Management of Acute Coronary Syndromes

171 question(s) with answers and explanations.

Question 1

What combination of parameters is recommended for the diagnosis and initial short-term risk stratification of acute coronary syndrome (ACS)?

• ✓ Clinical history, symptoms, vital signs, physical findings, ECG, and hs-cTn.
• ○ Only clinical history and ECG.
• ○ Symptoms, vital signs, and ECG.
• ○ Vital signs, ECG, and chest X-ray.
• ○ Clinical history, symptoms, and systolic blood pressure.

Explanation. It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs-cTn. (I, B)

Question 2

What combination of parameters is recommended for the diagnosis and initial short-term risk stratification of acute coronary syndrome (ACS)?

• ✓ Clinical history, symptoms, vital signs, physical findings, ECG, and hs-cTn.
• ○ Only clinical history and ECG.
• ○ Symptoms, vital signs, and ECG.
• ○ Vital signs, ECG, and chest X-ray.
• ○ Clinical history, symptoms, and systolic blood pressure.

Explanation. It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs-cTn. (I, B)

Question 3

What is the recommended target time for recording and interpreting a 12-lead ECG at the point of first medical contact (FMC) for patients with suspected acute coronary syndrome?

• ○ <5 minutes
• ✓ <10 minutes
• ○ <15 minutes
• ○ <20 minutes
• ○ <30 minutes

Explanation. 12-lead ECG recording and interpretation is recommended as soon as possible at the point of FMC, with a target of <10 min. (I, B)

Question 4

What is the recommended target time for recording and interpreting a 12-lead ECG at the point of first medical contact (FMC) for patients with suspected acute coronary syndrome?

• ○ <5 minutes
• ✓ <10 minutes
• ○ <15 minutes
• ○ <20 minutes
• ○ <30 minutes

Explanation. 12-lead ECG recording and interpretation is recommended as soon as possible at the point of FMC, with a target of <10 min. (I, B)

Question 5

In patients with suspected acute coronary syndrome (ACS), when is continuous ECG monitoring and the availability of defibrillator capacity recommended?

• ○ Only after the diagnosis of myocardial infarction (MI) is confirmed
• ○ Only in patients with ongoing chest pain
• ○ Only in patients with suspected STEMI
• ✓ As soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made
• ○ Only in patients with suspected ACS (STEMI, NSTEMI, UA) and no ECG changes

Explanation. Continuous ECG monitoring and the availability of defibrillator capacity is recommended as soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made. (I, B)

Question 6

In cases of suspected acute coronary syndrome, when is the use of additional ECG leads (V3R, V4R, and V7-V9) recommended?

• ○ When there are signs of anterior STEMI on standard leads.
• ✓ When there are signs of inferior STEMI or total vessel occlusion is suspected and standard leads are inconclusive.
• ○ When there are signs of lateral STEMI on standard leads.
• ○ When there are no ST-T changes detected on standard leads.
• ○ When the patient has a history of previous myocardial infarctions.

Explanation. The use of additional ECG leads (V3R, V4R, and V7V9) is recommended in cases of inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive. (I, B) Figure 1. Right-sided chest leads are used if there is suspicion of right ventricular infarction. Figure 2. Posterior leads are used if there is suspicion of posterolateral ischemia.

Question 7

In patients with suspected acute coronary syndrome, what is recommended in cases with recurrent symptoms or diagnostic uncertainty?

• ○ A chest X-ray
• ○ An echocardiogram
• ○ A stress test
• ✓ An additional 12-lead ECG
• ○ Cardiac MRI

Explanation. An additional 12- lead ECG is recommended in cases with recurrent symptoms or diagnostic uncertainty. (I, C)

Question 8

What is recommended regarding the measurement of cardiac troponins in patients with suspected acute coronary syndrome?

• ○ To measure cardiac troponins with standard-sensitivity assays and obtain the results within 30 minutes of blood sampling.
• ✓ To measure cardiac troponins with high-sensitivity assays immediately after presentation and obtain the results within 60 minutes of blood sampling.
• ○ To measure cardiac troponins with high-sensitivity assays within 1 hour of presentation and obtain the results within 60 minutes of blood sampling.
• ○ To measure cardiac troponins with standard-sensitivity assays immediately after presentation and obtain the results within 60 minutes of blood sampling.
• ○ To measure cardiac troponins with high-sensitivity assays immediately after presentation and obtain the results within 120 minutes of blood sampling.

Explanation. It is recommended to measure cardiac troponins with high- sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling. (I, B)

Question 9

What is the recommended approach to rule in and rule out NSTEMI in patients with suspected acute coronary syndrome according to the guideline?

• ✓ Use an ESC algorithmic approach with serial hs-cTn measurements (0 h/1 h or 0 h/2 h)
• ○ Use a single hs-cTn measurement at 3 hours
• ○ Use a single hs-cTn measurement at 2 hours
• ○ Use a single hs-cTn measurement at 1 hour
• ○ Use a 12-lead ECG immediately upon presentation and hs-cTn within 1 hour of presentation.

Explanation. It is recommended to use an ESC algorithmic approach with serial hs- cTn measurements (0 h/ 1 h or 0 h/ 2 h) to rule in and rule out NSTEMI. (I, B)

Question 10

What is recommended if the first two hs-cTn measurements of the 0 h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made?

• ○ It is safe to discharge the patient
• ✓ Additional hs-cTn testing after 3 hours
• ○ Referral to myocardial perfusion scintigraphy
• ○ Initiation of antiplatelet agent (initially aspirin)
• ○ Repeat the initial hs-cTn measurements

Explanation. Additional testing after 3 h is recommended if the first two hs cTn measurements of the 0 h/ 1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made. (I, B)

Question 11

In patients with suspected acute coronary syndrome, what is recommended for prognosis estimation?

• ○ Killip class
• ○ CCS score
• ✓ The use of established risk scores (e.g. GRACE risk score)
• ○ Assessment of hemodynamic status
• ○ Hs-cTn levels

Explanation. The use of established risk scores (e.g. GRACE risk score) for prognosis estimation should be considered. (IIa, B)

Question 12

A 60-year-old woman with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden onset of severe, crushing chest pain that began 45 minutes ago. An electrocardiogram (ECG) performed upon arrival shows significant ST-segment elevation in the inferior leads. What immediate management strategy should be pursued for this patient with suspected ST-elevation myocardial infarction (STEMI)?

• ○ Patient should be monitored closely.
• ○ Patients should be scheduled for a follow-up appointment within 24 hours.
• ○ Patients should receive emergency reperfusion therapy after confirming diagnosis with multiple tests.
• ✓ Patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy.
• ○ Patients with suspected STEMI are immediately triaged for primary PCI.

Explanation. It is recommended that patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy. (I, A) The alternative "Patients with suspected STEMI are immediately triaged for primary PCI" is wrong because thrombolysis is an alternative strategy. References Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction - PubMed link . Boersma E, Maas AC, Deckers JW, Simoons ML. “Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour.” Lancet 1996;348:771–775. PubMed link. Keeley EC, Boura JA, Grines CL. “Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.” Lancet 2003;361:13–20. PubMed link.

Question 13

In patients with suspected acute coronary syndrome presenting with cardiogenic shock or suspected mechanical complications, what is recommended? A 70-year-old male with a history of coronary artery disease presents to the emergency department with severe chest pain and profound shortness of breath that began three hours ago. On examination, he is pale and clammy. His blood pressure is 80/50 mmHg, heart rate is 120 beats per minute, and oxygen saturation is 88% on room air. Jugular venous distension is noted, and lung auscultation reveals bilateral crackles. A systolic murmur is also noted. An ECG shows ST-segment elevation in the anterior leads. The patient is immediately transferred to the PCI laboratory. What is recommended for this patient, in addition to primary PCI?

• ✓ 1. Emergency TTE
• ○ 2. Emergency TEE (TOE)
• ○ 3. Emergency CT scan (coronary arteries, aorta, pulmonary arteries)
• ○ 4. Emergency MRI scan
• ○ 5. Emergency angiography

Explanation. Emergency TTE is recommended in patients with suspected ACS presenting with cardiogenic shock or suspected mechanical complications. (I, C)

Question 14

In patients with suspected acute coronary syndrome (ACS), non-elevated (or uncertain) hs-cTn levels, no ECG changes, and no recurrence of pain, which test should be considered as part of the initial workup?

• ○ 1. Echocardiography
• ✓ 2. Coronary CT angiography (CCTA)
• ○ 3. Cardiac MRI with perfusion
• ○ 4. Myocardial perfusion scintigraphy
• ○ 5. Intravascular Ultrasound (IVUS)

Explanation. In patients with suspected ACS, non-elevated (or uncertain) hs- cTn levels, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered. (IIa, A) References Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, et al. “Coronary CT angiography versus standard evaluation in acute chest pain.” N Engl J Med 2012;367:299–308. PubMed link Samad Z, Hakeem A, Mahmood SS, Pieper K, Patel MR, Simel DL, et al. “A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department.” J Nucl Cardiol 2012;19:364–376. PubMed link Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, et al. “CT angiography for safe discharge of patients with possible acute coronary syndromes.” N Engl J Med 2012;366:1393–1403. PubMed link Hulten E, Pickett C, Bittencourt MS, Villines TC, Petrillo S, Di Carli MF, et al. “Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials.” J Am Coll Cardiol 2013;61:880–892. PubMed link Gaibazzi N, Reverberi C, Badano L. “Usefulness of contrast stress-echocardiography or exercise-electrocardiography to predict long-term acute coronary syndromes in patients presenting with chest pain without electrocardiographic abnormalities or 12-hour troponin elevation.” Am J Cardiol 2011;107:161–167. PubMed link Lim SH, Anantharaman V, Sundram F, Chan ES-Y, Ang ES, Yo SL, et al. “Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: a randomized controlled trial.” J Nucl Cardiol 2013;20:1002–1012. PubMed link Nabi F, Kassi M, Muhyieddeen K, Chang SM, Xu J, Peterson LE, et al. “Optimizing evaluation of patients with low-to-intermediate-risk acute chest pain: a randomized study comparing stress myocardial perfusion tomography incorporating stress-only imaging versus cardiac CT.” J Nucl Med 2016;57:378–384. PubMed link

Question 15

In patients with suspected acute coronary syndrome, under what circumstances should emergency TTE be considered?

• ○ 1. In all cases
• ○ 2. Only in cases where there is a clear diagnosis
• ✓ 3. At triage in cases of diagnostic uncertainty
• ○ 4. After transfer to the cardiac catheterization laboratory
• ○ 5. If there is no suspicion of an acute coronary artery occlusion

Explanation. Emergency TTE should be considered at triage in cases of diagnostic uncertainty but this should not result in delays in transfer to the cardiac catheterization laboratory if there is suspicion of an acute coronary artery occlusion. (IIa, C)

Question 16

In the initial assessment of patients with suspected acute coronary syndrome (ACS), which of the following is NOT recommended?

• ✓ 1. Routine, early CCTA
• ○ 2. Routine, early ECG
• ○ 3. Routine, early cardiac biomarkers
• ○ 4. Routine, early echocardiogram
• ○ 5. Routine, early stress testing

Explanation. Routine, early CCTA in patients with suspected ACS is not recommended. (III, B)

Question 17

In patients with acute coronary syndrome, at what level of SaO2 is oxygen administration recommended?

• ○ 1. SaO2 <85%
• ○ 2. SaO2 <88%
• ✓ 3. SaO2 <90%
• ○ 4. SaO2 <92%
• ○ 5. SaO2 <95%

Explanation. Oxygen is recommended in patients with hypoxaemia (SaO2 <90%). (I, C) Routine oxygen is not recommended in patients without hypoxaemia (SaO2 >90%). (III, A)

Question 18

Which of the following is recommended for relieving pain in patients with acute coronary syndrome?

• ○ 1. Intravenous acetaminophen
• ○ 2. Inhaled nitrous oxide
• ✓ 3. Intravenous opioids
• ○ 4. Intravenous lidocaine
• ○ 5. Intravenous midazolam

Explanation. Intravenous opioids should be considered to relieve pain. (IIa, C)

Question 19

What should be considered for very anxious patients with acute coronary syndrome?

• ○ 1. A mild analgesic
• ✓ 2. A mild tranquilizer
• ○ 3. Beta-blocker
• ○ 4. Opioid
• ○ 5. Propofol

Explanation. A mild tranquilizer should be considered in very anxious patients. (IIa, C)

Question 20

A 55-year-old male presents to the emergency department with sudden onset chest pain. On arrival, his vital signs are stable with a blood pressure of 130/85 mmHg, heart rate of 85 beats per minute, and oxygen saturation of 98% on room air. An ECG shows ST-segment elevation in the inferior leads. He is promptly diagnosed with an anterior ST-elevation myocardial infarction (STEMI) and is being prepared for primary percutaneous coronary intervention (PPCI). He has no signs of acute heart failure.

What role should intravenous beta-blockers play at the time of presentation?

• ✓ 1. Intravenous beta-blockers (preferably metoprolol) should be considered
• ○ 2. Oral beta-blockers should be considered
• ○ 3. Intravenous calcium channel blockers should be considered
• ○ 4. Oral ACE inhibitors are indicated
• ○ 5. Intravenous nitrates are indicated

Explanation. Intravenous beta-blockers (preferably metoprolol) should be considered at the time of presentation in patients undergoing PPCI with no signs of acute heart failure, an SBP >120 mmHg, and no other contraindications. (IIa, A) References Terkelsen CJ, Sørensen JT, Maeng M, Jensen LO, Tilsted HH, Trautner S, et al. “System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.” JAMA 2010;304:763–771. PubMed link Jortveit J, Pripp AH, Halvorsen S. “Outcomes after delayed primary percutaneous coronary intervention vs. pharmaco-invasive strategy in ST-segment elevation myocardial infarction in Norway.” Eur Heart J Cardiovasc Pharmacother 2022;8:442–451. PubMed link Larsen AI, Løland KH, Hovland S, Bleie Ø, Eek C, Fossum E, et al. “Guideline-recommended time less than 90 minutes from ECG to primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction is associated with major survival benefits, especially in octogenarians: a contemporary report in 11 226 patients from NORIC.” J Am Heart Assoc 2022;11:e024849. PubMed link Fordyce CB, Al-Khalidi HR, Jollis JG, Roettig ML, Gu J, Bagai A, et al. “Association of rapid care process implementation on reperfusion times across multiple ST-segment-elevation myocardial infarction networks.” Circ Cardiovasc Interv 2017;10:e004061. PubMed link Stowens JC, Sonnad SS, Rosenbaum RA. “Using EMS dispatch to trigger STEMI alerts decreases door-to-balloon times.” West J Emerg Med 2015;16:472–480. PubMed link Parikh SV, Treichler DB, DePaola AA, Chan W, Keeley EC. “System delays in transfer patients undergoing primary percutaneous coronary intervention in the United States: a report from the National Cardiovascular Data Registry.” Am Heart J 2011;161:260–266. PubMed link

Question 21

In the initial management of patients with acute coronary syndrome, what is recommended for patients transferred for primary PCI?

• ○ 1. They should be evaluated in the emergency department before being transferred to the catheterization laboratory.
• ○ 2. They should be admitted to the CCU/ICU before undergoing catheterization.
• ✓ 3. They should bypass the emergency department and CCU/ICU and be transferred directly to the catheterization laboratory.
• ○ 4. They should receive thrombolytic therapy before being transferred to the catheterization laboratory.
• ○ 5. They should undergo a TTE before being transferred to the catheterization laboratory.

Explanation. It is recommended that patients transferred for PPCI bypass the emergency department and CCU/ ICU and are transferred directly to the catheterization laboratory. (I, B)

Question 22

In the initial management of patients with acute coronary syndrome, what is the recommended action for EMS when transporting patients with suspected STEMI?

• ○ 1. Transfer to the nearest hospital.
• ○ 2. Transfer to a center with cardiothoracic surgery.
• ✓ 3. Transfer to a PCI-capable center, bypassing non-PCI centers.
• ○ 4. Transfer to a center with capability to perform PCI and cardiothoracic surgery.
• ○ 5. Transfer to any hospital for stabilization before moving to a PCI-capable center.

Explanation. It is recommended that EMS transfer patients with suspected STEMI to a PCI- capable centre, bypassing non-PCI centres. (I, C)

Question 23

Which of the following is recommended for ambulance teams managing patients with acute coronary syndromes?

• ○ 1. Ambulance teams should only transport patients to the nearest hospital.
• ○ 2. Ambulance teams should be equipped to perform basic life support (BLS) measures.
• ○ 3. Ambulance teams should administer initial therapy and transmit the ECG to a hospital for interpretation
• ✓ 4. Ambulance teams should identify ECG patterns suggestive of acute coronary occlusion and administer initial therapy, including defibrillation and fibrinolysis when applicable.
• ○ 5. Ambulance teams should identify ECG patterns suggestive of acute coronary occlusion and administer initial therapy, including defibrillation.

Explanation. It is recommended that ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation, and fibrinolysis when applicable. (I, C)

Question 24

A 62-year-old female with no prior history of cardiac issues presents to the emergency department with acute onset chest pain that started six hours ago. The pain is described as intense and crushing, radiating to her left shoulder and jaw. She is also experiencing shortness of breath and nausea. On examination, her blood pressure is 145/90 mmHg, heart rate is 95 beats per minute, and oxygen saturation is 96% on room air. An electrocardiogram (ECG) shows persistent ST-segment elevation in the anterior leads.

What is the recommended management strategy for this patient?

• ○ 1. Immediate coronary artery bypass graft surgery
• ○ 2. Conservative management due to duration of symptoms
• ✓ 3. Reperfusion (PCI or fibrinolysis) therapy
• ○ 4. Immediate anticoagulant therapy
• ○ 4. Immediate antiplatelet therapy

Explanation. Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalents) and symptoms of ischaemia of ≤12 h duration. (I, A) Reperfusion strategy in acute STEMI Primary PCI For symptom duration of 0 hours to 12 hours: - PPCI is recommended if the time to wire passing is less than 120 minutes (class Ia). - PPCI is also recommended (class Ic) in unstable patients, including those with recurrent ventricular arrhythmias. For symptom duration of 12 hours to 48 hours: - PPCI should be considered (class IIa), irrespective of symptoms. Fibrinolysis: Fibrinolysis is recommended if the time to wire passing is greater than 120 minutes (class Ia) and symptom duration is <12 hours.

Question 25

A 58-year-old male presents to the emergency department with sudden onset of severe chest pain that began 7 hours ago. An ECG reveals ST-segment elevation in the inferior leads. The hospital has a catheterization lab available, and the anticipated time from diagnosis to percutaneous coronary intervention (PCI) is estimated to be 110 minutes. What reperfusion strategy should be recommended for this patient?

• ○ 1. Fibrinolysis
• ○ 2. CABG
• ○ 3. Medical therapy
• ✓ 4. PPCI
• ○ 5. None

Explanation. A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min. (I, A)

Question 26

A 64-year-old male presents to the emergency department with severe chest pain that began five hours ago. On examination, his blood pressure is 145/85 mmHg, heart rate is 100 beats per minute, and oxygen saturation is 94% on room air. An ECG shows significant ST-segment elevation in the anterior leads. The nearest hospital can perform primary percutaneous coronary intervention (PPCI) at best within 125 minutes of diagnosis. What is the recommended reperfusion strategy?

• ○ 1. Antiplatelet therapy
• ○ 2. Coronary artery bypass grafting
• ✓ 3. Fibrinolytic therapy
• ○ 4. PPCI with readiness for fibrinolysis
• ○ 5. PPCI

Explanation. If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications. (I, A)

Question 27

Under which conditions is rescue PCI recommended for patients with STEMI after fibrinolysis?

• ○ 1. When ST-segment resolution is less than 90% within 60-90 minutes of fibrinolytic administration, or in the presence of hemodynamic or electrical instability, worsening ischemia, or persistent chest pain
• ✓ 2. When ST-segment resolution is less than 50% within 60-90 minutes of fibrinolytic administration, or in the presence of hemodynamic or electrical instability, worsening ischemia, or persistent chest pain
• ○ 3. When ST-segment resolution is less than 50% within 60-90 minutes of fibrinolytic administration
• ○ 4. In the presence of hemodynamic or electrical instability, worsening ischemia, or persistent chest pain
• ○ 5. When there is no improvement in symptoms after 24 hours of fibrinolytic administration

Explanation. Rescue PCI is recommended for failed fibrinolysis (i.e. ST-segment resolution <50% within 60-90 min of fibrinolytic administration) or in the presence of haemodynamic or electrical instability, worsening ischaemia, or persistent chest pain. (I, A) Rescue PCI is performed after fibrinolytic therapy has failed to adequately restore blood flow in patients with STEMI. Rescue PCI aims to mechanically reopen the occluded coronary artery when initial fibrinolytic treatment does not achieve sufficient reperfusion of the occlusion. Indications for Rescue PCI: 1. Failed Fibrinolysis: ST-segment resolution is less than 50% within 60-90 minutes of fibrinolytic administration. 2. Haemodynamic Instability: Presence of shock or severe hypotension. 3. Electrical Instability: Life-threatening arrhythmias or recurrent ventricular tachycardia/fibrillation. 4. Worsening Ischaemia: Increasing signs and symptoms of ischaemia despite fibrinolytic therapy. 5. Persistent Chest Pain: Ongoing severe chest pain indicating continued myocardial ischaemia.

Question 28

In patients with a working diagnosis of STEMI and a time from symptom onset >12 hours, when is a PPCI strategy recommended?

• ○ 1. In the presence of ongoing symptoms suggestive of ischaemia
• ✓ 2. In the presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias
• ○ 3. Regardless of symptom presence or haemodynamic stability
• ○ 4. Only if the patient is over 65 years old
• ○ 5. In patients with no history of cardiovascular disease

Explanation. In patients with a working diagnosis of STEMI and a time from symptom onset >12 h, a PPCI strategy is recommended in the presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias. (I, C) This should not be confused with the class IIa recommendation stating that PPCI should be considered when time from symptom onset is between 12 and 48 hours.

Question 29

In patients with STEMI presenting 12 to 48 hours after symptom onset, what reperfusion strategy should be considered?

• ○ 1. Thrombolytic therapy
• ✓ 2. Routine PPCI strategy
• ○ 3. CABG
• ○ 4. Conservative management
• ○ 5. Elective PCI after 48 hours

Explanation. A routine PPCI strategy should be considered in STEMI patients presenting late (12-48 h) after symptom onset. (IIa, B)

Question 30

What is the recommendation for PCI of an occluded infarct-related artery (IRA) in STEMI patients presenting more than 48 hours after symptom onset and without persistent symptoms?

• ○ 1. PCI is recommended
• ○ 2. It is recommended only after resuscitation
• ✓ 3. It is not recommended.
• ○ 4. PCI is recommended in the presence of additional risk factors.
• ○ 5. It is recommended as a second-line treatment.

Explanation. Routine PCI of an occluded IRA is not recommended in STEMI patients presenting >48 h after symptom onset and without persistent symptoms. (III, A) Persisting artery occlusions due to STEMI are managed as CTO (chronic total occlusions) in asymptomatic patients presenting later than 48 hours after symptom onset.

Question 31

A 58-year-old female with a history of hypertension presents to a hospital without PCI capabilities, experiencing severe chest pain and shortness of breath. Her ECG shows ST-segment elevation, and she receives fibrinolytic therapy within 90 minutes of symptom onset. ST-segment resolution is satisfactory and the patient is asymptomatic 60 minutes after infusion of the fibrinolytic agent.

What is the recommended subsequent step in the management of this patient?

• ○ 1. Transfer to a non-PCI-capable center is acceptable
• ○ 2. Immediate discharge home
• ○ 3. Admission and observation
• ✓ 4. Transfer to a PCI-capable center
• ○ 5. Start of anticoagulant therapy

Explanation. Transfer to a PCI-capable centre is recommended in all patients immediately after fibrinolysis. (I, A) Angiography should be performed within 2 to 24 hours after administration of the fibrinolytic agent.

Question 32

A 62-year-old male with a history of diabetes presents to the emergency department with severe chest pain and shortness of breath. His ECG shows ST-segment elevation, and he receives fibrinolytic therapy. Despite initial treatment, he develops signs of persistent heart failure and hypotension. His blood pressure drops to 85/60 mmHg, and he has significant pulmonary edema on auscultation.

What is the recommended next step in the management of this patient?

• ○ 1. Repeat fibrinolysis therapy
• ○ 2. Immediate coronary artery bypass grafting (CABG)
• ✓ 3. Emergency angiography and PCI of the IRA
• ○ 4. Non-emergency angiography within 2 hours
• ○ 5. No further intervention is possible due to bleeding risk

Explanation. Emergency angiography and PCI of the IRA, if indicated is recommended in patients with new-onset or persistent heart failure/shock after fibrinolysis. (I, A)

Question 33

A 55-year-old male presents to the emergency department with severe chest pain that started three hours ago. His ECG shows ST-segment elevation, and he receives fibrinolytic therapy. The treatment is successful, with significant resolution of symptoms and ECG changes. He remains hemodynamically stable.

What is the recommended timing for angiography and potential PCI of the infarct-related artery (IRA) in this patient?

• ○ 1. Within 2 hours
• ✓ 2. Within 2 to 24 hours
• ○ 3. Within 12 hours
• ○ 4. Within 12 to 24 hours
• ○ 5. Within 72 hours

Explanation. Angiography and PCI of the IRA, if indicated, is recommended between 2 and 24 h after successful fibrinolysis. (I, A)

Question 34

A 68-year-old female with a history of hypertension presents to the emergency department with chest pain that started four hours ago. Her ECG shows nonspecific ST-segment changes. She is diagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS). What is the recommended management strategy during hospital admission for this patient?

• ○ 1. An invasive strategy is not recommended
• ○ 2. An invasive strategy is recommended if symptoms of ischemia persist after admission
• ○ 3. An invasive strategy is recommended if high-risk criteria are present
• ✓ 4. An invasive strategy is recommended if high-risk criteria or if there is a high index of suspicion for unstable angina
• ○ 5. An invasive strategy is recommended after initial imaging for myocardial ischemia (e.g myocardial SPECT or coronary CT angiography)

Explanation. An invasive strategy during hospital admission is recommended in NSTE-ACS patients with high-risk criteria or a high index of suspicion for unstable angina. (I, A)

Question 35

In patients without very high- or high-risk NSTE-ACS criteria and with a low index of suspicion for NSTE-ACS, what approach is recommended?

• ○ 1. Invasive approach is recommended
• ○ 2. Conservative approach is recommended
• ✓ 3. Selective invasive approach
• ○ 4. Non-invasive imaging only
• ○ 5. Conservative approach is recommended if GRACE risk score <100

Explanation. A selective invasive approach is recommended in patients without very high- or high- risk NSTE- ACS criteria and with a low index of suspicion for NSTE- ACS. (I, A)

Question 36

According to clinical practice guidelines, in patients with a working diagnosis of NSTE-ACS, an immediate invasive strategy is recommended if they exhibit which of the following very high-risk criteria?

• ○ 1. Mild chest pain that resolves with rest
• ✓ 2. Haemodynamic instability or cardiogenic shock
• ○ 3. Stable heart rate and blood pressure
• ○ 4. No changes in ST-segment or T wave
• ○ 5. Absence of in-hospital life-threatening arrhythmias

Explanation. An immediate invasive strategy is recommended in patients with a working diagnosis of NSTE- ACS and with at least one of the following very high- risk criteria: - Haemodynamic instability or cardiogenic shock - Recurrent or refractory chest pain despite medical treatment - In-hospital life-threatening arrhythmias - Mechanical complications of MI - Acute heart failure presumed secondary to ongoing myocardial ischaemia - Recurrent dynamic ST-segment or T wave changes, particularly intermittent ST-segment elevation Class IC

Question 37

Under which condition should an early invasive strategy within 24 hours not be considered for patients with NSTE-ACS?

• ✓ 1. Confirmed diagnosis of unstable angina
• ○ 2. Dynamic ST-segment or T wave changes
• ○ 3. Transient ST-segment elevation
• ○ 4. GRACE risk score >140
• ○ 5. Confirmed diagnosis of NSTEMI

Explanation. An early invasive strategy within 24 h should be considered in patients with at least one of the following high- risk criteria: - Confirmed diagnosis of NSTEMI - Dynamic ST-segment or T wave changes - Transient ST-segment elevation - GRACE risk score >140. (IIa, A)

Question 38

What is the recommended initial oral loading dose (LD) of aspirin for patients without contraindications in acute coronary syndrome?

• ○ 1. 50-150 mg
• ✓ 2. 150-300 mg
• ○ 3. 300-450 mg
• ○ 4. 75-250 mg
• ○ 5. 75-100 mg

Explanation. Aspirin is recommended for all patients without contraindications at an initial oral LD of 150-300 mg (or 75-250 mg i.v.) and an MD of 75-100 mg o.d. for long-term treatment. (I, A)

Question 39

In all ACS patients, what is recommended in addition to aspirin, given as an initial oral loading dose (LD) followed by a maintenance dose (MD) for 12 months unless there is high bleeding risk (HBR)?

• ✓ 1. A P2Y12 receptor inhibitor
• ○ 2. A beta-blocker
• ○ 3. A calcium channel blocker
• ○ 4. An SGLT2 inhibitor
• ○ 5. An angiotensin-converting enzyme inhibitor

Explanation. In all ACS patients, a P2Y12 receptor inhibitor is recommended in addition to aspirin, given as an initial oral loading dose followed by a maintenance dose for 12 months unless there is HBR. (I, A)

Question 40

In patients at high risk of gastrointestinal bleeding, what is recommended in combination with dual antiplatelet therapy (DAPT)?

• ○ 1. H2 receptor antagonist
• ○ 2. Warfarin
• ✓ 3. Proton pump inhibitor
• ○ 4. Calcium channel blocker
• ○ 5. Measurement of HbA1c or fasting glucose

Explanation. A proton pump inhibitor in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding. (I, A)

Question 41

What is the recommended dosing regimen of prasugrel in patients proceeding to PCI? LD = loading dose. MD = maintenance dose.

• ○ 1. 75 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged 75 years or with a body weight <60 kg
• ✓ 2. 60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged 75 years or with a body weight <60 kg
• ○ 3. 50 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged 75 years or with a body weight <60 kg
• ○ 4. 60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for all patients regardless of age or weight
• ○ 5. 75 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged 65 years or with a body weight <70 kg

Explanation. Prasugrel is recommended in P2Y12 receptor inhibitor- nave patients proceeding to PCI (60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged 75 years or with a body weight <60 kg). (I, B)

Question 42

Which antiplatelet therapy is recommended irrespective of the treatment strategy (invasive or conservative) in patients with acute coronary syndrome, and at what dosages?

• ○ 1. Clopidogrel
• ○ 2. Prasugrel
• ✓ 3. Ticagrelor
• ○ 4. Aspirin
• ○ 5. Warfarin or NOAC

Explanation. Ticagrelor is recommended irrespective of the treatment strategy (invasive or conservative) (180 mg LD, 90 mg b.i.d. MD). (I, B) Prasugrel is only recommended in patients proceeding to PCI. Clopidogrel is only recommended if ticagrelor and prasugrel are inappropriate.

Question 43

In the context of antiplatelet therapy for acute coronary syndrome, when is clopidogrel recommended?

• ○ 1. When prasugrel or ticagrelor are contraindicated
• ✓ 2. When prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated
• ○ 3. When patients have a history of gastrointestinal bleeding
• ○ 4. When patients are undergoing coronary artery bypass graft surgery
• ○ 5. When patients are managed conservatively

Explanation. Clopidogrel (300-600 mg LD, 75 mg o.d. MD) is recommended when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated. (I, C)

Question 44

In patients presenting with acute coronary syndrome (ACS) who stop dual antiplatelet therapy (DAPT) to undergo coronary artery bypass grafting (CABG), what is the recommended duration for resuming DAPT after surgery?

• ○ 1. At least 6 months
• ○ 2. At least 9 months
• ✓ 3. At least 12 months
• ○ 4. At least 18 months
• ○ 5. At least 24 months

Explanation. If patients presenting with ACS stop DAPT to undergo CABG, it is recommended they resume DAPT after surgery for at least 12 months. (I, C)

Question 45

Which antiplatelet therapy should be considered in preference for ACS patients who proceed to PCI?

• ○ 1. Bivalirudin
• ○ 2. Clopidogrel
• ✓ 3. Prasugrel
• ○ 4. Warfarin
• ○ 5. Ticagrelor

Explanation. Prasugrel should be considered in preference to ticagrelor for ACS patients who proceed to PCI. (IIa, B)

Question 46

In the context of antiplatelet therapy in acute coronary syndrome, when should GP IIb/ IIIa receptor antagonists be considered?

• ○ 1. When there is evidence of significant bleeding.
• ✓ 2. When there is evidence of no-reflow or a thrombotic complication during PCI.
• ○ 3. When there is evidence of an unstable (vulnerable) plaque.
• ○ 4. When there is evidence of low coronary perfusion pressure
• ○ 5. When there is evidence of complete arterial occlusion

Explanation. GP IIb/IIIa receptor antagonists should be considered if there is evidence of no-reflow or a thrombotic complication during PCI. (IIa, C)

Question 47

In P2Y12 receptor inhibitor-nave patients undergoing PCI, which antiplatelet therapy may be considered?

• ○ 1. Rivaroxaban
• ○ 2. Edoxaban
• ○ 3. Dabigatran
• ✓ 4. Cangrelor
• ○ 5. Tirofiban

Explanation. In P2Y12 receptor inhibitor-naive patients undergoing PCI, cangrelor may be considered. (IIb, A)

Question 48

In older ACS patients, especially those with high bleeding risk (HBR), which P2Y12 receptor inhibitor may be considered?

• ○ 1. Fondaparinux
• ○ 2. Apixaban
• ✓ 3. Clopidogrel
• ○ 4. Bivalirudin
• ○ 5. Warfarin

Explanation. In older ACS patients, especially if HBR, clopidogrel as the P2Y12 receptor inhibitor may be considered. (IIb, B)

Question 49

In patients undergoing a primary PCI strategy, what is the role of pretreatment with P2Y12 inhibitors?

• ○ 1. Pre-treatment is contraindicated prior to angiography (class III recommendation)
• ○ 2. Pre-treatment is recommended prior to angiography (class I recommendation)
• ✓ 3. Pre-treatment may be considered (class IIb recommendation)
• ○ 4. Pre-treatment should be considered (class IIa recommendation)
• ○ 5. Pre-treatment is recommended in patients with previous myocardial infarction

Explanation. Pretreatment with a P2Y12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy. (IIb, B)

Question 50

In the context of NSTE-ACS, when may pretreatment with a P2Y12 receptor inhibitor be considered?

• ○ 1. In patients who are expected to undergo an early invasive strategy (<24 h) and have high bleeding risk (HBR).
• ○ 2. In patients who are not expected to undergo an early invasive strategy (<24 h) and have high bleeding risk (HBR).
• ○ 3. In patients who are expected to undergo an early invasive strategy (<24 h) and do not have high bleeding risk (HBR).
• ✓ 4. In patients who are not expected to undergo an early invasive strategy (<24 h) and do not have high bleeding risk (HBR).
• ○ 5. In patients who are expected to undergo a late invasive strategy (>24 h) and have high bleeding risk (HBR).

Explanation. Pretreatment with a P2Y12 receptor inhibitor may be considered in NSTE-ACS patients who are not expected to undergo an early invasive strategy (<24 h) and do not have HBR. (IIb, C)

Question 51

In the context of acute coronary syndrome, which of the following is NOT recommended as pretreatment?

• ○ 1. Aspirin
• ○ 2. Clopidogrel
• ✓ 3. GP IIb/IIIa receptor antagonist
• ○ 4. Prasugrel
• ○ 5. Ticagrelor

Explanation. Pretreatment with a GP IIb/ IIIa receptor antagonist is not recommended. (III, A)

Question 52

In patients with NSTE-ACS where coronary anatomy is unknown and early invasive management (<24 hours) is planned, what is the guideline recommendation regarding routine pretreatment with a P2Y12 receptor inhibitor?

• ○ 1. It is recommended.
• ○ 2. It is recommended in high-risk patients.
• ✓ 3. It is not recommended.
• ○ 4. It is recommended for most patients.
• ○ 5. It is to be considered based on GRACE and TIMI Score

Explanation. Routine pretreatment with a P2Y12 receptor inhibitor in NSTE- ACS patients in whom coronary anatomy is not known and early invasive management (<24 h) is planned is not recommended. (III, A)

Question 53

In patients diagnosed with acute coronary syndrome (ACS), what is recommended regarding anticoagulation therapy?

• ○ 1. Oral anticoagulation is recommended for all patients with ACS at the time of diagnosis.
• ○ 2. Parenteral anticoagulation is recommended only for patients undergoing surgery.
• ✓ 3. Parenteral anticoagulation is recommended for all patients with ACS at the time of diagnosis.
• ○ 4. Anticoagulation therapy is not recommended for patients with ACS.
• ○ 5. Anticoagulation therapy should be deferred until after initial treatment for ACS.

Explanation. Parenteral anticoagulation is recommended for all patients with ACS at the time of diagnosis. (I, A)

Question 54

In patients undergoing PCI, what is the recommended routine use of a UFH bolus during the procedure?

• ○ 1. A fixed i.v. bolus of 50 IU/kg
• ✓ 2. A weight-adjusted i.v. bolus during PCI of 70-100 IU/kg
• ○ 3. A weight-adjusted i.v. bolus during PCI of 50-70 IU/kg
• ○ 4. A fixed i.v. bolus of 100 IU/kg
• ○ 5. An i.v. bolus adjusted to patient age and renal function

Explanation. Routine use of a UFH bolus (weight- adjusted i.v. bolus during PCI of 70100 IU/ kg) is recommended in patients undergoing PCI. (I, C)

Question 55

In patients pretreated with subcutaneous enoxaparin, what is recommended at the time of PCI?

• ○ 1. Intravenous unfractionated heparin
• ○ 2. Intravenous bivalirudin
• ○ 3. Discontinuation of anticoagulants
• ✓ 4. Intravenous enoxaparin
• ○ 5. No additional anticoagulant therapy

Explanation. Intravenous enoxaparin at the time of PCI should be considered in patients pretreated with subcutaneous enoxaparin. (IIa, B)

Question 56

When should discontinuation of parenteral anticoagulation be considered in patients undergoing an invasive procedure?

• ○ 1. Before the invasive procedure
• ○ 2. During the invasive procedure
• ✓ 3. Immediately after the invasive procedure
• ○ 4. One day after the invasive procedure
• ○ 5. One week after the invasive procedure

Explanation. Discontinuation of parenteral anticoagulation should be considered immediately after an invasive procedure. (IIa, C)

Question 57

Which anticoagulant should be considered as an alternative to UFH in patients with STEMI undergoing PPCI?

• ○ 1. Warfarin
• ○ 2. Dabigatran
• ○ 3. Rivaroxaban
• ✓ 4. Enoxaparin
• ○ 5. Apixaban

Explanation. Enoxaparin should be considered as an alternative to UFH in patients with STEMI undergoing PPCI. (IIa, A)

Question 58

In patients with STEMI undergoing PPCI, what alternative to UFH should be considered with a full-dose post-PCI infusion?

• ○ 1. TXA2
• ○ 2. Fibrin
• ○ 3. Warfarin
• ✓ 4. Bivalirudin
• ○ 5. Dabigatran

Explanation. Bivalirudin with a full-dose post PCI infusion should be considered as an alternative to UFH in patients with STEMI undergoing PPCI (IIa, A)

Question 59

Which anticoagulant is not recommended in patients with STEMI undergoing PPCI?

• ○ 1. Aspirin
• ○ 2. Clopidogrel
• ○ 3. UFH
• ✓ 4. Fondaparinux
• ○ 5. Enoxaparin

Explanation. Fondaparinux is not recommended in patients with STEMI undergoing PPCI. (III, B)

Question 60

For patients with NSTE-ACS in whom early invasive angiography (i.e., within 24 h) is not anticipated, which anticoagulant is recommended?

• ○ 1. Heparin
• ○ 2. Warfarin
• ○ 3. Enoxaparin
• ✓ 4. Fondaparinux
• ○ 5. Dabigatran

Explanation. For patients with NSTE- ACS in whom early invasive angiography (i.e. within 24 h) is not anticipated, fondaparinux is recommended. (I, B)

Question 61

For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is anticipated, which antithrombotic agent should be considered as an alternative to UFH?

• ○ 1. Clopidogrel
• ○ 2. Warfarin
• ✓ 3. Enoxaparin
• ○ 4. Aspirin
• ○ 5. Dabigatran

Explanation. For patients with NSTE- ACS in whom early invasive angiography (i.e. within 24 h) is anticipated, enoxaparin should be considered as an alternative to UFH. (IIa, B)

Question 62

In patients with atrial fibrillation with an indication for oral anticoagulation, what is the recommended strategy for antithrombotic therapy after 1 week of triple antithrombotic therapy (TAT) following an acute coronary syndrome (ACS) event? TAT = triple antithrombotic therapy. DAT = dual antithrombotic therapy.

• ○ 1. Continue TAT for 12 months.
• ✓ 2. Switch to DAT using a NOAC and clopidogrel for up to 12 months.
• ○ 3. Use only clopidogrel for 12 months.
• ○ 4. Use only a NOAC for 12 months.
• ○ 5. Switch to DAPT using aspirin and clopidogrel for up to 12 months.

Explanation. As the default strategy for patients with atrial fibrillation and CHA2DS2- VASc score 1 in men and 2 in women, after up to 1 week of triple antithrombotic therapy following the ACS event, dual antithrombotic therapy using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel) for up to 12 months is recommended. (I, A)

Question 63

A 70-year-old male with atrial fibrillation presents with acute coronary syndrome and is scheduled for percutaneous coronary intervention (PCI). He is currently taking a non-vitamin K antagonist oral anticoagulant (NOAC).

What is the recommended anticoagulation management strategy during PCI for this patient?

• ○ 1. Intravenous aspirin
• ○ 2. Switch NOAC to warfarin
• ✓ 3. UFH bolus
• ○ 4. UFH bolus if INR < 3
• ○ 5. UFH bolus if INR < 3.5

Explanation. During PCI, a UFH bolus is recommended (class I, level of evidence C) in any of the following circumstances: - if the patient is on a NOAC - if the INR is <2.5 in VKA-treated patients.

Question 64

In patients with an indication for OAC with VKA in combination with aspirin and/or clopidogrel, what is the recommended target INR and time in the therapeutic range?

• ○ 1. Target INR of 1.5-2.0 with a time in the therapeutic range >60%
• ✓ 2. Target INR of 2.0-2.5 with a time in the therapeutic range >70%
• ○ 3. Target INR of 2.5-3.0 with a time in the therapeutic range >75%
• ○ 4. Target INR of 3.0-3.5 with a time in the therapeutic range >65%
• ○ 5. Target INR of 1.0-1.5 with a time in the therapeutic range >50%

Explanation. In patients with an indication for OAC with VKA in combination with aspirin and/or clopidogrel, careful regulation of the dose intensity of VKA with a target INR of 2.0-2.5 and a time in the therapeutic range >70% should be considered. (IIa, B)

Question 65

When combining antiplatelets and OAC, which dosage of rivaroxaban should be considered when concerns about high bleeding risk (HBR) prevail over ischemic stroke?

• ○ 1. Rivaroxaban 10 mg o.d.
• ✓ 2. Rivaroxaban 15 mg o.d.
• ○ 3. Rivaroxaban 20 mg o.d.
• ○ 4. Rivaroxaban 25 mg o.d.
• ○ 5. Rivaroxaban 30 mg o.d.

Explanation. When rivaroxaban is used and concerns about HBR prevail over ischaemic stroke, rivaroxaban 15 mg o.d. should be considered in preference to rivaroxaban 20 mg o.d. for the duration of concomitant SAPT or DAPT. (IIa, B)

Question 66

In patients at high bleeding risk (HBR) undergoing combination therapy with antiplatelets and oral anticoagulants (OAC), which dosing regimen of dabigatran should be considered to mitigate bleeding risk?

• ○ 1. Dabigatran 75 mg b.i.d.
• ✓ 2. Dabigatran 110 mg b.i.d.
• ○ 3. Dabigatran 150 mg b.i.d.
• ○ 4. Dabigatran 220 mg once daily
• ○ 5. Dabigatran 300 mg once daily

Explanation. In patients at HBR, dabigatran 110 mg b.i.d. should be considered in preference to dabigatran 150 mg b.i.d. for the duration of concomitant SAPT or DAPT, to mitigate bleeding risk. (IIa, B)

Question 67

In patients requiring anticoagulation and treated medically, how long should a single antiplatelet agent in addition to an OAC be considered?

• ○ 1. 3 months
• ○ 2. 6 months
• ○ 3. 9 months
• ✓ 4. Up to 12 months
• ○ 5. Indefinitely

Explanation. In patients requiring anticoagulation and treated medically, a single antiplatelet agent in addition to an OAC should be considered for up to 1 year. (IIa, B)

Question 68

In patients treated with an OAC, for how long should aspirin plus clopidogrel be considered in those with high ischaemic risk or with other anatomical/procedural characteristics that are judged to outweigh the bleeding risk?

• ✓ 1. Longer than 1 week and up to 1 month
• ○ 2. Up to 1 week
• ○ 3. Up to 3 months
• ○ 4. Longer than 3 months
• ○ 5. Indefinitely

Explanation. In patients treated with an OAC, aspirin plus clopidogrel for longer than 1 week and up to 1 month should be considered in those with high ischaemic risk or with other anatomical/ procedural characteristics that are judged to outweigh the bleeding risk. (IIa, C)

Question 69

In patients requiring OAC, when can antiplatelet therapy be withdrawn while continuing OAC?

• ○ 1. It may be considered at 3 months
• ✓ 2. It may be considered at 6 months
• ○ 3. It may be considered at 9 months
• ○ 4. It may be considered at 12 months
• ○ 5. It may be considered at 18 months

Explanation. In patients requiring OAC, withdrawing antiplatelet therapy at 6 months while continuing OAC may be considered. (IIb, B)

Question 70

In the context of triple antithrombotic therapy (TAT) for acute coronary syndrome, which of the following is NOT recommended?

• ○ 1. The use of aspirin in combination with an oral anticoagulant
• ✓ 2. The use of ticagrelor or prasugrel as part of triple antithrombotic therapy
• ○ 3. The use of clopidogrel in combination with an oral anticoagulant
• ○ 4. The use of rivaroxaban in combination with an antiplatelet agent
• ○ 5. The use of dual antiplatelet therapy without an oral anticoagulant

Explanation. The use of ticagrelor or prasugrel as part of triple antithrombotic therapy is not recommended. (III, C)

Question 71

In patients who are event-free after 3-6 months of DAPT and who are not at high ischaemic risk, what change in antithrombotic therapy may be considered?

• ○ 1. Stop DAPT
• ○ 2. Start monotherapy with aspirin
• ✓ 3. Start monotherapy with a P2Y12 receptor inhibitor
• ○ 4. Continue with TAT
• ○ 5. Discontinue all antithrombotic therapy

Explanation. In patients who are event-free after 3-6 months of DAPT and who are not high ischaemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered. (IIa, A)

Question 72

What alternative DAPT strategy may be considered to reduce bleeding risk according to the recommendation for de-escalation of P2Y12 receptor inhibitor treatment?

• ○ 1. Switching from clopidogrel to prasugrel
• ○ 2. Switching from ticagrelor to prasugrel
• ○ 3. Switching from clopidogrel to ticagrelor
• ✓ 4. Switching from prasugrel/ticagrelor to clopidogrel
• ○ 5. Switching from prasugrel to ticagrelor

Explanation. De-escalation of P2Y12 receptor inhibitor treatment (e.g. with a switch from prasugrel/ ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk. (IIb, A)

Question 73

In HBR patients, what antithrombotic therapy regimen may be considered after 1 month of DAPT? HBR = high bleeding risk.

• ○ 1. Dual antiplatelet therapy (DAPT) for another 12 months
• ✓ 2. Aspirin or P2Y12 inhibitor monotherapy (P2Y12 inhibitor preferred)
• ○ 3. Triple antithrombotic therapy (TAT)
• ○ 4. Aspirin or P2Y12 inhibitor monotherapy (aspirin preferred)
• ○ 5. Switching to OAC monotherapy

Explanation. In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered. (IIb, B)

Question 74

In the first 30 days after an ACS event, what is the recommendation regarding the de-escalation of antiplatelet therapy?

• ○ 1. It is strongly recommended.
• ○ 2. It is recommended.
• ✓ 3. It is not recommended.
• ○ 4. It is recommended in patients at low ischemic risk.
• ○ 5. It is recommended in patients at high ischemic risk.

Explanation. De-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended. (III, B) De-escalation of antiplatelet therapy is recommended if bleeding risk is high.

Question 75

After an acute coronary syndrome, when is it recommended to discontinue antiplatelet treatment in patients treated with an oral anticoagulant (OAC)?

• ○ 1. After 3 months
• ○ 2. After 6 months
• ○ 3. After 9 months
• ✓ 4. After 12 months
• ○ 5. After 18 months

Explanation. Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. (I, B)

Question 76

When should a second antithrombotic agent be added to aspirin for extended long-term secondary prevention?

• ○ 1. In patients with low ischaemic risk and with high bleeding risk (HBR)
• ○ 2. Only in patients with high bleeding risk (HBR)
• ✓ 3. In patients with high ischaemic risk and without high bleeding risk (HBR)
• ○ 4. In all patients regardless of risk factors
• ○ 5. Only in the first month after an ischemic event

Explanation. Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered in patients with high ischaemic risk and without HBR. (IIa, A)

Question 77

For extended long-term secondary prevention, in which group of patients may adding a second antithrombotic agent to aspirin be considered?

• ○ 1. Patients with moderate ischaemic risk and high bleeding risk
• ○ 2. Patients with low ischaemic risk and without high bleeding risk
• ○ 3. Patients with high ischaemic risk and high bleeding risk
• ✓ 4. Patients with moderate ischaemic risk and without high bleeding risk*
• ○ 5. Patients with low ischaemic risk and with high bleeding risk

Explanation. Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention may be considered in patients with moderate ischaemic risk and without HBR. (IIb, A)

Question 78

Which of the following regimens may be considered as an alternative to aspirin monotherapy for long-term antithrombotic therapy?

• ○ 1. Warfarin monotherapy
• ○ 2. Dual antiplatelet therapy (DAPT)
• ○ 3. Triple antiplatelet therapy (TAT)
• ✓ 4. P2Y12 inhibitor monotherapy
• ○ 5. Direct oral anticoagulant (DOAC) monotherapy

Explanation. P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment. (IIb, A)

Question 79

When fibrinolysis is the reperfusion strategy, what is the recommended target time to initiate treatment after diagnosis in the pre-hospital setting?

• ○ 1. <5 minutes
• ✓ 2. <10 minutes
• ○ 3. <15 minutes
• ○ 4. <20 minutes
• ○ 5. <30 minutes

Explanation. When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after diagnosis in the pre-hospital setting (aim for target of <10 min to lytic bolus). (I, A)

Question 80

Which of the following agents are recommended for fibrinolytic therapy?

• ○ 1. Tenecteplase, alteplase, streptokinase
• ○ 2. Tenecteplase, alteplase, urokinase
• ✓ 3. Tenecteplase, alteplase, reteplase
• ○ 4. Tenecteplase, alteplase, saruplase
• ○ 5. Tenecteplase, alteplase, metaplase

Explanation. A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended. (I, B)

Question 81

Regarding fibrinolytic therapy using tenecteplase, what is recommended for patients over 75 years of age?

• ○ 1. A full dose of tenecteplase should be considered.
• ○ 2. A quarter dose of tenecteplase should be avoided.
• ✓ 3. A half-dose of tenecteplase should be considered.
• ○ 4. Tenecteplase is contraindicated in patients 75 years or older
• ○ 5. Tenecteplase is contraindicated in patients 75 years or older and reduced eGFR

Explanation. A half-dose of tenecteplase should be considered in patients >75 years of age. (IIa, B)

Question 82

Which of the following is recommended as antiplatelet co-therapy with fibrinolysis?

• ○ 1. Antiplatelets are contraindicated in patients treated with fibrinolysis
• ○ 2. Aspirin and ticagrelor
• ○ 3. Aspirin and prasugrel
• ✓ 4. Aspirin and clopidogrel
• ○ 5. Aspirin and rivaroxaban

Explanation. Aspirin and clopidogrel are recommended as antiplatelet co-therapy in patients treated with fibrinolysis. (I, A)

Question 83

In patients treated with fibrinolysis, for how long is anticoagulation recommended?

• ○ 1. Until discharge
• ○ 2. For 3 days, or until complete ST segment resolution
• ✓ 3. Until revascularization (if performed) or for the duration of hospital stay (up to 8 days)
• ○ 4. For 2 days
• ○ 5. Until ECG changes and symptoms have resolved

Explanation. Anticoagulation is recommended in patients treated with fibrinolysis until revascularization (if performed) or for the duration of hospital stay (up to 8 days). (I, A)

Question 84

Which anticoagulant is recommended as the preferred co-therapy with fibrinolysis?

• ○ 1. Heparin i.v followed by s.c.
• ○ 2. Warfarin p.o.
• ✓ 3. Enoxaparin i.v. followed by s.c.
• ○ 4. Dabigatran
• ○ 5. Bivalirudin or eptifibatide

Explanation. Enoxaparin i.v. followed by s.c. is recommended as the preferred anticoagulant. (I, A)

Question 85

When enoxaparin is not available, which anticoagulant is recommended as a weight-adjusted i.v. bolus, followed by infusion for fibrinolytic therapy?

• ○ 1. Eptifibatide
• ○ 2. Tirofiban
• ○ 3. Fondaparinux
• ✓ 4. Unfractionated Heparin (UFH)
• ○ 5. Bivalirudin

Explanation. When enoxaparin is not available, UFH is recommended as a weight- adjusted i.v. bolus, followed by infusion. (I, B)

Question 86

In patients treated with streptokinase, what anticoagulation co-therapy should be considered?

• ○ 1. An i.v. bolus of heparin followed by an oral dose 24 h later
• ○ 2. An i.v. bolus of heparin followed by an s.c. dose 24 h later
• ○ 3. An i.v. bolus of UFH followed by an s.c. dose 24 h later
• ✓ 4. An i.v. bolus of fondaparinux followed by an s.c. dose 24 h later
• ○ 5. An i.v. bolus of eptifibatide followed by an s.c. dose 24 h later

Explanation. In patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an s.c. dose 24 h later should be considered. (IIa, B)

Question 87

A 58-year-old female is resuscitated following a cardiac arrest. Her ECG, after ROSC, shows persistent ST-segment elevations in leads V2-V5). She becomes hemodynamically unstable with low blood pressure despite repeated intravenous epinephrine. The emergency physician suggested fibrinolysis and continued mechanical CPR.

What is the recommended management strategy for this patient?

• ○ 1. Fibrinolysis
• ○ 2. Immediate defibrillation
• ✓ 3. Primary PCI
• ○ 4. 1 mg epinephrine and immediate fibrinolysis
• ○ 5. New ECG to confirm the presence of ST elevations

Explanation. A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents). (I, B) A new ECG is not required. Fibrinolysis is only indicated if primary PCI is not available.

Question 88

In the case of resuscitated cardiac arrest, what is the recommendation for routine immediate angiography in hemodynamically stable patients without persistent ST-segment elevation (or equivalents)?

• ○ 1. It is always recommended.
• ○ 2. It is recommended only if the patient is symptomatic.
• ✓ 3. It is not recommended.
• ○ 4. It is recommended if the patient's history suggests previous heart issues.
• ○ 5. It is recommended only if the patient is above a certain age.

Explanation. Routine immediate angiography after resuscitated cardiac arrest is not recommended in haemodynamically stable patients without persistent ST-segment elevation (or equivalents). (III, A) Several randomized clinical trials have failed to demonstrate benefit of immediate PCI in resuscitated patients without ST elevations. Several randomized trials have investigated the utility of early coronary angiography and percutaneous coronary intervention (PCI) in patients resuscitated from cardiac arrest without ST-segment elevation. The key trials and their results are: ### 1. COACT (Coronary Angiography after Cardiac Arrest) Trial: This was the first large randomized trial to address this question. It included 552 patients who were successfully resuscitated after out-of-hospital cardiac arrest without ST-segment elevation. Results: - No significant difference in 90-day survival between immediate angiography (64.5%) and delayed angiography (67.2%) groups [3]. - No difference in one-year mortality or other secondary endpoints like myocardial injury, shock, or neurologic status [3]. - Only 5% of patients who underwent immediate angiography had acute thrombotic occlusions [4]. ### 2. TOMAHAWK (Immediate Unselected Coronary Angiography Versus Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation) Trial: This trial included 554 patients with out-of-hospital cardiac arrest without ST-segment elevation. Results: - No benefit in 30-day all-cause mortality with immediate angiography compared to delayed or selective angiography. - Higher risk of severe bleeding in the immediate angiography group. ### 3. EMERGE (Emergency Versus Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest) Trial: This was a smaller trial with 279 patients. Results: - No significant difference in 180-day survival with good neurological outcome between immediate and delayed angiography groups. ### 4. DISCO (Direct or Subacute Coronary Angiography for Out-of-Hospital Cardiac Arrest) Trial: This trial included 1006 patients. Results: - No significant difference in 30-day survival between immediate and delayed angiography groups. - No difference in neurological outcomes or other secondary endpoints. These randomized trials consistently show that immediate coronary angiography does not improve survival or neurological outcomes compared to delayed or selective angiography in patients resuscitated from cardiac arrest without ST-segment elevation. However, it's important to note that coronary artery disease was still present in a significant proportion of these patients, suggesting that careful risk stratification may be necessary to identify those who might benefit from early intervention [4][5]. References [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4072834/ [2] https://pubmed.ncbi.nlm.nih.gov/32985249/ [3] https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.006363 [4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8911187/ [5] https://www.jacc.org/doi/10.1016/j.jacc.2015.05.009

Question 89

What is recommended for adults who remain unresponsive after return of spontaneous circulation following either out-of-hospital or in-hospital cardiac arrest?

• ○ 1. Immediate transfer to a cardiac care unit
• ✓ 2. Temperature control and prevention of fever (>37.7C)
• ○ 3. Administration of high-dose steroids
• ○ 4. Initiation of mechanical ventilation
• ○ 5. Routine use of anti-arrhythmic drugs

Explanation. Temperature control (i.e. continuous monitoring of core temperature and active prevention of fever [i.e. >37.7C]) is recommended after either out-of-hospital or in-hospital cardiac arrest for adults who remain unresponsive after return of spontaneous circulation. (I, B)

Question 90

When is the evaluation of neurological prognosis recommended in comatose survivors after cardiac arrest?

• ○ 1. Within 24 hours after admission
• ○ 2. Between 24 and 48 hours after admission
• ○ 3. Between 48 and 72 hours after admission
• ✓ 4. No earlier than 72 hours after admission
• ○ 5. It is not recommended to evaluate neurological prognosis in comatose survivors

Explanation. Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest. (I, C)

Question 91

What is recommended for patients with cardiogenic shock (CS) complicating acute coronary syndrome (ACS)?

• ✓ 1. Immediate coronary angiography and PCI of the IRA (if indicated)
• ○ 2. Delayed coronary angiography and PCI of the IRA (if indicated)
• ○ 3. Immediate coronary angiography and PCI of the IRA (if indicated) and bystander lesions (if indicated)
• ○ 4. Delayed coronary angiography and PCI of the IRA (if indicated) and bystander lesions (if indicated)
• ○ 5. Delayed coronary angiography with optimization of inotropic and vasopressor agents.

Explanation. Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS. (I, B) PCI is only indicated for the IRA (infarct-related artery); bystander lesions are not treated during the initial management.

Question 92

In the management of cardiogenic shock, what is recommended if percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) is not feasible or unsuccessful?

• ✓ 1. Emergency CABG
• ○ 2. Thrombolytic therapy.
• ○ 3. Perform an immediate heart transplant.
• ○ 4. Medical management only.
• ○ 5. Mechanical circulatory support.

Explanation. Emergency CABG is recommended for ACS-related CS if PCI of the IRA is not feasible/unsuccessful. (I, B)

Question 93

In cases of hemodynamic instability, what is recommended for the repair of mechanical complications of Acute Coronary Syndrome (ACS)?

• ○ 1. Immediate surgical intervention
• ✓ 2. Emergency surgical/catheter-based repair based on Heart Team discussion
• ○ 3. Conservative medical management
• ○ 4. Immediate catheter-based intervention
• ○ 5. Conservative medical management if hemodynamically stable

Explanation. In cases of haemodynamic instability, emergency surgical/catheter-based repair of mechanical complications of ACS is recommended, based on Heart Team discussion. (I, C)

Question 94

In patients with STEMI presenting with cardiogenic shock, under what condition should fibrinolysis be considered?

• ○ 1. When PPCI strategy is not available within 130 minutes from the time of STEMI diagnosis
• ○ 2. When PPCI strategy is not available within 120 minutes from the time of STEMI diagnosis
• ○ 3. When PPCI strategy is not available within 110 minutes from the time of STEMI diagnosis and mechanical complications have been ruled out
• ✓ 4. When PPCI strategy is not available within 120 minutes from the time of STEMI diagnosis and mechanical complications have been ruled out
• ○ 5. When mechanical complications have been ruled out regardless of PPCI availability

Explanation. Fibrinolysis should be considered in STEMI patients presenting with CS if a PPCI strategy is not available within 120 min from the time of STEMI diagnosis and mechanical complications have been ruled out. (IIa, C)

Question 95

In patients with ACS and severe/refractory cardiogenic shock, what intervention may be considered according to clinical practice guidelines?

• ○ 1. ECMO
• ○ 2. Heart transplantation
• ✓ 3. Short-term mechanical circulatory support
• ○ 4. CRRT and ECMO
• ○ 5. Long-term mechanical circulatory support

Explanation. In patients with ACS and severe/ refractory CS, short-term mechanical circulatory support may be considered. (IIb, C)

Question 96

In patients with acute coronary syndrome (ACS) and cardiogenic shock (CS) without mechanical complications, what is the recommendation regarding the routine use of an intra-aortic balloon pump (IABP)?

• ○ 1. It is strongly recommended.
• ○ 2. It is recommended.
• ✓ 3. It is not recommended.
• ○ 4. It should be used as a second-line treatment.
• ○ 5. It is recommended only if other treatments fail.

Explanation. The routine use of an IABP in ACS patients with CS and without mechanical complications is not recommended. (III, B)

Question 97

What is recommended for STEMI patients and very high-risk NSTE-ACS patients regarding ECG monitoring?

• ○ 1. ECG monitoring for a minimum of 48 hours
• ✓ 2. ECG monitoring for a minimum of 24 hours
• ○ 3. ECG monitoring for a minimum of 72 hours
• ○ 1. ECG monitoring for a minimum of 24 hours and asymptomatic
• ○ 5. Daily blood tests for the first 48 hours

Explanation. It is recommended that high- risk patients (including all STEMI patients and very high- risk NSTE- ACS patients) have ECG monitoring for a minimum of 24 h. (I, C)

Question 98

For high-risk patients with successful reperfusion therapy and an uncomplicated clinical course, how long should they be kept in the CCU/ICCU before being moved to a step-down monitored bed?

• ○ 1. A minimum of 12 hours
• ✓ 2. A minimum of 24 hours
• ○ 3. A minimum of 36 hours
• ○ 4. A minimum of 48 hours
• ○ 5. A minimum of 72 hours

Explanation. It is recommended that high-risk patients with successful reperfusion therapy and an uncomplicated clinical course (including all STEMI patients and very high- risk NSTE- ACS patients) are kept in the CCU/ ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored bed for an additional 2448 h. (I, C)

Question 99

Which of the following statements is true regarding the discharge of selected high-risk patients with ACS?

• ○ 1. Discharge within 24-48 hours should be considered if early rehabilitation and adequate follow-up are arranged.
• ○ 2. Discharge within 48-72 hours should be avoided.
• ✓ 3. Discharge of selected high-risk patients within 48-72 hours should be considered if early rehabilitation and adequate follow-up are arranged.
• ○ 4. Discharge within 72 hours should be considered in all patients.
• ○ 5. Discharge within 48-72 hours should be considered only if no follow-up is required.

Explanation. Discharge of selected high- risk patients within 4872 h should be considered if early rehabilitation and adequate follow- up are arranged. (IIa, A)

Question 100

What is recommended for selected stable patients after successful and uneventful PCI?

• ○ 1. Immediate discharge from the hospital
• ✓ 2. Same-day transfer should be considered
• ○ 3. Overnight observation in the hospital
• ○ 4. Weekly follow-up appointments
• ○ 5. Prolonged hospital stay for monitoring

Explanation. Same-day transfer in selected stable patients after successful and uneventful PCI should be considered. (IIa, C)

Question 101

Which patients should undergo routine echocardiography after an ACS?

• ✓ 1. All patients with ACS to assess regional and global LV function, detecting mechanical complications, and excluding LV thrombus.
• ○ 2. Patients with STEMI or NSTEMI in order to assess regional and global LV function, detecting mechanical complications, and excluding LV thrombus.
• ○ 3. All patients with elevated NT-pro-BNP, BNP or troponin
• ○ 4. All patients with signs of left or right ventricular dysfunction
• ○ 5. All patients prior to PCI

Explanation. Routine echocardiography is recommended during hospitalization to assess regional and global LV function, detect mechanical complications, and exclude LV thrombus. (I, C)

Question 102

When echocardiography is suboptimal or inconclusive, which imaging modality may be considered?

• ○ 1. CT
• ○ 2. PET
• ✓ 3. CMR
• ○ 4. TEE
• ○ 5. SPECT scan

Explanation. When echocardiography is suboptimal/inconclusive, CMR imaging may be considered. (IIb, C)

Question 103

Which access route is recommended as the standard approach for PCI?

• ○ 1. Femoral access
• ○ 2. Jugular access
• ○ 3. Brachial access
• ✓ 4. Radial access
• ○ 5. Subclavian access

Explanation. Radial access is recommended as the standard approach, unless there are overriding procedural considerations. (I, A)

Question 104

In patients undergoing primary percutaneous coronary intervention (PPCI), what is recommended regarding the infarct-related artery (IRA) during the index procedure?

• ○ 1. PCI with balloon angioplasty only
• ✓ 2. PCI with stent deployment in the IRA
• ○ 3. Medical management without PCI
• ○ 4. Delayed stent deployment in the IRA
• ○ 5. PCI with rotational atherectomy

Explanation. PCI with stent deployment in the IRA during the index procedure is recommended in patients undergoing PPCI. (I, A)

Question 105

Which type of stent is recommended in all cases according to the guidelines?

• ○ 1. Bioabsorbable stents
• ✓ 2. Drug-eluting stents
• ○ 3. DAPT compatible stents
• ○ 4. Tacrolimus stents
• ○ 5. Bare metal stents

Explanation. Drug- eluting stents are recommended in preference to bare metal stents in all cases. (I, A)

Question 106

A 45-year-old woman presents to the emergency department with severe chest pain and immediate angiography reveals spontaneous coronary artery dissection (SCAD). When is PCI indicated in patients with SCAD?

• ✓ 1. Symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow.
• ○ 2. In presence of multiple ST depressions
• ○ 3. In presence of troponin elevations
• ○ 4. In all cases
• ○ 5. In cases with hemodynamic instability

Explanation. In patients with spontaneous coronary artery dissection, PCI is recommended only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. (I, C)

Question 107

What is the role of intravascular imaging during primary PCI in acute coronary syndromes?

• ✓ 1. Intravascular imaging should be considered to guide PCI, even if there is a clear culprit lesion
• ○ 2. Intravascular imaging should be considered to guide PCI, if there is no clear culprit lesion
• ○ 3. Intravascular imaging should not be considered to guide PCI in acute coronary syndromes
• ○ 4. Only OCT is suitable for imaging in acute coronary syndromes
• ○ 4. Only IVUS is suitable for imaging in acute coronary syndromes

Explanation. Intravascular imaging should be considered to guide PCI  (class IIa, A). This recommendation is valid even if there is a clear culprit lesion. IVUS or OCT can be utilized. In cases without a clear culprit lesion, imaging may be considered (class IIb, A), preferably OCT.

Question 108

In patients with ACS and an occluded IRA, what should be considered when primary PCI is not feasible or unsuccessful and there is a large area of myocardium in jeopardy?

• ○ 1. Conservative management with high-intensity statin therapy and DAPT (dual antiplatelet therapy)
• ○ 2. Thrombolysis
• ○ 3. Drug eluting balloon (DEB)
• ✓ 4. Coronary artery bypass grafting (CABG)
• ○ 5. Thrombus aspiration

Explanation. Coronary artery bypass grafting should be considered in patients with an occluded IRA when PPCI is not feasible/ unsuccessful and there is a large area of myocardium in jeopardy. (IIa, C)

Question 109

Which of the following statements is true regarding the use of thrombus aspiration during primary PCI?

• ○ 1. Thrombus aspiration should be routinely used in all cases.
• ○ 2. Thrombus aspiration is not recommended.
• ✓ 3. The routine use of thrombus aspiration is not recommended.
• ○ 4. Thrombus aspiration is recommended if no-reflow occurs.
• ○ 5. Thrombus aspiration is recommended in cases with complete occlusions.

Explanation. The routine use of thrombus aspiration is not recommended. (III, A)

Question 110

What is recommended for ACS patients presenting in cardiogenic shock with multivessel disease during the index procedure?

• ○ 1. Complete revascularization (PCI of all significant lesions and occlusions)
• ○ 2. Conservative medical management
• ✓ 3. PCI of the IRA only
• ○ 4. CABG
• ○ 5. PCI of the IRA and all significant lesions

Explanation. IRA-only PCI during the index procedure is recommended. (I, B) Staged PCI of non- IRA should be considered. (IIa, C)

Question 111

What is the recommended timeframe for complete revascularization in hemodynamically stable STEMI patients undergoing PPCI?

• ○ 1. Within 48 hours
• ✓ 2. During the index PCI procedure or within 45 days
• ○ 3. Within 72 days
• ○ 4. 2. During the index PCI procedure or within 7 days
• ○ 5. Only during the index PCI procedure

Explanation. Complete revascularization is recommended either during the index PCI procedure or within 45 days. (I, A)

Question 112

How is non-infarct-related artery (non-IRA) stenosis severity evaluated in patients with STEMI?

• ○ 1. Based on instantaneous wave-free ratio (iFR)
• ○ 1. Based on fractional flow reserve (FFR)
• ✓ 3. Based on angiographic severity
• ○ 4. Based on instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR)
• ○ 5. Based on IVUS or OCT

Explanation. It is recommended that PCI of the non-IRA is based on angiographic severity. (I, B) Invasive epicardial functional assessment of non-culprit segments of the IRA is not recommended during the index procedure. (III, C)

Question 113

In patients presenting with NSTE-ACS and multivessel disease (MVD), what is the recommended approach regarding revascularization?

• ○ 1. Complete revascularization is always performed during the index procedure.
• ○ 2. Complete revascularization is not performed during the index procedure.
• ✓ 3. Complete revascularization should be considered in all patients, preferably during the index procedure.
• ○ 4. IRA-only PCI is recommended.
• ○ 5. Complete revascularization should be considered in patients with hemodynamic instability

Explanation. In patients presenting with NSTE- ACS and MVD, complete revascularization should be considered, preferably during the index procedure. (IIa, C)

Question 114

How is non-infarct-related artery (non-IRA) stenosis severity evaluated in patients with NSTE-ACS?

• ✓ 1. Functional invasive evaluation during the index procedure may be considered
• ○ 2. Angiographic evaluation during the index procedure may be considered
• ○ 3. Non-invasive imaging (preferably SPECT) should precede non-IRA PCI.
• ○ 4. Non-IRA PCI is based on the presence of elevated troponin levels.
• ○ 5. Non-IRA PCI is based on correlation with ECG changes

Explanation. Functional invasive evaluation of non-IRA severity during the index procedure may be considered. (IIb, B)

Question 115

Which imaging modality is recommended for patients presenting with MINOCA (myocardial infarction with non-obstructive coronary arteries) following invasive angiography, if the diagnosis is not clear?

• ○ 1. CT coronary angiography
• ○ 2. Echocardiography
• ○ 3. Echocardiography and CT coronary angiography
• ✓ 4. Cardiac MRI
• ○ 5. Nuclear stress test

Explanation. In patients with a working diagnosis of MINOCA, CMR imaging is recommended after invasive angiography if the final diagnosis is not clear. (I, B)

Question 116

When should an intra-aortic balloon pump (IABP) be considered in patients with acute coronary syndrome (ACS)?

• ○ 1. IABP is no longer recommended due to lack of efficacy in randomized trials
• ○ 2. In patients with haemodynamic instability/cardiogenic shock
• ✓ 3. In patients with haemodynamic instability/cardiogenic shock due to ACS-related mechanical complications
• ○ 4. In patients with mechanical complications
• ○ 5. In patients with hypotension

Explanation. IABP should be considered in patients with haemodynamic instability/ cardiogenic shock due to ACS- related mechanical complications. (IIa, C)

Question 117

A 60-year-old male presents to the emergency department with an acute anterior myocardial infarction. Echocardiography reveals a reduced ejection fraction (approximately 30%) with anterior hypokinesia/akinesia. During hospitalization, the patient experienced several embolic events, including a stroke, which led to the suspicion of a left ventricular (LV) thrombus.

What imaging modality should be considered to confirm or rule out the presence of an LV thrombus?

• ○ 1. CT
• ✓ 2. Cardiac MRI
• ○ 3. Repeated echocardiography
• ○ 4. Transesophageal echocardiography
• ○ 5. PET

Explanation. CMR imaging should be considered in patients with equivocal echocardiographic images or in cases of high clinical suspicion of LV thrombus. (IIa, C)

Question 118

For how long should oral anticoagulant therapy (VKA or NOAC) be considered in patients with confirmed left ventricular thrombus?

• ○ 1. 1-2 months
• ✓ 2. 3-6 months
• ○ 3. 6-9 months
• ○ 4. 9-12 months
• ○ 5. Indefinitely

Explanation. Oral anticoagulant therapy (VKA or NOAC) should be considered for 36 months in patients with confirmed LV thrombus. (IIa, C)

Question 119

A 62-year-old male presents to the hospital with an acute anterior myocardial infarction. During his evaluation, a standard echocardiogram is performed, but the apex of the left ventricle is not well visualized.

What imaging strategy may be considered in this patient to detect a LV thrombus?

• ○ 1. Contrast CT
• ○ 2. CT
• ○ 3. Radionuclide imaging
• ✓ 4. Contrast echocardiogram
• ○ 5. PET scan

Explanation. Following an acute anterior MI, a contrast echocardiogram may be considered for the detection of LV thrombus if the apex is not well visualized on echocardiography. (IIb, C)

Question 120

In patients with atrial fibrillation as a complication of acute coronary syndrome, when is the use of intravenous beta-blockers recommended for rate control?

• ○ 1. In all patients
• ○ 2. In the presence of hemodynamic instability caused by atrial fibrillation
• ✓ 3. In the absence of acute heart failure or hypotension
• ○ 4. When oral beta-blockers are ineffective
• ○ 5. When calcium channel blockers are ineffective or contraindicated

Explanation. Intravenous beta-blockers are recommended when rate control is needed in the absence of acute HF or hypotension. (I, C)

Question 121

A 65-year-old female with a history of coronary artery disease presents to the emergency department with an acute coronary syndrome. She has developed rapid atrial fibrillation and signs of acute heart failure (HF), but her blood pressure remains stable at 115/70 mmHg.

What is the recommended medication for rate control in this patient?

• ○ 1. Verapamil
• ○ 2. Diltiazem
• ○ 3. Metoprolol
• ○ 4. Bisoprolol
• ✓ 5. Intravenous amiodarone

Explanation. Intravenous amiodarone is recommended when rate control is needed in the presence of acute HF and no hypotension. (I, C) Verapamil, diltiazem, bisoprolol and metoprolol are contraindicated in acute HF.

Question 122

In patients with acute coronary syndrome (ACS) and haemodynamic instability due to atrial fibrillation, what is recommended when adequate rate control cannot be achieved promptly with pharmacological agents?

• ✓ 1. Immediate electrical cardioversion
• ○ 2. Intravenous labetalol
• ○ 3. Intravenous digoxin
• ○ 4. Intravenous amiodarone
• ○ 5. Intravenous metoprolol

Explanation. Immediate electrical cardioversion is recommended in patients with ACS and haemodynamic instability and when adequate rate control cannot be achieved promptly with pharmacological agents. (I, C)

Question 123

In unstable patients with recent-onset atrial fibrillation (AF), which medication is recommended to facilitate electrical cardioversion and/or decrease the risk for early recurrence of AF after electrical cardioversion?

• ○ 1. Intravenous diltiazem or verapmail
• ○ 2. Oral metoprolol
• ✓ 3. Intravenous amiodarone
• ○ 4. Oral digoxin
• ○ 5. Any class III antiarrhythmic agent

Explanation. Intravenous amiodarone is recommended to facilitate electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion in unstable patients with recent-onset AF. (I, C)

Question 124

In patients with de novo atrial fibrillation (AF) during the acute phase of acute coronary syndrome (ACS), how is long-term management of anticoagulation and antiplatelet therapy determined?

• ○ 1. Long-term oral anticoagulation with Vitamin K antagonists (VKA) is generally recommended
• ✓ 2. Long-term oral anticoagulation (NOAC as the preferred drug) depending on the CHA2DS2-VASc score, after considering the HAS-BLED score and concomitant antiplatelet therapy
• ○ 3. Long-term oral anticoagulation depending on the CHA2DS2-VASc score.
• ○ 4. Anticoagulation is postponed until completion of dual antiplatelet therapy (12 months)
• ○ 5. Anticoagulation is not required in patients managed with dual antiplatelet therapy

Explanation. In patients with documented de novo AF during the acute phase of ACS, long- term oral anticoagulation should be considered depending on the CHA2DS2- VASc score, after taking the HAS- BLED score and the need for concomitant antiplatelet therapy into consideration. NOACs are the preferred drugs. (IIa, C)

Question 125

A 68-year-old male with a history of myocardial infarction (MI) 5 months ago and symptomatic heart failure (NYHA Class II) is being evaluated in the outpatient clinic. His left ventricular ejection fraction (LVEF) is 30%, despite being on optimal medical therapy for the past four months. He is otherwise in good functional status.

What therapy is recommended to reduce the risk of sudden cardiac death in this patient?

• ○ 1. Amiodarone and/or beta-blocker
• ○ 2. Conduct electrophysiological testing before proceeding to implantation of ICD (implantable cardioverter-defibrillator)
• ✓ 3. Implant an ICD (implantable cardioverter-defibrillator)
• ○ 4. Assess residual myocardial ischemia with SPECT or other non-invasive imaging
• ○ 4. Assess residual myocardial ischemia with coronary angiography, including functional assessment (FFR, iFR)

Explanation. ICD therapy is recommended to reduce sudden cardiac death in patients with symptomatic HF (NYHA Class II-III) and LVEF 35% despite optimal medical therapy for >3 months and at least 6 weeks after MI who are expected to survive for at least 1 year with good functional status. (I, A) Requirements for ICD implantation in patients with heart failure: - NYHA class II-III. - OMT (optimal medical therapy) for heart failure for 3 months or longer - Elapsed 6 weeks or longer since acute myocardial infarction - Life-expectancy >12 months, good functional status - Ejection fraction <35% If the patient is asymptomatic or in NYHA class I, the requirement for ejection fraction is <30%.

Question 126

A 65-year-old female with a history of hypertension presents to the emergency department with acute coronary syndrome. Due to ongoing gastrointestinal bleeding, it is determined to postpone angiography and PCI (which requires anticoagulation and antiplatelet drugs). She develops polymorphic ventricular tachycardia (VT) which degenerates into ventricular fibrillation (VF). Resuscitation, with 3 defibrillations, is successful.

What is the recommended treatment for managing the ventricular arrhythmias in this patient, assuming there are no contraindications?

• ○ 1. Oral beta-blocker
• ✓ 2. Intravenous beta-blocker and/or amiodarone
• ○ 3. Oral calcium channel blocker
• ○ 4. Oral amiodarone
• ○ 5. Intravenous magnesium sulfate

Explanation. Intravenous beta- blocker and/or amiodarone treatment is recommended for patients with polymorphic VT and/or VF, unless contraindicated. (I, B)

Question 127

A 62-year-old male is admitted to the coronary care unit due to unstable angina. He experiences recurrent episodes of ventricular tachycardia (VT). Troponin levels are not elevated and he is asymptomatic, except from recurrent VT.

What is the recommended strategy to treat the underlying myocardial ischaemia in this patient with recurrent VT and/or VF?

• ○ 1. Administration of beta-blockers
• ○ 2. Administration of amiodarone
• ○ 3. Administration of beta-blockers and amiodarone
• ✓ 4. Prompt and complete revascularization
• ○ 5. No intervention is required for recurrent VT without hemodynamic effects

Explanation. Prompt and complete revascularization is recommended to treat myocardial ischaemia that may be present in patients with recurrent VT and/or VF. (I, C)

Question 128

In the context of acute coronary syndrome complications, what should be considered if ventricular tachycardia (VT) cannot be controlled by revascularization, pharmacological agents and repeated electrical cardioversion?

• ○ 1. CABG
• ○ 2. Class III antiarrhythmic drugs
• ✓ 3. Transvenous catheter pacing termination and/or overdrive pacing
• ○ 4. Surgical intervention
• ○ 5. Continuous infusion of intravenous beta-blockers

Explanation. Transvenous catheter pacing termination and/or overdrive pacing should be considered if VT cannot be controlled by repeated electrical cardioversion. (IIa, C)

Question 129

In patients with acute coronary syndromes and recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy, what should be considered?

• ○ 1. Amiodarone
• ○ 2. Non-invasive imaging to assess residual ischemia
• ○ 3. Invasive functional assessment of residual ischemia
• ✓ 4. Radiofrequency catheter ablation at a specialized ablation centre followed by ICD implantation
• ○ 5. Conservative management

Explanation. Radiofrequency catheter ablation at a specialized ablation centre followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy. (IIa, C)

Question 130

When treating recurrent ventricular tachycardia (VT) with hemodynamic effects, which medication may be considered if beta-blockers, amiodarone, and overdrive stimulation are not effective or applicable?

• ○ 1. Diltiazem
• ○ 2. Sotalol infusion
• ✓ 3. Lidocaine
• ○ 4. Verapamil
• ○ 5. Digoxin

Explanation. Treatment of recurrent VT with haemodynamic relevance (despite repeated electrical cardioversion) with lidocaine may be considered if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable. (IIb, C)

Question 131

What may be considered for patients with recurrent life-threatening ventricular arrhythmias to reduce sympathetic drive?

• ○ 1. Beta-blockers
• ○ 2. Amiodarone
• ✓ 3. Sedation or general anaesthesia
• ○ 4. Sotalol
• ○ 5. Calcium channel blockers

Explanation. In patients with recurrent life- threatening ventricular arrhythmias, sedation or general anaesthesia to reduce sympathetic drive may be considered. (IIb, C)

Question 132

In which patients may ICD implantation or the temporary use of a wearable cardioverter defibrillator be considered within 40 days after MI?

• ○ 1. In patients who experienced sudden cardiac arrest prior to hospitalization
• ○ 2. In patients who experienced sudden cardiac arrest prior to revascularization
• ✓ 3. Patients who developed ventricular arrhythmias more than 48 hours after STEMI onset
• ○ 4. Patients with left ventricular ejection fraction <25%
• ○ 5. Patients with left ventricular ejection fraction <35%

Explanation. ICD implantation or the temporary use of a wearable cardioverter defibrillator may be considered (class IIb, level of evidence C) <40 days after MI in the following scenarios: - incomplete revascularization - pre-existing LVEF dysfunction - occurrence of arrhythmias >48 h after STEMI onset - polymorphic VT or VF.

Question 133

Which of the following is recommended for the treatment of asymptomatic and haemodynamically irrelevant ventricular arrhythmias in patients with acute coronary syndromes?

• ○ 1. Class I antiarrhythmics
• ○ 2. Class 2 antiarrhythmics
• ○ 3. Class 3 antiarrhythmics
• ○ 4. Beta-blockers
• ✓ 5. Anti-arrhythmic drugs are not recommended

Explanation. Treatment of asymptomatic and haemodynamically irrelevant ventricular arrhythmias with anti-arrhythmic drugs is not recommended. (III, C)

Question 134

A patient with NSTEMI undergoes successful PCI, but subsequently develops sinus bradycardia with hemodynamic intolerance, and episodes of high-degree AV block without stable escape rhythm. Which of the following treatments is recommended?

• ○ 1. Initial treatment is oral beta-blockers
• ✓ 2. Initial treatment is i.v. positive chronotropic medication (atropine, adrenaline, vasopressin)
• ○ 3. Initial treatment is permanent pacing
• ○ 4. Initial treatment is temporary pacing
• ○ 5. No treatment required the first 5 days

Explanation. In cases of sinus bradycardia with haemodynamic intolerance or high-degree AV block without stable escape rhythm: i.v. positive chronotropic medication (adrenaline, vasopressin, and/or atropine) is recommended. Temporary pacing is recommended in cases of failure to respond to atropine; (I, C)

Question 135

If a patient with NSTEMI develops hemodynamically significant sinus bradycardia, or high-degree AV block without stable escape rhythm, what is the recommended urgent intervention if the patient has not received previous reperfusion therapy?

• ○ 1. Permanent pacemaker
• ○ 2. Thrombolysis
• ✓ 3. Urgent angiography with a view to revascularization
• ○ 4. i.v. Atropine, vasopressin or adrenalin
• ○ 5. Conservative management

Explanation. In cases of sinus bradycardia with haemodynamic intolerance or high- degree AV block without stable escape rhythm, urgent angiography with a view to revascularization is recommended if the patient has not received previous reperfusion therapy. (I, C)

Question 136

When is the implantation of a permanent pacemaker recommended in patients with acute coronary syndrome complicated by high-degree AV-block?

• ○ 1. Immediately after high-degree AV block is detected
• ✓ 2. If high-degree AV block does not resolve within a waiting period of at least 5 days after MI
• ○ 3. If the patient experiences recurrent syncope
• ○ 4. If high-degree AV block persists for more than 24 hours after MI
• ○ 5. If high-degree AV block does not resolve within a waiting period of at least 7 days after MI

Explanation. Implantation of a permanent pacemaker is recommended when high- degree AV block does not resolve within a waiting period of at least 5 days after MI. (I, C)

Question 137

In patients with a high-degree AV block in the context of an anterior wall MI and acute heart failure, what treatment may be considered?

• ○ 1. It is not recommended
• ○ 2. In patients with left ventricular ejection fraction <35%
• ○ 3. In patients with QRS duration >150 ms
• ○ 4. In patients with high-degree AV block in the context of an anterior wall MI.
• ✓ 5. In patients with high-degree AV block in the context of an anterior wall MI and acute HF.

Explanation. In selected patients with high-degree AV block in the context of an anterior wall MI and acute HF, early device implantation (CRT-D/ CRT-P) may be considered. (IIb, C)

Question 138

Under which condition is pacing NOT recommended for patients experiencing high-degree AV block?

• ✓ 1. When high-degree AV block resolves after revascularization or spontaneously.
• ○ 2. When high-degree AV block resolves within 7 days
• ○ 3. When high-degree AV block is accompanied by hypotension.
• ○ 4. When high-degree AV block is accompanied by adequate escape rhythm
• ○ 5. When high-degree AV block is responsive to pharmacological therapy.

Explanation. Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously. (III, B)

Question 139

In patients with chronic kidney disease undergoing invasive strategies for acute coronary syndrome, what is recommended regarding the use of contrast media?

• ○ 1. Use high-osmolar contrast media
• ○ 2. Avoid the use of contrast media.
• ✓ 3. Use low- or iso-osmolar contrast media at the lowest possible volume.
• ○ 4. Use iso-osmolar contrast media
• ○ 5. Use low-osmolar contrast media with rapid infusion rate

Explanation. The use of low- or iso- osmolar contrast media (at the lowest possible volume) is recommended for invasive strategies. (I, A)

Question 140

In patients with acute coronary syndrome (ACS), what is the recommended method for assessing kidney function?

• ○ 1. Serum creatinine
• ○ 2. Plasma creatinine
• ○ 3. Iohexol clearance
• ✓ 4. eGFR (estimated Glomerular Filtration Rate) assessment
• ○ 5. LVEF

Explanation. It is recommended to assess kidney function using eGFR in all patients with ACS. (I, C)

Question 141

In patients with chronic kidney disease (CKD) who present with acute coronary syndrome, which of the following is recommended regarding diagnostic and therapeutic strategies?

• ○ 1. Avoid antiarrhythmic drugs
• ○ 2. Avoid high-dose statin therapy
• ✓ 3. Apply the same diagnostic and therapeutic strategies as in patients with normal kidney function, with dose adjustment if necessary.
• ○ 4. Initiate SGLT2 inhibitors in all patients with reduced eGFR
• ○ 5. Inititiate finerenone in all patients with diabetes and reduced eGFR

Explanation. It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as in patients with normal kidney function. (I, C)

Question 142

In patients at risk of contrast-induced nephropathy, especially those with acute kidney injury and/or CKD with eGFR <30 mL/min/1.73m, what should be considered during and after angiography?

• ○ 1. Loop diuretics
• ○ 2. Metolazone
• ✓ 3. Hydration
• ○ 4. Corticosteroids and hydration
• ○ 5. ACE inhibitors or SGLT2 inhibitors.

Explanation. Hydration during and after angiography should be considered in patients at risk of contrast- induced nephropathy, especially in patients with acute kidney injury and/ or CKD with eGFR <30 mL/ min/ 1.73m2. (IIa, B)

Question 143

In which patients with acute coronary syndrome should glycemic status be evaluated?

• ○ 1. All patients with a history of diabetes
• ✓ 2. All patients
• ○ 3. Patients with elevated troponin levels
• ○ 4. Patients with features of the metabolic syndrome
• ○ 5. Patients who are overweight or obese

Explanation. It is recommended to assess glycaemic status at initial evaluation in all patients with ACS. (I, B)

Question 144

In patients with acute coronary syndrome (ACS) and persistent and significant hyperglycaemia, what treatment should be commenced?

• ○ 1. Glucose-lowering therapy according to guidelines
• ○ 2. Initiation of insulin therapy during hospital admission and oral therapies after discharge
• ✓ 3. SGLT2 inhibitors are initiated during hospital stay. Other treatments are initiated after discharge.
• ○ 4. Metformin is initiated during hospital stay. Other treatments are initiated after discharge.
• ○ 5. Hyperglycemia is generally due to stress caused by ACS; treatment of hyperglycemia is not indicated.

Explanation. Glucose- lowering therapy should be considered in patients with ACS with persistent hyperglycaemia, while episodes of hypoglycaemia should be avoided. (IIa, C)

Question 145

What is the recommended approach to diagnostic and treatment strategies in older patients compared to younger patients with ACS?

• ○ 1. Use more conservative diagnostic and treatment strategies in older patients.
• ○ 2. Avoid invasive procedures in patients older than 80 years
• ✓ 3. Apply the same diagnostic and treatment strategies in older patients as in younger patients.
• ○ 4. Avoid invasive procedures in patients older than 75 years
• ○ 5. DAPT and anticoagulants are avoided if possible

Explanation. It is recommended to apply the same diagnostic and treatment strategies in older patients as in younger patients. (I, B)

Question 146

In cancer patients presenting with high-risk acute coronary syndrome (ACS), what is the recommended strategy concerning PCI?

• ○ 1. PCI is discouraged in patients with cancer
• ✓ 2. PCI is discouraged in patients with metastasized cancer
• ○ 3. PCI is recommended in all patients
• ○ 4. PCI is recommended in all patients with >6 months expected survival from cancer
• ○ 5. No recommendations have been issued

Explanation. An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival 6 months. (I, B) A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (i.e. with expected survival <6 months) and/or very high bleeding risk. (IIa, C)

Question 147

In patients with cancer who are suspected to have cancer therapy contributing to acute coronary syndrome (ACS), what is the recommended?

• ○ 1. Continue cancer therapy
• ○ 2. Use DAPT irrespective of PCI
• ✓ 3. Lower the dosage of the current cancer medications
• ○ 4. Switch to a different cancer therapy
• ○ 5. Temporarily interrupt cancer therapy

Explanation. A temporary interruption of cancer therapy is recommended in patients in whom the cancer therapy is suspected to be a contributing cause of ACS. (I, C)

Question 148

At what platelet count is aspirin not recommended in patients with cancer?

• ✓ 1. <10 000/ L
• ○ 2. <5000/ L
• ○ 3. Aspirin is recommended in all patients
• ○ 4. <20 000/ L
• ○ 5. <30 000/ L

Explanation. Aspirin is not recommended in cancer patients with a platelet count <10 000/ L. (III, C)

Question 149

At what platelet count is clopidogrel not recommended in patients with ACS?

• ○ <10 000/ L
• ○ <20 000/ L
• ✓ <30 000/ L
• ○ <40 000/ L
• ○ <50 000/ L

Explanation. Clopidogrel is not recommended in cancer patients with a platelet count <30 000/ L. (III, C)

Question 150

At what platelet count are prasugrel and ticagrelor not recommended in patients with ACS?

• ○ <10 000/ L
• ○ <20 000/ L
• ○ <30 000/ L
• ○ <40 000/ L
• ✓ <50 000/ L

Explanation. In ACS patients with cancer and <50 000/ L platelet count, prasugrel or ticagrelor are not recommended. (III, C)

Question 151

What is recommended for all ACS patients regarding cardiac rehabilitation?

• ○ 1. Exercise should be avoided during the first 90 days after ACS
• ✓ 2. A medically supervised, structured, multidisciplinary, exercise-based rehabilitation and programme is recommended.
• ○ 3. They should engage in light physical activities.
• ○ 4. They should participate in a diet-focused cardiac rehabilitation programmes.
• ○ 5. Cardiac rehabilitation is optional and can be decided based on the patient's personal preference.

Explanation. It is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, multidisciplinary exercise- based cardiac rehabilitation and prevention programme. (I, A)

Question 152

Which of the following lifestyle changes is recommended for ACS patients for long-term management?

• ○ 1. Healthy diet, alcohol restriction, regular aerobic physical activity and resistance exercise, reduced sedentary time
• ○ 2. Adopting a Mediterranean-style diet
• ○ 3. Stopping smoking, alcohol restriction, regular aerobic physical activity and resistance exercise, reduced sedentary time
• ○ 4. Stopping smoking
• ✓ 5. Stopping smoking, healthy diet (Mediterranean style), alcohol restriction, regular aerobic physical activity and resistance exercise, reduced sedentary time

Explanation. It is recommended that ACS patients adopt a healthy lifestyle, including: stopping all smoking of tobacco healthy diet (Mediterranean style) alcohol restriction regular aerobic physical activity and resistance exercise reduced sedentary time (I, B)

Question 153

In smokers, which of the following should be considered for long-term management support?

• ○ 1. Nicotine replacement therapy (NRT)
• ○ 2. Varenicline or bupropion
• ✓ 3. Follow-up support, NRT, varenicline or bupropion, individually or in combination
• ○ 4. Follow-up support at a certified centre
• ○ 5. None of the above are evidence-based

Explanation. In smokers, offering follow- up support, nicotine replacement therapy, varenicline or bupropion, individually or in combination, should be considered. (IIa, A)

Question 154

What is recommended regarding high-dose statin therapy after ACS?

• ○ 1. High-dose statin therapy is indicated if initial LDL-C values are above 1.8 mmol/L (70 mg/dL)
• ○ 2. High-dose statin therapy is indicated if initial LDL-C values are above 1.0 mmol/L (40 mg/dL)
• ○ 3. High-dose statin therapy is indicated if initial LDL-C values are above 2.6 mmol/L (100 mg/dL)
• ✓ 4. High-dose statin therapy is indicated in all patients, regardless of LDL-C values
• ○ 5. It is recommended to use high-dose statin therapy only after lifestyle modifications have failed.

Explanation. It is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values. (I, A)

Question 155

What is the recommended LDL-C level to aim for in long-term pharmacological treatment?

• ○ 1. <1.4 mmol/L (<55 mg/dL) and a reduction by 30% from baseline
• ○ 2. <1.8 mmol/L (<70 mg/dL) and a reduction by 40% from baseline
• ○ 3. <2.0 mmol/L (<80 mg/dL) and a reduction by 45% from baseline
• ✓ 4. <1.4 mmol/L (<55 mg/dL) and a reduction by 50% from baseline
• ○ 5. <1.0 mmol/L (<40 mg/dL) and a reduction by 60% from baseline

Explanation. It is recommended to aim to achieve an LDL- C level of <1.4 mmol/ L (<55 mg/ dL) and to reduce LDL- C by 50% from baseline. (I, A)

Question 156

If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4-6 weeks, what is the recommended next step?

• ○ 1. Intensify lifestyle modifications
• ○ 2. Switch to a different high-dose statin
• ✓ 3. Add ezetimibe
• ○ 4. Add GLP-1 receptor (semaglutide, tirzepatide, etc.) agonist
• ○ 5. Add PCSK9 inhibitor

Explanation. If the LDL- C goal is not achieved despite maximally tolerated statin therapy after 4-6 weeks, the addition of ezetimibe is recommended. (I, B)

Question 157

If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4-6 weeks, what is recommended?

• ○ 1. Increasing the dose of ezetimibe
• ○ 2. Switching to a different high-dose statin
• ○ 3. Evaluate for familial hypercholesterolemia
• ○ 4. Initiating fibrate therapy
• ✓ 5. Adding a PCSK9 inhibitor

Explanation. If the LDL- C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4-6 weeks, the addition of a PCSK9 inhibitor is recommended. (I, A)

Question 158

A 70-year-old female with a history of hyperlipidemia and statin (rosuvastatin 20 mg) use presents to the hospital with an acute coronary syndrome (ACS).

What is the recommended approach to lipid-lowering therapy for this patient during her hospitalization?

• ○ 1. Add PCSK9 inhibitor
• ○ 2. Maintain current lipid-lowering therapy
• ○ 3. Add ezetimibe
• ✓ 4. intensify lipid-lowering therapy
• ○ 5. Switch statin to exetimibe and PCSK9 inhibitor

Explanation. It is recommended to intensify lipid- lowering therapy during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission. (I, C)

Question 159

For patients with a recurrent atherothrombotic event within 2 years of the first ACS episode while taking maximally tolerated statin-based therapy, what LDL-C goal may be considered?

• ○ 1. <2.0 mmol/L (<80 mg/dL)
• ○ 2. <1.5 mmol/L (<60 mg/dL)
• ✓ 3. <1.0 mmol/L (<40 mg/dL)
• ○ 4. <0.5 mmol/L (<20 mg/dL)
• ○ 5. <2.5 mmol/L (<100 mg/dL)

Explanation. For patients with a recurrent atherothrombotic event (recurrence within 2 years of first ACS episode) while taking maximally tolerated statin-based therapy, an LDL- C goal of <1.0 mmol/ L (<40 mg/ dL) may be considered. (IIb, B)

Question 160

A 65-year-old male presents to the hospital with an acute coronary syndrome (ACS). His LDL levels are very high (6 mmol/L [230 mg/dL]) despite being on a moderate-dose statin.

What combination therapy may be considered during his index hospitalization to manage his LDL levels?

• ○ 1. High-dose statin
• ○ 2. PCSK9 inhibitor
• ✓ 3. Combination therapy with high-dose statin plus ezetimibe
• ○ 4. Combination therapy with high-dose statin, ezetimibe and PCSK9 inhibitor
• ○ 5. Same recommendation as for other patients with ACS

Explanation. Combination therapy with high-dose statin plus ezetimibe may be considered during index hospitalization. (IIb, B)

Question 161

In which patients are beta-blockers recommended regardless of heart failure symptoms?

• ○ 1. ACS patients with LVEF >50%
• ○ 2. ACS patients with LVEF between 40-50%
• ✓ 3. ACS patients with LVEF <40%
• ○ 4. ACS patients without any LVEF assessment
• ○ 5. ACS patients with normal LVEF

Explanation. Beta-blockers are recommended in ACS patients with LVEF <=40% regardless of HF symptoms. (I, A)

Question 162

Which of the following is a recommendation for the routine use of beta-blockers in patients with ACS?

• ○ 1. Routine use of beta-blockers for all ACS patients is recommended (class I) regardless of LVEF
• ✓ 2. Routine use of beta-blockers for all ACS patients should be considered (class IIa) regardless of LVEF
• ○ 3. Routine use of beta-blockers for all ACS patients may be considered (class IIb) regardless of LVEF
• ○ 4. Routine use of beta-blockers is not recommended (class III) regardless of LVEF
• ○ 5. No recommendation exists.

Explanation. Routine beta-blockers for all ACS patients regardless of LVEF should be considered. (IIa, B)

Question 163

In patients with Acute Coronary Syndrome (ACS), which of the following conditions would warrant the recommendation of Angiotensin-converting enzyme (ACE) inhibitors for long-term management?

• ○ 1. Patients with HF symptoms
• ○ 2. Patients with HF symptoms, LVEF <40%
• ○ 3. Patients with HF symptoms, LVEF <40%, diabetes
• ○ 4. Patients with HF symptoms, LVEF <40%, diabetes, hypertension
• ✓ 5. Patients with HF symptoms, LVEF <40%, diabetes, hypertension, and/or CKD

Explanation. Angiotensin-converting enzyme (ACE) inhibitorsb are recommended in ACS patients with HF symptoms, LVEF <40%, diabetes, hypertension, and/or CKD. (I, A)

Question 164

In the long-term management of ACS patients, when is treatment with mineralocorticoid receptor antagonists (MRA) indicated?

• ○ 1. MRA is not indicated
• ✓ 2. LVEF <40% and HF or diabetes
• ○ 3. LVEF <40%
• ○ 4. Diabetes
• ○ 5. LVEF <35

Explanation. Mineralocorticoid receptor antagonists are recommended in ACS patients with an LVEF <40% and HF or diabetes. (I, A)

Question 165

What is the recommendation for routine ACE inhibitors in patients with ACS?

• ○ 1. Routine ACE inhibitors should be avoided.
• ✓ 2. Routine ACE inhibitors should be considered.
• ○ 3. Routine ACE inhibitors may be considered
• ○ 4. No recommendation has been issued
• ○ 5. No randomized trials have been conducted

Explanation. Routine ACE inhibitors for all ACS patients regardless of LVEF should be considered. (IIa, A)

Question 166

Which of the following is recommended to improve adherence and outcomes in secondary prevention after acute coronary syndrome (ACS)?

• ○ 1. Telemedicine monitoring
• ○ 2. No intervention is evidence-based
• ✓ 3. A polypill
• ○ 4. Monthly outpatient visits
• ○ 5. Annual outpatient visits

Explanation. A polypill should be considered as an option to improve adherence and outcomes in secondary prevention after ACS. (IIa, B)

Question 167

In patients with pre-discharge LVEF <40%, when is it recommended to repeat the evaluation of LVEF to assess the potential need for primary prevention ICD implantation?

• ○ 1. 2-4 weeks after an ACS
• ○ 2. 4-6 weeks after an ACS
• ✓ 3. 6-12 weeks after an ACS
• ○ 4. 12-16 weeks after an ACS
• ○ 5. 16-20 weeks after an ACS

Explanation. In patients with pre-discharge LVEF <40%, repeat evaluation of the LVEF 6-12 weeks after an ACS (and after complete revascularization and the institution of optimal medical therapy) is recommended to assess the potential need for sudden cardiac death primary prevention ICD implantation. (I, C)

Question 168

Which imaging modality should be considered as an adjunctive tool to assess the potential need for primary prevention ICD implantation?

• ○ 1. Echocardiography
• ○ 2. Nuclear imaging
• ✓ 3. Cardiac magnetic resonance
• ○ 4. Computed tomography (CT)
• ○ 5. Positron emission tomography (PET)

Explanation. Cardiac magnetic resonance should be considered as an adjunctive imaging modality in order to assess the potential need for primary prevention ICD implantation. (IIa, C)

Question 169

What is recommended for all ACS patients in terms of vaccination?

• ○ 1. Hepatitis B vaccination
• ○ 2. Tetanus vaccination
• ✓ 3. Influenza vaccination
• ○ 4. Meningococcal vaccination
• ○ 5. Pneumococcal vaccination

Explanation. Influenza vaccination is recommended for all ACS patients. (I, A)

Question 170

When may low-dose colchicine (0.5 mg once daily) be considered?

• ○ 1. When all risk factors are sufficiently controlled.
• ✓ 2. If recurrent cardiovascular disease events occur despite optimal therapy.
• ○ 3. As the first line of treatment for all patients.
• ○ 4. Only in patients without any other risk factors.
• ○ 5. As a substitute for optimal therapy.

Explanation. Low- dose colchicine (0.5 mg once daily) may be considered, particularly if other risk factors are insufficiently controlled or if recurrent cardiovascular disease events occur under optimal therapy. (IIb, A)

Question 171

In the context of acute coronary syndrome care, which of the following is recommended for assessing mental well-being?

• ○ 1. Routine physical examinations
• ✓ 2. Use of a validated tool for mental well-being assessment and onward psychological referral when appropriate
• ○ 3. Regular cardiovascular stress testing
• ○ 4. Comprehensive metabolic panel screenings
• ○ 5. Genetic testing for predisposition to coronary artery disease

Explanation. Assessment of mental well- being using a validated tool and onward psychological referral when appropriate should be considered. (IIa, B)