Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Reperfusion strategies (fibrinolysis vs PCI). These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 1: A 56-year-old man comes to the emergency department complaining of substernal chest pain that radiates to the left shoulder. Electrocardiogram (EKG) demonstrates ST-elevations in leads II, III, and aVF. The patient subsequently underwent catheterization with drug-eluting stent placement with stabilization of his condition. On post-operative day 3, the patient experiences stabbing chest pain that is worse with inspiration, diaphoresis, and general distress. His temperature is 98.7°F (37.1°C), blood pressure is 145/97mmHg, pulse is 110/min, and respirations are 23/min. EKG demonstrates diffuse ST-elevations. What is the best treatment for this patient?
- A. Lisinopril
- B. Surgery
- C. Needle thoracotomy
- D. Atorvastatin
- E. Aspirin (Correct Answer)
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Aspirin***
- The patient's symptoms (stabbing chest pain worse with inspiration, diffuse ST-elevations) on **post-operative day 3** following a myocardial infarction and stent placement are highly suggestive of **early post-MI pericarditis** (also called acute pericarditis or epistenocardiac pericarditis).
- This occurs within the **first few days** after MI due to direct inflammatory response from myocardial necrosis, distinguished from **Dressler's syndrome** which is a delayed autoimmune phenomenon occurring **1-6 weeks** post-MI.
- **Aspirin** is the first-line treatment for post-MI pericarditis (both early and late forms), as it effectively reduces inflammation while being safer than other NSAIDs in the post-MI setting.
*Lisinopril*
- **Lisinopril** is an ACE inhibitor used for **hypertension**, heart failure, and post-MI remodeling, but it does not address the acute inflammatory process of pericarditis.
- While beneficial for long-term cardiac health post-MI, it is not the immediate treatment for these new inflammatory symptoms.
*Surgery*
- **Surgery** (e.g., pericardiectomy) is reserved for severe, recurrent, or constrictive pericarditis that is refractory to medical therapy.
- It is an invasive procedure and not the initial treatment for an acute episode of post-MI pericarditis.
*Needle thoracotomy*
- A **needle thoracotomy** (needle decompression) is an emergency procedure used to treat a **tension pneumothorax**, which involves air accumulation in the pleural space causing hemodynamic compromise.
- The patient's symptoms and EKG findings of diffuse ST-elevations are consistent with pericarditis, not tension pneumothorax.
*Atorvastatin*
- **Atorvastatin** is a statin used to lower cholesterol and prevent further cardiovascular events.
- While important for secondary prevention after an MI, it does not provide acute relief or treatment for the inflammatory chest pain this patient is experiencing.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 2: 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
Reperfusion strategies (fibrinolysis vs PCI) 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.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 3: A 79-year-old man is brought to the emergency department after he noted the abrupt onset of weakness accompanied by decreased sensation on his left side. His symptoms developed rapidly, peaked within 1 minute, and began to spontaneously resolve 10 minutes later. Upon arrival in the emergency room 40 minutes after the initial onset of symptoms, they had largely resolved. The patient has essential hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and a 50 pack-year smoking history. He also had an ST-elevation myocardial infarction 3 years ago. His brain CT scan without contrast is reported as normal. Carotid duplex ultrasonography reveals 90% stenosis of the right internal carotid. His transthoracic echocardiogram does not reveal any intracardiac abnormalities. Which of the following interventions is most appropriate for this patient's condition?
- A. Carotid stenting (Correct Answer)
- B. Warfarin
- C. Low molecular weight heparin
- D. Hypercoagulability studies
- E. Aspirin and clopidogrel
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Carotid stenting***
- The patient experienced a **transient ischemic attack (TIA)** with **90% stenosis of the right internal carotid artery**, which is a high-grade stenosis.
- **Carotid revascularization** is highly recommended for symptomatic patients with **high-grade carotid stenosis** (70–99%) to prevent future strokes.
- Both **carotid endarterectomy (CEA)** and **carotid stenting** are acceptable options. In this elderly patient (79 years) with significant comorbidities (COPD, prior MI, 50 pack-year smoking history), **carotid stenting** may be preferred as it avoids the surgical risks of general anesthesia and neck dissection.
*Warfarin*
- **Warfarin** is primarily used for preventing strokes in patients with **atrial fibrillation** or mechanical heart valves.
- It is **not the first-line treatment** for stroke prevention directly caused by symptomatic carotid artery stenosis.
*Low molecular weight heparin*
- **Low molecular weight heparin (LMWH)** is typically used for acute treatment of **deep vein thrombosis** and **pulmonary embolism**, or in certain acute coronary syndromes.
- It does not address the underlying **structural issue of severe carotid stenosis** for long-term stroke prevention.
*Hypercoagulability studies*
- While hypercoagulability can cause strokes, the patient's symptoms are clearly attributed to **severe carotid stenosis**.
- These studies are usually reserved for patients with strokes of **unexplained etiology**, especially younger patients, or those with unusual clot locations.
*Aspirin and clopidogrel*
- **Dual antiplatelet therapy (aspirin and clopidogrel)** is often used after a TIA or minor stroke, but typically for a limited duration (e.g., 21-90 days), and it is an adjunct to revascularization in severe carotid stenosis.
- Although important for **secondary stroke prevention**, it does not address the critical **90% carotid stenosis** that warrants revascularization.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 4: A 54-year-old woman comes to the emergency department because of two episodes of bright red blood per rectum within the past day. She has a history of migraine, which is treated prophylactically with verapamil. She appears well and is hemodynamically stable. Cardiac exam reveals a regular heart rate without any murmurs or gallops. Lungs are clear to auscultation. Her abdomen is mildly tender without rebound or guarding. Digital rectal examination shows fresh blood on the glove. Laboratory studies show:
Hemoglobin 10.4 g/dL
Leukocyte count 5,000/mm3
Platelet count 175,000/mm3
Partial thromboplastin time 35 seconds
Serum
Na+ 140 mEq/L
K+ 3.7 mEq/L
Cl- 101 mEq/L
HCO3- 25 mEq/L
Mg2+ 1.8 mEq/L
A routine ECG shows a heart rate of 75/min, a normal axis, PR interval of 280 ms, QRS interval of 80 ms with a QRS complex following each p wave, and no evidence of ischemic changes. Which of the following is the most appropriate next step in management with respect to this patient's cardiovascular workup?
- A. Observation (Correct Answer)
- B. Atropine therapy
- C. Synchronized cardioversion
- D. Metoprolol therapy
- E. Pacemaker placement
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Observation***
- The patient is currently **hemodynamically stable** despite the prolonged PR interval, indicating that the **first-degree AV block** is not causing immediate compromise.
- Continuation of **verapamil** (a calcium channel blocker) for migraine prophylaxis is the likely cause of the prolonged PR interval; however, in the absence of symptoms attributable to the AV block, observation is appropriate.
*Atropine therapy*
- **Atropine** is used to increase heart rate in **symptomatic bradycardia** or higher-degree AV blocks (second or third-degree) if the patient is unstable.
- This patient is **hemodynamically stable** with a heart rate of 75/min and has only a first-degree AV block, making atropine unnecessary.
*Synchronized cardioversion*
- **Synchronized cardioversion** is reserved for **unstable tachyarrhythmias** or some unstable bradyarrhythmias not responsive to chemical therapy.
- The patient's heart rate is 75/min, and she has **no evidence of an arrhythmia** requiring cardioversion; her prolonged PR interval is a conduction delay, not an arrhythmia.
*Metoprolol therapy*
- **Metoprolol** is a beta-blocker that would **further slow AV nodal conduction** and could potentially worsen the first-degree AV block or precipitate a higher-degree block.
- It is contraindicated as a treatment for AV block and would exacerbate the underlying issue caused by verapamil.
*Pacemaker placement*
- **Pacemaker placement** is considered for **symptomatic second-degree or third-degree AV block**, or in some cases of first-degree AV block if it progresses to a higher degree and causes severe symptoms.
- This patient has a **first-degree AV block** and is **asymptomatic** and **hemodynamically stable**, thus a pacemaker is not indicated at this time.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 5: A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?
- A. No further testing
- B. 24-hour ambulatory ECG monitoring
- C. Radionuclide myocardial perfusion imaging (Correct Answer)
- D. Treadmill stress test
- E. Resting echocardiography
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Radionuclide myocardial perfusion imaging***
- This patient requires **perioperative cardiac risk assessment** before intermediate-risk surgery (radical prostatectomy).
- Key factors include: history of **myocardial infarction**, current cardiac risk factors, and **inability to exercise** due to severe osteoarthritis.
- Since he cannot perform exercise stress testing, **pharmacologic stress testing** with radionuclide myocardial perfusion imaging (using agents like adenosine, dipyridamole, or regadenoson) is the most appropriate test to assess for **inducible myocardial ischemia**.
- This provides functional assessment of coronary perfusion under pharmacologic stress, helping guide perioperative risk stratification and management.
- *Note: The presence of unstable angina would typically require cardiac stabilization first; this question focuses on selecting the appropriate stress test modality for a patient unable to exercise.*
*No further testing*
- This patient has significant cardiac risk factors including **prior MI**, ongoing cardiac medications, and ECG changes suggesting old infarction.
- Proceeding directly to surgery without functional cardiac assessment would be **inappropriate** given his risk profile and the intermediate-risk nature of the planned surgery.
*24-hour ambulatory ECG monitoring*
- Holter monitoring detects arrhythmias and silent ischemic episodes but does not provide **functional capacity assessment** or evaluation of inducible ischemia under stress conditions.
- It is not the primary tool for **perioperative cardiac risk stratification** before major surgery.
*Treadmill stress test*
- The patient's **severe osteoarthritis** prevents him from climbing stairs or walking fast, making him unable to achieve adequate exercise workload for a treadmill stress test.
- This functional limitation makes **exercise stress testing contraindicated**; pharmacologic stress testing is required instead.
*Resting echocardiography*
- Resting echocardiography assesses **baseline left ventricular function**, wall motion abnormalities from prior infarction, and valvular disease.
- While useful for structural assessment, it does **not evaluate for exercise-induced or stress-induced ischemia**, which is critical for perioperative risk assessment in patients with coronary artery disease.
- His normal BNP (84 pg/mL) suggests adequate baseline ventricular function, making functional ischemia assessment more relevant than structural evaluation alone.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 6: A 70-year-old man is brought to the emergency room with complaints of severe substernal chest pain for the last hour. The pain started suddenly, and the patient describes the pain as “going into the shoulder”. The patient took aspirin at home and has been given multiple doses of sublingual nitroglycerin, but the pain has not subsided. He has a blood pressure of 112/84 mm Hg, the pulse is 63/min, the respiratory rate is 18/min, and the temperature is 36.9°C (98.0°F). Cardiac auscultation reveals normal S1 and S2 sounds, however, an additional S4 sound is heard. The patient is sweating profusely, and the lungs are clear to auscultation. No jugular venous distension or pedal edema is observed. His initial ECG shows ST elevation in leads II, III, and aVF. Which of the following will likely have the most benefit in this patient?
- A. Antiarrhythmics
- B. Percutaneous coronary intervention (Correct Answer)
- C. Thrombolytics
- D. Beta blockers
- E. Clopidogrel
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Percutaneous coronary intervention***
- This patient is experiencing a **ST-elevation myocardial infarction (STEMI)**, indicated by severe chest pain radiating to the shoulder, no relief with nitroglycerin, and ST elevation in leads II, III, and aVF.
- **Reperfusion therapy** is crucial for STEMI, and PCI is the preferred method when available within the recommended timeframe (typically <90-120 minutes from first medical contact) as it directly opens the occluded coronary artery.
*Antiarrhythmics*
- While **arrhythmias** can occur during an MI, there is no indication that the patient is currently experiencing a life-threatening arrhythmia requiring immediate antiarrhythmic drug administration.
- The primary goal in STEMI is **reperfusion**, not immediate arrhythmia suppression unless the arrhythmia is hemodynamically unstable.
*Thrombolytics*
- **Thrombolytics (fibrinolytics)** are an alternative reperfusion strategy for STEMI if PCI is not available or cannot be performed within the recommended timeframe.
- Given that the question asks for the "most benefit," and PCI is generally superior to thrombolytics in terms of complete reperfusion and clinical outcomes when available promptly, thrombolytics would not be the first choice.
*Beta blockers*
- **Beta blockers** are important for managing MI by reducing myocardial oxygen demand and preventing arrhythmias; however, they are often initiated after reperfusion and careful patient evaluation, especially in the acute phase of STEMI where immediate reperfusion is paramount.
- They should be used with caution if there are signs of **heart failure** or **cardiogenic shock**, which are not present here but still highlight that it's not the immediate, most beneficial intervention.
*Clopidogrel*
- **Clopidogrel** is an antiplatelet agent that would be part of the medical management for STEMI, along with aspirin and anticoagulants, to prevent further clot formation.
- While important, it is an adjunctive therapy and does not directly address the need for **rapid reperfusion** to restore blood flow to the ischemic myocardium, which is the most critical intervention in STEMI.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 7: 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
Reperfusion strategies (fibrinolysis vs PCI) 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.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 8: A 58-year-old woman with anterior STEMI underwent primary PCI with drug-eluting stent placement. Post-procedure echocardiogram shows left ventricular ejection fraction of 30% with apical akinesis. She is started on aspirin, ticagrelor, high-intensity statin, and ACE inhibitor. On hospital day 3, she develops atrial fibrillation with rapid ventricular response. CHA2DS2-VASc score is 4. Creatinine is normal. Evaluate the optimal antithrombotic strategy balancing ischemic and bleeding risk.
- A. Triple therapy with aspirin, ticagrelor, and apixaban indefinitely
- B. Triple therapy for 6 months, then aspirin and apixaban indefinitely
- C. Aspirin and ticagrelor only, hold anticoagulation due to bleeding risk
- D. Warfarin with INR 2-3 plus aspirin, discontinue ticagrelor
- E. Triple therapy for 1 month, then apixaban and clopidogrel for 11 months, then apixaban alone (Correct Answer)
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Triple therapy for 1 month, then apixaban and clopidogrel for 11 months, then apixaban alone***
- In patients with **Atrial Fibrillation** (CHA2DS2-VASc ≥2) undergoing **PCI**, current guidelines recommend minimizing the duration of **triple therapy** (aspirin, P2Y12 inhibitor, and anticoagulant) to 1 week to 1 month to reduce **bleeding risk**.
- Transitioning to **dual therapy** with a **NOAC** (like apixaban) and a P2Y12 inhibitor (preferably **clopidogrel**) for up to 12 months, followed by NOAC monotherapy, provides an optimal balance between preventing **stent thrombosis** and systemic **thromboembolism**.
*Triple therapy with aspirin, ticagrelor, and apixaban indefinitely*
- Indefinite **triple therapy** carries a prohibitively high risk of life-threatening **major bleeding** without added benefit for stroke prevention.
- **Ticagrelor** is generally avoided in triple therapy regimens due to a significantly higher bleeding profile compared to **clopidogrel**.
*Triple therapy for 6 months, then aspirin and apixaban indefinitely*
- **Triple therapy** for 6 months is rarely indicated and significantly increases the risk of **gastrointestinal and intracranial hemorrhage** compared to the 1-month strategy.
- Aspirin is usually discontinued after the first year in favor of **anticoagulant monotherapy**, as the latter is sufficient for both AF and stable CAD protection.
*Aspirin and ticagrelor only, hold anticoagulation due to bleeding risk*
- This approach leaves the patient with a high **CHA2DS2-VASc score of 4** unprotected against **cardioembolic stroke**, which carries high morbidity and mortality.
- Dual antiplatelet therapy (DAPT) alone is significantly less effective than **oral anticoagulants** for stroke prevention in the setting of atrial fibrillation.
*Warfarin with INR 2-3 plus aspirin, discontinue ticagrelor*
- **NOACs** (like apixaban) are now preferred over **Warfarin** for non-valvular AF due to a superior safety profile, including a lower risk of **intracranial hemorrhage**.
- Discontinuing the P2Y12 inhibitor (ticagrelor) immediately post-PCI in favor of aspirin and warfarin significantly increases the risk of **stent thrombosis**.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 9: A 60-year-old man with inferoposterior STEMI presents to a rural hospital. The nearest PCI-capable facility is 3 hours away. He arrives 90 minutes after symptom onset. Blood pressure is 130/85 mmHg, heart rate 88/min, oxygen saturation 96% on room air. He has no contraindications to fibrinolysis. The transfer team can arrive in 30 minutes. Evaluate the evidence-based approach considering time metrics and available resources.
- A. Immediate fibrinolytic therapy followed by transfer (Correct Answer)
- B. Helicopter transfer to reduce transfer time, then primary PCI
- C. Administer half-dose fibrinolytic and transfer for immediate PCI
- D. Fibrinolytic therapy at rural hospital, transfer only if fails
- E. Wait for transfer team and proceed directly to PCI facility
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Immediate fibrinolytic therapy followed by transfer***
- In a STEMI patient where the expected **door-to-balloon time** exceeds **120 minutes**, and the patient is seen within **12 hours** of symptom onset, **fibrinolytic therapy** is the preferred reperfusion strategy.
- Following fibrinolysis, a **pharmacoinvasive strategy** is recommended, involving a routine transfer to a PCI-capable center for angiography within **3 to 24 hours**.
*Helicopter transfer to reduce transfer time, then primary PCI*
- Even with expedited transport, the distance and total time likely still exceed the recommended **120-minute window** for primary PCI superiority over fibrinolysis.
- Choosing transfer over immediate thrombolysis in a rural setting when delays are significant increases the risk of **myocardial necrosis**.
*Administer half-dose fibrinolytic and transfer for immediate PCI*
- **Half-dose fibrinolytics** are generally only considered in specific subsets like elderly patients (over 75) to reduce **intracranial hemorrhage** risk, which does not apply here.
- Combining half-dose thrombolysis with immediate PCI (facilitated PCI) has not shown superior outcomes and may increase **bleeding complications**.
*Fibrinolytic therapy at rural hospital, transfer only if fails*
- Modern guidelines recommend a **pharmacoinvasive approach**, meaning all patients should be transferred for **coronary angiography** regardless of clinical success of fibrinolysis.
- Waiting only for "failure" (rescue PCI) ignores the benefit of definitive **revascularization** and stabilization provided by routine post-thrombolysis PCI.
*Wait for transfer team and proceed directly to PCI facility*
- Delaying reperfusion for a 3-hour transport window violates the "**time is muscle**" principle, as the patient is currently in the highly time-sensitive **early window** (under 3 hours).
- Failure to administer fibrinolytics when the **PCI-related delay** is over 90-120 minutes is a deviation from standard **STEMI management protocols**.
Reperfusion strategies (fibrinolysis vs PCI) US Medical PG Question 10: A 65-year-old man with extensive anterior STEMI underwent PCI 6 hours after symptom onset due to delayed presentation. Peak troponin was significantly elevated. Three days later, he develops progressive dyspnea. Examination reveals a new holosystolic murmur at the apex radiating to the axilla. Echocardiogram shows severe mitral regurgitation with flail posterior leaflet and hyperdynamic left ventricle. Pulmonary capillary wedge pressure tracing shows prominent v waves. He is euvolemic on examination. Analyze this complication to determine timing of intervention.
- A. Immediate surgical mitral valve repair or replacement
- B. Aggressive diuresis and ACE inhibitor, reassess in 2 weeks
- C. Intra-aortic balloon pump with surgery within 24-48 hours (Correct Answer)
- D. Percutaneous mitral valve repair with MitraClip
- E. Medical management with afterload reduction for 6 weeks, then surgery
Reperfusion strategies (fibrinolysis vs PCI) Explanation: ***Intra-aortic balloon pump with surgery within 24-48 hours***
- **Acute papillary muscle rupture** leads to severe mitral regurgitation and hemodynamic instability; an **IABP** provides essential **afterload reduction** and increases forward flow while reducing the regurgitant fraction.
- Providing a brief period of stabilization for 24-48 hours allows for therapeutic optimization before **urgent surgical intervention**, balancing the high risk of immediate surgery with the extreme mortality of medical delay.
*Immediate surgical mitral valve repair or replacement*
- Performing surgery immediately upon diagnosis carries an exceptionally high mortality rate due to the **friable, necrotic myocardial tissue** that is difficult to suture.
- While definitive, Proceeding without initial **hemodynamic stabilization** (like IABP) increases the risk of intraoperative cardiovascular collapse.
*Aggressive diuresis and ACE inhibitor, reassess in 2 weeks*
- This patient has a mechanical complication (flail leaflet); medical management alone for **acute MR** has a mortality rate exceeding 90%.
- **ACE inhibitors** may be poorly tolerated in the acute setting of a large MI if the patient becomes hypotensive, and waiting 2 weeks is far too long for a **mechanical emergency**.
*Percutaneous mitral valve repair with MitraClip*
- **MitraClip** is primarily indicated for chronic secondary MR or in patients with prohibitive surgical risk, rather than as first-line treatment for **acute post-MI papillary muscle rupture**.
- The necrotic and distorted nature of the **subvalvular apparatus** in an acute rupture makes it a poor substrate for percutaneous repair techniques.
*Medical management with afterload reduction for 6 weeks, then surgery*
- Delaying surgery for 6 weeks for "tissue healing" is inappropriate for **papillary muscle rupture** as the patient will likely suffer from progressive **pulmonary edema** or cardiogenic shock.
- While chronic MR can be managed medically, **acute structural failure** requires urgent mechanical correction once stable, not prolonged medical therapy.
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