MI

MI US Medical PG Question 1: A 53-year-old man with a past medical history significant for hyperlipidemia, hypertension, and hyperhomocysteinemia presents to the emergency department complaining of 10/10 crushing, left-sided chest pain radiating down his left arm and up his neck into the left side of his jaw. His ECG shows ST-segment elevation in leads V2-V4. He is taken to the cardiac catheterization laboratory for successful balloon angioplasty and stenting of a complete blockage in his left anterior descending coronary artery. Echocardiogram the following day shows decreased left ventricular function and regional wall motion abnormalities. A follow-up echocardiogram 14 days later shows a normal ejection fraction and no regional wall motion abnormalities. This post-infarct course illustrates which of the following concepts?

• A. Coronary collateral circulation
• B. Ventricular remodeling
• C. Myocardial hibernation
• D. Myocardial stunning (Correct Answer)
• E. Reperfusion injury

MI Explanation: ***Myocardial stunning*** - This refers to a temporary **post-ischemic contractile dysfunction** that persists even after blood flow has been restored following an acute ischemic event. - The return to normal left ventricular function and absence of regional wall motion abnormalities after successful reperfusion indicates that the initial dysfunction was transient and not due to permanent myocardial damage. - Classic timeframe: recovery occurs over **days to weeks** after reperfusion, as seen in this patient (14 days). *Coronary collateral circulation* - This involves the development of alternative pathways for blood supply to the myocardium when the primary coronary arteries are occluded. - While it can mitigate the extent of myocardial injury, it generally doesn't explain the reversal of severe regional wall motion abnormalities and low ejection fraction to normal in such a short period after a complete blockage. *Ventricular remodeling* - This refers to changes in the **size, shape, and function of the ventricles** in response to myocardial injury or chronic pressure/volume overload, often leading to progressive heart failure. - It typically involves *persistent* and *often detrimental* changes, which is contrary to the improvement seen in this patient's echocardiogram. *Myocardial hibernation* - This is a state of **persistently impaired myocardial function at rest** due to **chronic inadequate blood flow** that can improve with revascularization. - Hibernation requires **pre-existing chronic ischemia** with baseline dysfunction prior to intervention, not an acute complete occlusion presenting as STEMI. - This patient had an **acute presentation** with complete blockage and no history suggesting chronic stable ischemia, making stunning (not hibernation) the correct answer. *Reperfusion injury* - This is damage to the myocardial tissue that occurs **after blood flow is restored** to an ischemic area, often involving oxidative stress and inflammation. - While it can worsen myocardial function, it is a complication of reperfusion that causes *additional damage*, not a phenomenon that explains the *recovery* of cardiac function after reperfusion.

MI US Medical PG Question 2: A 64-year-old man presents to his physician for a scheduled follow-up visit. He has chronic left-sided heart failure with systolic dysfunction. His current regular medications include captopril and digoxin, which were started after his last episode of symptomatic heart failure approximately 3 months ago. His last episode of heart failure was accompanied by atrial fibrillation, which followed an alcohol binge over a weekend. Since then he stopped drinking. He reports that he has no current symptoms at rest and is able to perform regular physical exercise without limitation. On physical examination, mild bipedal edema is noted. The physician suggested to him that he should discontinue digoxin and continue captopril and scheduled him for the next follow-up visit. Which of the following statements best justifies the suggestion made by the physician?

• A. Long-term digoxin therapy produces significant survival benefits in patients with heart failure, but at the cost of increased heart failure-related admissions.
• B. Both captopril and digoxin are likely to improve the long-term survival of the patient with heart failure, but digoxin has more severe side effects.
• C. Captopril is likely to improve the long-term survival of the patient with heart failure, unlike digoxin.
• D. Digoxin does not benefit patients with left-sided heart failure in the absence of atrial fibrillation.
• E. Digoxin is useful to treat atrial fibrillation, but does not benefit patients with systolic dysfunction who are in sinus rhythm. (Correct Answer)

MI Explanation: ***Digoxin is useful to treat atrial fibrillation, but does not benefit patients with systolic dysfunction who are in sinus rhythm.*** - The patient's **atrial fibrillation** was likely triggered by the alcohol binge and has since resolved, suggesting he is now in **sinus rhythm**. - Digoxin's primary benefit in heart failure with **systolic dysfunction** (HFrEF) is to control ventricular rate in patients with **atrial fibrillation**, but it does not offer survival benefit in HFrEF patients who are in **sinus rhythm** and well-managed with other therapies. *Long-term digoxin therapy produces significant survival benefits in patients with heart failure, but at the cost of increased heart failure-related admissions.* - This statement is incorrect; digoxin has been shown to **reduce hospital admissions** for heart failure, but it does **not provide a significant survival benefit** in patients with HFrEF in sinus rhythm. - The main benefit of digoxin in HFrEF is to improve symptoms and quality of life, alongside reducing hospitalizations, but not prolonging life. *Both captopril and digoxin are likely to improve the long-term survival of the patient with heart failure, but digoxin has more severe side effects.* - **Captopril (an ACE inhibitor)** does improve **long-term survival** in heart failure, but **digoxin does not** demonstrably improve survival. - While digoxin can have side effects, its lack of survival benefit for HFrEF in sinus rhythm is the primary reason for discontinuation, not just side effect severity. *Captopril is likely to improve the long-term survival of the patient with heart failure, unlike digoxin.* - This statement is partially correct that **captopril improves survival**, but it does not fully explain the physician's decision to discontinue digoxin. - The key missing piece is the patient's current **sinus rhythm** and the lack of benefit of digoxin in that specific context for HFrEF. *Digoxin does not benefit patients with left-sided heart failure in the absence of atrial fibrillation.* - This statement is nearly correct, but "left-sided heart failure" is broad. It is specifically in patients with **systolic dysfunction (HFrEF)** who are in **sinus rhythm** that digoxin lacks significant benefit beyond symptom control, and does not provide survival benefit.

MI US Medical PG Question 3: A 54-year-old man is brought to the emergency department 1 hour after the sudden onset of shortness of breath, severe chest pain, and sweating. He has hypertension and type 2 diabetes mellitus. He has smoked one pack and a half of cigarettes daily for 20 years. An ECG shows ST-segment elevations in leads II, III, and avF. The next hospital with a cardiac catheterization unit is more than 2 hours away. Reperfusion pharmacotherapy is initiated. Which of the following is the primary mechanism of action of this medication?

• A. Conversion of plasminogen to plasmin (Correct Answer)
• B. Inhibition of glutamic acid residue carboxylation
• C. Blocking of adenosine diphosphate receptors
• D. Direct inhibition of thrombin activity
• E. Prevention of thromboxane formation

MI Explanation: ***Conversion of plasminogen to plasmin*** - **Fibrinolytic** (thrombolytic) drugs, like **tissue plasminogen activator (tPA)**, work by converting plasminogen to plasmin, which then degrades the **fibrin mesh** of a **blood clot**. - This action helps to **restore blood flow** in cases of ST-segment elevation myocardial infarction (STEMI) where primary **percutaneous coronary intervention (PCI)** is not immediately available. *Inhibition of glutamic acid residue carboxylation* - This is the mechanism of action of **warfarin**, an anticoagulant that inhibits the synthesis of **vitamin K-dependent clotting factors** (II, VII, IX, X, protein C, and protein S). - While important for long-term anticoagulation, it does not provide immediate reperfusion in an acute STEMI. *Blocking of adenosine diphosphate receptors* - This describes the mechanism of action of **P2Y12 inhibitors** such as **clopidogrel**, **prasugrel**, and **ticagrelor**. - These drugs are **antiplatelet agents** that prevent platelet aggregation, but they do not directly dissolve an existing thrombus to restore blood flow in STEMI. *Direct inhibition of thrombin activity* - This is the mechanism of action of **direct thrombin inhibitors** like **dabigatran** and **bivalirudin**. - These drugs primarily prevent clot formation or extension and are not used as primary reperfusion agents for acute STEMI due to an existing occlusive thrombus. *Prevention of thromboxane formation* - This is the primary mechanism of action of **aspirin**, which irreversibly inhibits **cyclooxygenase-1 (COX-1)**, thereby reducing the production of thromboxane A2. - Aspirin is an important antiplatelet drug in STEMI management but does not provide reperfusion by dissolving the clot.

MI US Medical PG Question 4: A 66-year-old female with hypertension and a recent history of acute ST-elevation myocardial infarction (STEMI) 6 days previous, treated with percutaneous transluminal angioplasty (PTA), presents with sudden onset chest pain, shortness of breath, diaphoresis, and syncope. Vitals are temperature 37°C (98.6°F), blood pressure 80/50 mm Hg, pulse 125/min, respirations 12/min, and oxygen saturation 92% on room air. On physical examination, the patient is pale and unresponsive. Cardiac exam reveals tachycardia and a pronounced holosystolic murmur loudest at the apex and radiates to the back. Lungs are clear to auscultation. Chest X-ray shows cardiomegaly with clear lung fields. ECG is significant for ST elevations in the precordial leads (V2-V4) and low-voltage QRS complexes. Emergency transthoracic echocardiography shows a left ventricular wall motion abnormality along with a significant pericardial effusion. The patient is intubated, and aggressive fluid resuscitation is initiated. What is the next best step in management?

• A. Immediate cardiac catheterization
• B. Immediate transfer to the operating room (Correct Answer)
• C. Emergency pericardiocentesis
• D. Intra-aortic balloon counterpulsation
• E. Administer dobutamine 5-10 mcg/kg/min IV

MI Explanation: ***Immediate transfer to the operating room*** - The patient's presentation with sudden onset chest pain, shortness of breath, profound cardiogenic shock, and a new **holosystolic murmur at the apex radiating to the back** in the context of a recent **STEMI**, strongly suggests **acute papillary muscle rupture** causing severe mitral regurgitation. This is a surgical emergency requiring immediate intervention. - The holosystolic murmur at the apex is pathognomonic for acute mitral regurgitation, distinguishing this from ventricular free wall rupture (which would present with tamponade physiology without a murmur). - The patient requires urgent surgical repair (mitral valve replacement or repair) to address this mechanical complication of **myocardial infarction (MI)**, which is causing severe hemodynamic compromise. *Immediate cardiac catheterization* - While cardiac catheterization is essential for diagnosing coronary artery disease and revascularization, in this emergent situation with profound shock and a mechanical complication (papillary muscle rupture), the primary issue is structural cardiac damage requiring surgical repair, not ongoing ischemia alone. - Delaying surgical intervention for catheterization in this hemodynamically unstable patient would be detrimental and potentially fatal. *Emergency pericardiocentesis* - Although there is a **pericardial effusion** on echocardiography, the patient's presentation with a new holosystolic murmur and profound shock after STEMI indicates **papillary muscle rupture with acute mitral regurgitation**, not cardiac tamponade. - The presence of a loud murmur excludes ventricular free wall rupture as the primary cause. The effusion is likely reactive or incidental. - Pericardiocentesis would not address the underlying mitral valve pathology causing the hemodynamic collapse. *Intra-aortic balloon counterpulsation* - **Intra-aortic balloon pump (IABP)** can improve cardiac output and reduce afterload, which may provide temporary hemodynamic support in cardiogenic shock. - However, in cases of **papillary muscle rupture** with severe acute mitral regurgitation, IABP provides only temporary support and does not fix the underlying structural problem. - It could be considered as a bridge to surgery, but the definitive treatment is surgical repair, which should be expedited without delay. *Administer dobutamine 5-10 mcg/kg/min IV* - **Dobutamine** is an inotrope that increases cardiac contractility. While it might improve cardiac output in some forms of cardiogenic shock, in the setting of **acute severe mitral regurgitation from papillary muscle rupture**, it cannot resolve the structural valvular incompetence. - Increasing contractility may paradoxically worsen the regurgitant fraction and further compromise forward cardiac output. - Medical management alone cannot resolve this mechanical complication, necessitating urgent surgical intervention.

MI US Medical PG Question 5: A 49-year-old man with a past medical history of hypertension on amlodipine presents to your office to discuss ways to lessen his risk of complications from heart disease. After a long discussion, he decides to significantly decrease his intake of trans fats in an attempt to lower his risk of coronary artery disease. Which type of prevention is this patient initiating?

• A. Secondary prevention
• B. Delayed prevention
• C. Quaternary prevention
• D. Tertiary prevention
• E. Primary prevention (Correct Answer)

MI Explanation: ***Primary prevention*** - This patient is initiating primary prevention by **modifying lifestyle choices** (decreasing trans fats) to **prevent the initial onset of coronary artery disease**, as he has a risk factor (hypertension) but no established heart disease. - Primary prevention focuses on **preventing disease before it occurs** through health promotion and risk reduction. *Secondary prevention* - Secondary prevention involves **early detection and treatment of existing disease** to prevent progression or recurrence. - Examples include **screening tests** like mammography or **medications for individuals already diagnosed** with a condition. *Delayed prevention* - This is **not a recognized category** of prevention in public health or medical practice. - Prevention stages are typically classified as primary, secondary, tertiary, and sometimes quaternary. *Quaternary prevention* - Quaternary prevention aims to **protect patients from medical interventions** that may cause harm, such as over-medicalization or unnecessary procedures. - It focuses on **reducing the burden of iatrogenic disease** and ensuring appropriate care. *Tertiary prevention* - Tertiary prevention focuses on **reducing the impact of an existing disease** or disability through rehabilitation and managing complications. - It applies to patients who **already have an established disease** and seeks to improve their quality of life and functionality.

MI US Medical PG Question 6: A 56-year-old man presents to the emergency room with severe substernal chest pain associated with a 2-hour history of breathlessness and sweating. An electrocardiogram shows an ST-segment elevation myocardial infarction. Cardiac enzyme levels confirm a diagnosis of acute myocardial infarction. The patient is rushed to the catheter lab for angioplasty with stenting. The patient complains of recurrent chest pain in the ICU 56 hours post-angioplasty. Which of the following enzymes facilitates the patient’s diagnosis based on his current symptoms?

• A. Creatine kinase (CK)-MB (Correct Answer)
• B. Creatine kinase – MM
• C. Troponin T
• D. Troponin I
• E. Lactate dehydrogenase (LDH)

MI Explanation: ***Creatine kinase (CK)-MB*** - **CK-MB** is elevated in myocardial infarction, rising within 4-6 hours, peaking at 24 hours, and **returning to baseline within 48-72 hours** after the initial event. - At **56 hours post-angioplasty**, CK-MB levels should have normalized from the initial MI, making a **new elevation highly specific** for reinfarction or new myocardial injury. - This makes CK-MB particularly useful for detecting **early reinfarction** when the timing allows it to have cleared from the initial event. - **Clinical pearl**: This represents classical teaching about cardiac enzyme kinetics, though modern practice increasingly uses serial troponin measurements with delta criteria. *Creatine kinase – MM* - **CK-MM** is the predominant isoform of creatine kinase found in **skeletal muscle**, not cardiac muscle. - While total CK (which includes CK-MM) increases in MI, CK-MM elevation is **not specific to cardiac injury** and can be elevated from skeletal muscle damage or other causes. - Its lack of cardiac specificity makes it a **poor indicator for myocardial reinfarction**. *Troponin T* - **Troponin T** is highly sensitive and specific for myocardial injury, but levels remain **elevated for 7-10 days** following an acute MI. - At 56 hours post-angioplasty, troponin T would **still be elevated from the initial MI**, making it difficult to distinguish baseline elevation from a new acute event. - While a **significant rise (>20%) from the previous value** can indicate reinfarction, the persistently elevated baseline makes interpretation more complex compared to CK-MB which should have normalized. *Troponin I* - **Troponin I** remains elevated for **5-7 days** following an acute MI, similar to troponin T. - At 56 hours post-initial MI, troponin I levels would **still be elevated**, making it challenging to clearly identify a new ischemic event without comparing to prior values. - Though troponins are the **gold standard for MI diagnosis**, their prolonged elevation window makes CK-MB more straightforward for detecting reinfarction at this specific timepoint (when CK-MB should have returned to baseline). *Lactate dehydrogenase (LDH)* - **LDH** elevation occurs later in MI (24-48 hours after onset) and remains elevated for **10-14 days**. - Due to its **delayed rise and prolonged elevation**, LDH is not useful for diagnosing acute reinfarction in the early post-MI period. - LDH lacks the rapid kinetics and cardiac specificity needed for timely diagnosis of new myocardial injury.

MI US Medical PG Question 7: A 61-year-old man is brought to the emergency department by ambulance because of severe retrosternal chest pain and shortness of breath for 30 minutes. Paramedics report that an ECG recorded en route to the hospital showed ST-segment elevation in I, aVL, and the precordial leads. On arrival, the patient is unresponsive to painful stimuli. Examination shows neither respiration nor pulse. Despite appropriate lifesaving measures, he dies 10 minutes later. Which of the following is the most likely cause of death in this patient?

• A. Left ventricular failure
• B. Cardiac free wall rupture
• C. Ventricular fibrillation (Correct Answer)
• D. Ventricular aneurysm
• E. Hemorrhagic stroke

MI Explanation: ***Ventricular fibrillation*** - The rapid onset of symptoms, severe chest pain, ST-segment elevation myocardial infarction (STEMI) involving extensive leads (I, aVL, and precordial), and sudden cardiac arrest without pulse or respiration strongly indicate a **malignant arrhythmia**, specifically ventricular fibrillation. - In a STEMI, **ischemia** can rapidly trigger electrical instability in the myocardium, leading to disorganized electrical activity and immediate hemodynamic collapse. *Left ventricular failure* - While a large anterior STEMI could lead to **left ventricular failure**, the patient's immediate collapse and absence of respiration and pulse suggest sudden electrical rather than mechanical failure. - **Left ventricular failure** typically manifests with progressive symptoms like severe dyspnea, pulmonary edema, and cardiogenic shock, which often allows for some period of clinical deterioration before death. *Cardiac free wall rupture* - **Cardiac free wall rupture** is a mechanical complication of MI that usually occurs several days post-infarction, though it can rarely occur acutely. - It typically presents with **sudden severe chest pain**, hypotension, and rapid death due to **cardiac tamponade**, but the immediate timeline and ECG findings of extensive STEMI followed by sudden arrest are more consistent with an electrical event. *Ventricular aneurysm* - A **ventricular aneurysm** is a late complication of an MI, developing weeks to months after the event. - It presents with symptoms like **heart failure**, arrhythmias, or mural thrombus formation, not as an acute cause of death within minutes of symptom onset. *Hemorrhagic stroke* - A **hemorrhagic stroke** would present with sudden neurological deficits, such as severe headache, altered consciousness, and focal neurological signs. - While it can cause sudden death, the prominent chest pain and the ECG findings of widespread ST-segment elevation are indicative of a primary cardiac event.

MI US Medical PG Question 8: A 55-year-old man comes to the emergency department because of left-sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST-elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures?

• A. Left coronary artery → left circumflex artery (Correct Answer)
• B. Right coronary artery → posterior descending artery
• C. Left coronary artery → left anterior descending artery
• D. Right coronary artery → right marginal artery
• E. Left coronary artery → posterior descending artery

MI Explanation: ***Left coronary artery → left circumflex artery*** - **ST-elevations** in leads I, aVL, and V5-V6 are indicative of a **lateral myocardial infarction**. - The **left circumflex artery** primarily supplies the lateral wall of the left ventricle. *Right coronary artery → posterior descending artery* - The **posterior descending artery** (PDA) typically supplies the inferior wall and posterior interventricular septum. - An occlusion here would cause **ST-elevations** in leads II, III, and aVF, which is not seen in this case. *Left coronary artery → left anterior descending artery* - The **left anterior descending** (LAD) artery supplies the anterior wall and apex of the left ventricle. - Occlusion of the LAD would typically cause **ST-elevations** in leads V1-V4, indicating an anterior MI. *Right coronary artery → right marginal artery* - The **right marginal artery** is a branch of the right coronary artery and supplies part of the right ventricle. - Occlusion here would primarily affect the **right ventricle**, and is not typically associated with the given ECG changes. *Left coronary artery → posterior descending artery* - While the **posterior descending artery** can sometimes originate from the left circumflex artery (**left dominant circulation**), it primarily supplies the inferior wall. - The observed ECG changes in leads I, aVL, and V5-V6 are characteristic of a **lateral wall infarct**, which is supplied by the left circumflex artery.

MI US Medical PG Question 9: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

• A. "Does the diarrhea typically precede the constipation, or vice-versa?"
• B. "Is the diarrhea foul-smelling?"
• C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
• D. "Are the symptoms worse in the morning or at night?"
• E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

MI Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

MI US Medical PG Question 10: A 70-year-old man with diabetes, hypertension, and chronic kidney disease (eGFR 35 mL/min/1.73m²) presents with NSTEMI. Troponin is elevated at 8.5 ng/mL. ECG shows 2mm ST depression in V2-V5. GRACE score is 165 (high risk). He is hemodynamically stable. Cardiologist recommends early invasive strategy within 24 hours. Nephrologist is concerned about contrast-induced nephropathy potentially requiring dialysis. Patient is on metformin. Evaluate the management strategy integrating multiple specialist perspectives and evidence.

• A. Proceed with angiography within 24 hours using iso-osmolar contrast and intravenous hydration, hold metformin (Correct Answer)
• B. Perform coronary CT angiography as alternative to invasive angiography
• C. Delay catheterization for 72 hours to optimize renal function with hydration
• D. Prophylactic hemodialysis before and after catheterization to remove contrast
• E. Medical management only with dual antiplatelet therapy, avoid catheterization

MI Explanation: ***Proceed with angiography within 24 hours using iso-osmolar contrast and intravenous hydration, hold metformin*** - High-risk NSTEMI patients with a **GRACE score >140** benefit from an **early invasive strategy** within 24 hours to reduce ischemic events and mortality. - Renal protection is maximized through **pre-procedural hydration** and **iso-osmolar contrast**, while **metformin** must be held to avoid the risk of lactic acidosis if acute kidney injury occurs. *Perform coronary CT angiography as alternative to invasive angiography* - **Coronary CTA** is primarily used for ruling out coronary artery disease in low-to-intermediate risk stable patients, not for high-risk **NSTEMI**. - This modality still requires **iodinated contrast** and does not provide the therapeutic benefit of percutaneous coronary intervention (**PCI**). *Delay catheterization for 72 hours to optimize renal function with hydration* - Delaying the procedure in a high-risk patient increases the risk of **re-infarction** and **cardiovascular death**, outweighing the minor benefits of prolonged hydration. - Evidence suggests that optimization of renal status should happen concurrently with the preparation for **early intervention** in high-risk ACS. *Prophylactic hemodialysis before and after catheterization to remove contrast* - **Prophylactic hemodialysis** has not been proven to prevent contrast-induced nephropathy and may actually increase the risk of adverse events. - High-volume **intravenous hydration** with isotonic saline remains the gold standard for preventing renal injury in patients with **CKD**. *Medical management only with dual antiplatelet therapy, avoid catheterization* - While **dual antiplatelet therapy** is essential, medical management alone is inferior to an invasive strategy in patients with **high GRACE scores**. - Avoiding catheterization based solely on **renal impairment** results in "renalism," where patients are undertreated for their life-threatening cardiac condition.

MI Flashcard 1 of 6

Question: Which major medical insurance plan limits patients to a network of doctors, specialists, and hospitals without requirement of referrals?_____

Answer: Exclusive provider organization (EPO)

MI Flashcard 2 of 6

Question: Medi-_____ is state/federal assistance for people with limited income/resources

Answer: caid

MI Flashcard 3 of 6

Question: Which part of medicare provides basic medical bills (e.g. doctor's fees, diagnostic testing)? _____

Answer: Part B

MI Flashcard 4 of 6

Question: Which healthcare payment model involves physicians receiving a set amount per patient assigned to them per period of time? _____

Answer: Capitation

MI Flashcard 5 of 6

Question: Which healthcare payment model involves patients paying for all expenses associated with a single incident of care with a single payment? _____

Answer: Global payment

MI Flashcard 6 of 6

Question: Which major medical insurance plan denies payment for any service that does not meet evidence-based guidelines?_____

Answer: Health maintenance organization