Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 157

1 Question 1. A 52-year-old man presents to a non-PCI hospital with 2 hours of chest pain. His ECG shows anterior ST-segment elevation. His blood pressure is 109/67 and his heart rate is 105. He has no known contraindication to thrombolysis. The closest PCI hospital is 90 miles away and no community transfer system is in place. The best reperfusion strategy for this patient is:No administration of thrombolysis. Transfer for primary PCIImmediate thrombolysis and immediate transfer to a PCI hospital for consideration of routine early PCI within 24 hours of presentation or for rescue PCI if thrombolysis failsImmediate thrombolysis. Transfer to the PCI center only if thrombolysis fails at 90 min after starting therapyAdminister aspirin, heparin and clopidogrel 300 mg before transferB and DC and D

2 Question 2. A 49-year-old man presents with progressive dyspnea over the last week. He recalls having 2 hours of mild chest discomfort and nausea 10 days ago. No chest pain is currently reported. His ECG shows anterior Q waves with 1 mm ST elevation and T inversion. The exam and X-ray suggest pulmonary edema. The echo shows anteroapical akinesis and thinning. Beside diuresis and medical therapy, what is the appropriate management?Coronary angiography emergentlyCoronary angiography is not urgent but should be performed before discharge. Attempt to open an occluded LADPerform stress SPECT before discharge, then perform coronary angiography if there is evidence of severe ischemiaTest for viability of anterior wall. If viable, perform coronary angiography and attempt to open an occluded LAD

3 Question 3. A 76-year-old female presents with 2 hours of chest pain to a non-PCI hospital. The closest PCI hospital is 100 miles away. ECG shows anterior ST-segment elevation. BP = 170/85, weight 62 kg. She has not had any recent bleed, surgery, fall, or history of stroke. A recent hemoglobin is 12 g/dl. What is the next step?Administer fibrinolytics then transfer for routine early PCIDo not administer fibrinolytics, transfer for primary PCI

4 Question 4. A 72-year-old man presents with 3–4 hours of chest pain and respiratory distress. BP = 80/60, heart rate = 120. He is intubated by paramedics and transferred to a non-PCI-capable hospital. ECG shows 5 mm ST elevation anterior leads. The closest cath lab is 3 hours away. What is the next step?Emergent transfer for PCI; thrombolysis is not helpful in cardiogenic shockThrombolysis and emergent transfer for PCIIABP and emergent transferThrombolysis, IABP, and emergent transfer for PCI

5 Question 5. The patient in Question 4 arrives to the cath lab. He still has ST elevation and is in shock. He is found to have thrombotic 100% proximal LAD, CTO of mid RCA, and 80% stenosis of mid LCx. What is the next step?PCI of LAD onlyPCI of LAD and LCxPCI of LAD initially. If no hemodynamic improvement, proceed with PCI of LCxEmergent CABG

6 Question 6. A 68-year-old man presents with inferior and lateral STEMI. He undergoes primary PCI of a large, thrombotic, codominant proximal LCx. While he has been doing well, he suddenly develops near syncope on day 2. BP 70/40, pulse 35, and no murmur is heard. ECG shows sinus bradycardia with re-elevation of ST segments in the inferior leads. What is the most important next step?Immediate coronary angiography ± PCIImmediate echocardiographyImmediate placement of a transvenous pacemaker

7 Question 7. A 57-year-old man presented with anterior STEMI and received primary PCI of the proximal LAD at 16 hours after pain onset. At day 3, the patient is doing well, ambulating without angina and no HF on exam. He had an asymptomatic 14-beat run of NSVT. At day 4, a pre-discharge echo is performed and shows a large area of anterior akinesis with LVEF 25%, mild MR, and moderate size (1 cm) pericardial effusion. What is the next step?Discharge home on ACE-I, carvedilol, spironolactone, statin, aspirin/plavix, and check echo in 40 days. If EF <35% → ICDDischarge home on ACE-I, carvedilol, statin, aspirin and plavix, and check echo in 40 days. If EF <35% → ICDMonitor the patient in the hospital for a longer period of time, repeat echo next day and obtain cardiac MRI.Discharge home on ACE-I, carvedilol, statin, aspirin/plavix. Place a lifevest and then ICD at 40 days if EF <35%

8 Question 8. A 64-year-old man presents with anterior STEMI, BP 105/75, pulse 110, and bibasilar crackles. He is found to have occluded LAD and mid RCA 80%. What is the next step?Perform multivessel PCI at the time of primary PCIPerform culprit PCI only. Plan for elective PCI of RCA only if the patient has residual anginaPerform LAD PCI, then plan for elective RCA PCI before home discharge, regardless of symptomsPerform LAD PCI, then plan for elective RCA angiography before home discharge, then RCA PCI if appropriate, regardless of symptoms

9 Question 9. A 70-year old female had chest pain 3 days previously. The chest pain resolved after 8 hours. She has syncope on the day of presentation and is currently dizzy and dyspneic. BP 80/60, pulse 30 bpm. ECG shows complete AV block with ventricular escape rhythm, and ST elevation concordant with the wide QRS in the anterolateral leads. She has bibasilar crackles and is hypoxic. What is her 30-day mortality?<10%20%50%

10 Question 10. For the patient in Question 9, a temporary pacemaker is placed. Her BP improves to 110/70, and she is not dizzy anymore. She is dyspneic at rest with bibasilar crackles on exam. What is the next step, beside starting diuretics?Take urgently to the cath lab for PCI of LADPerform coronary angiography after HF improvesPerform stress testing after HF improves, to assess for residual ischemia

11 Question 11. A 66-year-old man presents with chest pain that has lasted 3 hours earlier today and has now resolved. His ECG shows subtle ST elevation (<1 mm) in leads II, aVF and in leads V5 and V6, and inferior Q waves. Should he undergo emergent reperfusion?No emergent reperfusionEmergent reperfusion with PCIEmergent reperfusion with thrombolysisB or C

12 Question 12. A 50-year-old woman presents with a persistent, mild chest pain for the last 6 hours. Chest pain fully resolves after nitroglyc- erin administration. The ECG performed after pain resolution is shown (Figure 2.8). What is the next step?Perform coronary angiography/PCI next day (not urgent anymore)Perform emergent reperfusion, whether with thrombolysis or PCIObtain serial troponin levels, as the ECG is not definite for MI

13 Question 13. A 72-year-old man presents with waxing and waning episodes of resting chest pain for the last 10 hours. Chest pain is reproducible with palpation and the patient does not appear to be in distress. He is not actively having chest pain. The first troponin is 0.03 ng/ml. ECG is shown (Figure 2.9). What is the next step?Emergent reperfusion with PCIEmergent reperfusion with thrombolysisFollow serial cardiac markers (ECG non-diagnostic)Initiate antiplatelet therapy, heparin, and NTG and perform non-urgent coronary angiography (next day)Figure 2.8Figure 2.9

14 Question 14. A 66-year-old woman presents with anterior STEMI. She receives thrombolysis at a non-PCI hospital, with resolution of chest pain and >50% resolution of ST elevation. She had a mild degree of pulmonary edema on admission, which quickly responded to diuresis. Echo shows severe anterior hypokinesis with LVEF of 35%. Three days later, she is able to ambulate without chest pain and with a mild degree of dyspnea. What is the next step?Coronary angiographyTreadmill nuclear imaging (modified Bruce protocol)Pharmacological nuclear imagingContinue medical therapy without any further intervention

15 Question 15. A 67-year-old man presents with chest pain that started 45 minutes ago. His ECG shows 5 mm anterior ST elevation with ample T waves and no Q waves. His BP is 130/75, pulse is 105 bpm. He can be transferred for PCI with a DTB <90 minutes. Which reperfusion strategy achieves the lowest mortality?Primary PCIThrombolysisThrombolysis followed by routine PCI 3–24 hours laterAny of the above

16 Question 16. A patient presents with chest pain. ECG shows a new LBBB, severe discordant ST elevation in the anterior leads (>25% of S wave) and concordant ST elevation in the lateral leads. Which statement is incorrect?The left bundle receives dual arterial supply, hence LBBB rarely occurs in STEMILBBB implies a high-risk STEMI with extensive infarction and extensive CADLBBB is associated with 3–4 times higher mortality and a more drastic benefit from reperfusionLBBB is associated with increased mortality only when persistentA new LBBB is associated with a higher mortality than a new RBBBA new RBBB is usually seen with LAD-related infarct

17 Question 17. Which statement is incorrect?LV pseudoaneurysm has a neck to internal diameter ratio <0.5 (vs. >0.5 in LV aneurysm)LV pseudoaneurysm may be characterized by to-and-fro flow on Doppler and a murmur on exam (not present with aneurysm)MRI may help differentiate pseudoaneurysm from aneurysm in equivocal casesLeft ventriculogram does not help differentiate pseudoaneurysm from aneurysmPost-MI pericarditis often occurs in the 1st or 2nd day and implies a large MIA persistently upright T wave (lack of T inversion) or a reversal of T wave from an inverted to an upright position is 100% sensitive for post-MI pericarditis

18 Question 18. A 68-year-old man presents with chest pain. He is dizzy and weak. Blood pressure is 80/55 and pulse is 55 bpm. JVP is 5 cmH2O and lungs are clear. ECG shows sinus rhythm with 2:1 AV block and a ventricular rate of 55 bpm, along with inferior ST elevation. What is the immediate next step?IV fluidsIV fluids + dopamineIV fluids + atropineAtropine + transvenous pacing + IV fluidsPrimary PCIIABP followed by primary PCI

19 Question 19. The patient in Question 19 receives atropine and a fluid bolus. AV conduction improves and heart rate is 100 bpm. He remains hypotensive and dizzy. Peripheral O2 saturation is 94% on ambient air. No murmur or thrill is present. What is the most likely diagnosis?RV MI shockMechanical complication (papillary muscle rupture or ventricular septal rupture)LV shock from an isolated inferior MILV shock from inferior MI extending to the lateral wall or inferior MI associated with an old anterior MI

20 Question 20. The patient in Question 19 now has a JVP of 11 cmH2O. What is the next step?NorepinephrineAdminister another 500 ml IV fluid bolus. If he remains hypotensive, add norepinephrinePrimary PCIIABP followed by primary PCIA+CB+CA+D

21 Question 21. With the administration of more fluids, the patient in Question 19 now develops arterial desaturation (85%), which is mini- mally responsive to supplemental O2. His lungs are still clear and no murmur is heard. What is the most likely cause?Ventricular septal rupturePatent foramen ovaleSevere MRLV failure

22 Question 22. A 67-year-old woman had severe nausea 2 days ago. This was followed by dyspnea and cough. On presentation, she is hypotensive (90/45 mmHg) and has respiratory distress with lung crackles and orthopnea. A holosystolic mumur is heard with S3 and without a thrill. ECG shows lateral ST elevation of 1 mm in leads I and aVL. She later develops fever. What is the most likely diagnosis?Cardiogenic shock from extensive infarctionRV shockPosterior papillary muscle ruptureAnterior papillary muscle ruptureSeptic shockC + ED + E

23 Answers 1. E. The patient has an expected DTB>120 min, which justifies thrombolysis. This is even more paramount when the patient is presenting within 3 hours, or has high risk features: anterior STEMI, tachycardia>100 bpm, SBP<100, Killip≥ 2 (crackles). The current standard of care for every STEMI patient receiving thrombolysis is to immediately transfer for rescue PCI (if thrombolysis fails) or for systematic coronary angiography and PCI 3-24 hours later (even if thrombolysis succeeds, the so called pharmacoinvasive strategy).

24 Answers 2. C. This is a patient presenting with Q-wave MI >24 hours after MI onset without residual angina. Stress test may be performed and followed by angiography ± revascularization in the presence of severe residual ischemia in the infarcted territory. Alternatively, angiography may be performed first (class II): (i) if left main or three-vessel CAD is found, CABG may be considered on a non-urgent basis (>3–7 days after MI); (ii) if the culprit is not totally occluded, PCI may be performed (class IIb); (iii) if the culprit is totally occluded, PCI should not be immediately performed. In the latter case, stress testing should be performed and the patient brought back for PCI if severe ischemia is present. Viability is different from ischemia. It is important to document that the wall is ischemic with stress, not just viable. A moderate viability without documented ischemia is not a clear indication to revascularize. Ischemia is documented clinically (angina), by ECG (ST depression), or by reduction of nuclear uptake at stress.

25 Answers 3. B. This patient has a combination of four features (elderly small woman with HTN). The combination predicts >4% risk of intracranial hemorrhage with fibrinolytics.

26 Answers 4. D. Thrombolysis improved survival in the medically treated arm of the SHOCK trial and in all arms of the SHOCK registry. The insertion of IABP was part of the protocol of the SHOCK trial and was associated with better outcomes in the SHOCK registry (although recent data question its benefit).

27 Answers 5. A or D. In the SHOCK trial, patients with complex multivessel CAD more frequently underwent CABG than PCI. CABG was associated with the same survival as PCI, despite the higher prevalence of extensive CAD.PCI is reasonable at institutions where CABG cannot be promptly performed, which is commonly the case. Culprit-only PCI is performed; multivessel acute PCI is not advised in cardiogenic shock (CULPRIT SHOCK trial).

28 Answers 6. B. The presentation is consistent with free wall rupture. Stent thrombosis is a second possibility. Echocardiography is immedi- ately followed by pericardiocentesis and surgical correction if the diagnosis of myocardial rupture/tamponade is confirmed.

29 Answers 7. C. A moderate pericardial effusion is concerning for a sealed cardiac rupture (in at least 8% of the cases) and warrants further observation and MRI if possible. Late NSVT, while carrying a worse prognosis, does not, per se, change management and does not dictate earlier ICD or Lifevest placement.

30 Answers 8. D. Non-culprit lesions are revascularized even in the absence of angina. They are revascularized before discharge or within 45 days, as per COMPLETE trial; pre-discharge PCI is preferred in patients with critical disease or angina at mild exertion. Non-critical lesions may improve on subsequent angiograms as the vasospastic component improves (J Am Coll Cardiol 2002; 40: 911–16); thus, before elective revascularization of these lesions in asymptomatic patients, the lesion is reassessed on repeat angiography and non-culprit FFR may be performed.

31 Answers 9. C. In anterior MI, AV block indicates extensive anterior infarction. The patient likely has multivessel disease preventing collateral supply to the left bundle. In the pre-reperfusion era, the mortality of complete AV block in anterior MI was ≥50%. Also, a shock that persists with pacing (Killip IV) portends a mortality of ≥50%.

32 Answers 10. B. Cardiogenic shock or massive HF qualifies for emergent reperfusion regardless of the time of presentation, as long as it is not purely secondary to bradyarrhythmia (a purely bradycardic shock was excluded from the SHOCK trial). Massive HF is defined as Killip class III, i.e., massive pulmonary edema frequently requiring mechanical ventilation. Since the patient’s shock resolved with pacing and since she does not have massive HF, there is no indication for emergent PCI >24 hours after the infarct. However, persistent severe HF qualifies for coronary angiography after diuresis and stabilization (non-urgently, e.g., after 24 hours of diuresis), and may benefit from late revascularization. A persistent severe HF prevents the patient from receiving stress testing and was an exclusion criterion from the negative OAT trial of late post-STEMI PCI. Conversely, a patient who stabilizes and becomes ambulatory without severe HF qualifies for risk stratification with stress testing, in which case PCI is only performed for severe ischemia.

33 Answers 11. B. STEMI may be over 12–24 hours old, at a stage where ST-segment elevation is resolving but has not fully resolved yet (close to phase 3). Alternatively, STEMI may be more recent with ongoing or resolving ischemia. This patient does not qualify for fibrinolytics, as ST elevation is <1 mm and the occlusion duration is questionable, but qualifies for primary PCI if the discomfort is ongoing, or if the dis- comfort occurred within the last 24 hours, even if it is not ongoing.

34 Answers 12. B. The ECG shows persistent ST elevation in leads V1–V4. ST elevation is barely 2 mm, but the morphology is typical of STEMI (terminal T inversion, reciprocal ST depression in I–aVL, and lack of alternative explanation of the mild ST elevation in V1–V3, i.e., no LVH/ LBBB). Even if chest pain resolves, a persistent ST elevation along with a presentation <12 hours qualifies the patient for primary PCI or thrombolysis.

35 Answers 13. A. The ECG shows subtle signs of inferior, lateral, and posterior ST elevation injury. In fact, the isolated ST depression in leads V1–V3 implies posterior ST elevation. The ST segment is minimally elevated in the inferior leads and in leads V5 and V6 (~0.5 mm), but has a strikingly convex morphology with a wide hyperacute T wave, particularly evident on the aberrant beat. Also, reciprocal ST depression is seen in lead aVL. All this confirms that the ECG, while subtle, is definitely consistent with ST elevation injury. Being <1 mm, thrombolysis is not justified. Emergent PCI is warranted even if pain resolved (presentation within 24 hours). In reality, this patient was not emergently reperfused, his troponin ended up peaking at 76 ng/ml, and he was found to have subtotal OM occlusion.

36 Answers 14. B. The patient would have best been treated with early coronary angiography and PCI at 3–24 hours after thrombolysis. Beyond 24 hours, coronary angiography may still be performed (class IIa), even in the absence of recurrent pain or persistent HF (the patient only had transient HF on admission). However, stress testing has a higher recommendation in the ACC guidelines (ESC gives equal weight to both). Exercise testing is preferred as the patient is able to ambulate.

37 Answers 15. D. In the first 3 hours of STEMI, especially the first hour, and in the absence of shock, the mortality reduction with thrombolysis is likely equivalent to that of primary PCI, provided that rescue PCI is performed if needed (CAPTIM, PRAGUE [<3 hours subgroup], STREAM trials). If thrombolysis is used as a primary revascularization strategy, outcomes are improved when thrombolysis is followed by routine early PCI (further reduction of recurrent MI in comparison to thrombolysis alone).

38 Answers 16. E. Both new LBBB and RBBB are associated with a similarly increased mortality. A transient LBBB or RBBB is not associated with increased mortality.

39 Answers 17. D.

40 Answers 18. C. The patient is in shock, which is aggravated by the inappropriate heart rate. In shock, compensatory tachycardia is expected, but the 2:1 AV block is cutting the patient’s ventricular rate in half. In the first 24 hours of inferior MI, AV block is responsive to atropine. In the context of inferior MI, hypotension with clear lungs suggests hypovolemia or RV shock, so fluid administration is appropriate. Those simple measures are performed while PCI is being arranged.

41 Answers 19. A. The patient has shock with clear lungs and no hypoxia, which suggests RV shock. Inferior MI does not usually lead to LV shock, unless a mechanical complication occurs or the inferior MI is associated with posterolateral extension or an old anterior MI. The exam does not suggest LV failure or mechanical complication.

42 Answers 20. F. The most definitive therapy of RV shock is primary PCI. Simultaneously, IV fluids are administered. In acute RV failure, the RV is small and non-compliant, in a way that JVP of 10-14 mmHg (13-18 cmH2O) was associated with the best stroke volume in one study. Stroke volume universally declined when RA pressure exceeded 14 mmHg. If JVP is elevated and the patient is unresponsive to a fluid challenge, norepinephrine therapy is appropriate (preferred to dopamine). In RV shock, IABP is warranted if high-dose pressors are required despite reperfusion or if LV failure is concomitantly present.

43 Answers 21. B. Clinically, the patient does not appear to have pulmonary edema. His hypoxemia is likely due to an underlying, previously innocent PFO. With RV failure and fluid resuscitation, the RA pressure rises and causes exaggerated flow through the PFO and a right-to-left shunt with hypoxemia refractory to O2.

44 Answers 22. G. The patient’s nausea represents the true onset of MI (angina-equivalent). Her shock 2 days later is due to a papillary muscle rupture. It is likely that the anterior papillary muscle is ruptured in this patient with non-inferior MI (likely LCx-related MI). The anterior papillary muscle is supplied by both the LCx and the LAD (usually first diagonal); an LCx-related MI may lead to papillary muscle rupture if the LAD also has an underlying stenosis. The infarct associated with papillary muscle rupture may be small, as in this case. The wide pulse pressure and the fever suggest an associated vasodilatory or septic shock, which is seen in 25% of post-MI cardiogenic shock. In this patient, echo is subsequently performed and shows rupture of the anterolateral papillary muscle (echodense mass attached to the leaflets) with flailing of both leaflets and both a central and a posterior jet. SVR is low (~600–700) and cardiac index relatively high, despite MR (~4 l/min/m2), confirming an associated vasodilatory/septic shock.