplasty. The use of DES over BMS had decreased the incidence of ISR by over 70%.