Order Goals For Reperfusion Therapy Discussion

Order Goals For Reperfusion Therapy Discussion
Order 5940542
Order Goals For Reperfusion Therapy Discussion
A 49-year-old man with hypertension began experiencing chest ‘‘tightness’’ and shortness of breath
while at work as a construction contractor. The patient’s father died of a ‘‘massive heart attack’’ at
age 52. His coworkers called 911 and the Emergency Medical Services (EMS) arrived on the scene
within 10 minutes. Upon arrival, EMS gave the patient a chewable aspirin (325 mg), nitroglycerin SL
(0.4 mg), and IV morphine (2 mg). He was started
on oxygen 2 L through nasal cannula. Which of these
prehospital therapies has been shown to have the
most benefit on mortality?
(A) Chewable aspirin (325 mg)
(B) Nitroglycerin SL (0.4 mg)
(C) IV morphine (2 mg)
(D) Oxygen 2 L through nasal cannula
5 EMS was called to the home of a 68-year-old woman
with a history of diabetes and hypertension. Her
initial complaint was chest discomfort that started
2 hours ago. On arrival, the paramedics find the
patient to be minimally responsive with the following
vital signs: Pulse of 104 bpm, respiration 24 to 28
breaths/minute, BP 95/60, oxygenation 91% on room
air. She has bibasilar crackles on examination. The
nearest hospital is 5 minutes away, but it does not
have primary PCI capabilities. The nearest tertiary
care center with primary PCI capabilities is 15 to 20
minutes away. The EMS team should ideally:
(A) Transfer the patient to the nearest hospital
regardless of the facilities and capabilities of
primary PCI
(B) Transfer the patient to the nearest hospital that
utilizes fibrinolytic agents as the sole modality
for treatment of STEMI
(C) Transfer the patient to the nearest hospital with
primary PCI and coronary artery bypass grafting
(CABG) capabilities
(D) Administer prehospital fibrinolytic therapy
6 A 69-year-old man is admitted to the emergency
room with symptoms suggestive of an MI. The first
cardiac biomarker that will be elevated in an acute
MI is:
(A) Troponin I
(B) Troponin T
(C) Creatine kinase-MB
(D) Myoglobin
7 The most useful cardiac marker in the assessment of
reinfarction after STEMI is:
(A) Troponin I
(B) Troponin T
(C) Creatine kinase–MB
(D) Myoglobin
8 A 79-year-old man presents to the hospital with intermittent chest pain for 6 hours. His EKG shows an
evolving anterior STEMI. He is administered acetylsalicylic acid (ASA), heparin, and nitroglycerin and
is brought emergently to the cardiac catheterization
lab. He is found to have a 99% proximal left anterior descending (LAD) artery lesion as well as a 60%
proximal right coronary artery (RCA) lesion and a
ST-Elevation Myocardial Infarction: American College of Cardiology/American Heart Association Guidelines 311
50% mid left circumflex artery lesion. After primary
PCI of the proximal LAD lesion, he is clinically stable
with no further chest pain. In regard to the other
lesions, what therapy should be recommended at the
time of the primary PCI?
(A) PCI of the proximal RCA lesion
(B) PCI of the proximal RCA lesion and the mid left
circumflex lesions
(C) Fractional flow reserve evaluation of the RCA
and LCx lesions
(D) No further assessment or intervention at this
time
9 A 52-year-oldwomanwith diabetes and hypertension
presents to a rural hospital without primary PCI
capabilities within 90 minutes of the onset of
sudden crushing chest tightness. Her EKG reveals an
anterolateral STEMI. She has no signs or symptoms of
heart failure. Transfer to another facility for primary
PCI is expected to take 90 minutes and transfer-toballoon time is anticipated to be 120 minutes. In
regard to the reperfusion therapy of the patient, the
most appropriate plan of action is:
(A) Prompt administration of half-dose fibrinolytic
agents with transfer for facilitated PCI
(B) Prompt administration of full-dose fibrinolytic
agents
(C) Prompt transfer for primary PCI
(D) None of the above
10 A 68-year-old woman presented to the emergency
department within 2 hours of chest discomfort
described as an 8/10 ‘‘chest tightness.’’ The EKG
demonstrated a lateral STEMI with 4 to 5 mm
ST elevation in V5, V6, I, and aVL. The patient
received prompt reperfusion therapy with reteplase
(in addition to ASA, heparin, metoprolol, and
nitroglycerin) and was admitted to the coronary
intensive care unit. Within 90 minutes of fibrinolytic
administration, she has had some relief in her
symptoms now describing the ‘‘chest tightness’’ as
3/10. Her EKG showed partial resolution of the
ST elevations (now 3 mm). Her telemetry monitor
showed several runs of nonsustained ventricular
tachycardia (VT). What is the most appropriate
management for this patient at this point?
(A) Continued monitoring in the coronary intensive
care unit
(B) Transfer to a tertiary care center for rescue PCI
(C) Readministration of full-dose reteplase
(D) Readministration of half-dose reteplase
11 After primary PCI, which of the following findings is
associated with the worst mortality?
(A) Thrombolysis in myocardial infarction (TIMI)
2 flow grade
(B) Transient no-reflow
(C) Persistent ST-segment elevation
(D) TIMI 2 myocardial perfusion grade
12 Immediate β-blockers should not be used in which
of the following situations?
(A) Non–ST-segment elevation MIs
(B) Heart rate (HR) <70 bpm
(C) Systolic blood pressure (SBP) <100 mm Hg
(D) Patients undergoing primary PCI
13 Which of the following time delays in primary PCI is
associated with the highest mortality?
(A) Door-to-balloon time
(B) Door-to-balloon time minus door-to-needle
time
(C) Symptoms-to-balloon time
(D) Symptoms-to-door times
14 Goals for reperfusion therapy for STEMI are:
(A) Door-to-needle time <30 minutes and doorto-balloon time <120 minutes
(B) Door-to-needle time <60 minutes and doorto-balloon time <90 minutes
(C) Door-to-needle time <30 minutes and doorto-balloon time <90 minutes
(D) Door-to-needle time <60 minutes and doorto-balloon time <120 minutes
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