STEMI management algorithm US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for STEMI management algorithm. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
STEMI management algorithm US Medical PG Question 1: A 58-year-old man comes to the emergency department for complaints of crushing chest pain for 4 hours. He was shoveling snow outside when the pain started. It is rated 7/10 and radiates to his left arm. An electrocardiogram (ECG) demonstrates ST-segment elevation in leads V2-4. He subsequently undergoes percutaneous coronary intervention (PCI) and is discharged with aspirin, clopidogrel, carvedilol, atorvastatin, and lisinopril. Five days later, the patient is brought to the emergency department by his wife with complaints of dizziness. He reports lightheadedness and palpitations for the past 2 hours but otherwise feels fine. His temperature is 99.7°F (37.6°C), blood pressure is 95/55 mmHg, pulse is 105/min, and respirations are 17/min. A pulmonary artery catheter is performed and demonstrates an increase in oxygen concentration at the pulmonary artery. What finding would you expect in this patient?
- A. Widespread ST-segment elevations
- B. Harsh, loud, holosystolic murmur at the lower left sternal border (Correct Answer)
- C. Pulseless electrical activity
- D. Drop of systolic blood pressure by 20 mmHg during inspiration
- E. Normal findings
STEMI management algorithm Explanation: ***Harsh, loud, holosystolic murmur at the lower left sternal border***
- This patient's presentation, including recent **anterior STEMI**, dizziness, lightheadedness, palpitations, hypotension, tachycardia, and **increased oxygen saturation in the pulmonary artery** (oxygen "step-up" indicating a left-to-right shunt), is highly suggestive of **ventricular septal rupture (VSR)**.
- VSR is a **mechanical complication** of MI that typically occurs **3-7 days post-infarction** when the necrotic myocardium is weakest.
- A **VSR** causes a **harsh, loud, holosystolic murmur** best heard at the **lower left sternal border** due to turbulent blood flow through the septal defect from the left ventricle to the right ventricle.
- The left-to-right shunt results in oxygenated blood from the left ventricle mixing with deoxygenated blood in the right ventricle, causing the characteristic oxygen saturation step-up detected by pulmonary artery catheterization.
*Widespread ST-segment elevations*
- Widespread ST-segment elevations are characteristic of **acute pericarditis**, which typically presents with **pleuritic chest pain** that improves when leaning forward and a **friction rub**, not the hemodynamic compromise described here.
- While **Dressler syndrome** (post-MI pericarditis) can occur weeks after MI, the acute hemodynamic instability, left-to-right shunt evidence, and 5-day timeframe point to VSR rather than pericarditis.
*Pulseless electrical activity*
- **Pulseless electrical activity (PEA)** indicates cardiac arrest with organized electrical activity but no mechanical cardiac output, resulting in an **unpalpable pulse**.
- The patient has a documented pulse of **105/min**, which directly contradicts PEA.
- A patient in PEA would be unconscious and unable to report symptoms for 2 hours.
*Drop of systolic blood pressure by 20 mmHg during inspiration*
- A drop in systolic blood pressure >10 mmHg during inspiration (**pulsus paradoxus**) is characteristic of **cardiac tamponade** or severe obstructive airway disease.
- While **free wall rupture** leading to tamponade is another mechanical complication post-MI, the **oxygen saturation step-up** in the pulmonary artery is pathognomonic for an **intracardiac shunt** (VSR), not tamponade.
- Tamponade would show equalization of diastolic pressures across all chambers, not increased PA oxygen saturation.
*Normal findings*
- The patient presents with clear evidence of hemodynamic compromise: **hypotension (95/55 mmHg)**, **tachycardia (105/min)**, dizziness, and lightheadedness.
- The **oxygen saturation step-up** in the pulmonary artery is an objective abnormal finding indicating an intracardiac left-to-right shunt.
- Therefore, normal findings are incompatible with this clinical presentation.
STEMI management algorithm US Medical PG Question 2: 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
STEMI management algorithm 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.
STEMI management algorithm US Medical PG Question 3: 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
STEMI management algorithm 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.
STEMI management algorithm US Medical PG Question 4: A 60-year-old man presents to the emergency department with progressive dyspnea for the last 3 weeks. He complains of shortness of breath while lying flat and reports nighttime awakenings due to shortness of breath for the same duration. The patient has been a smoker for the last 30 years. Past medical history is significant for myocardial infarction 7 months ago. Current medications include metoprolol, aspirin, and rosuvastatin, but the patient is noncompliant with his medications. His temperature is 37.2°C (98.9°F), the blood pressure is 150/115 mm Hg, the pulse is 110/min, and the respiratory rate is 24/min. Oxygen saturation on room air is 88%. Chest auscultation reveals bilateral crackles and an S3 gallop. On physical examination, the cardiac apex is palpated in left 6th intercostal space. Bilateral pitting edema is present, and the patient is in moderate distress. Which of the following is the best next step in the management of the patient?
- A. Intravenous beta blockers
- B. Intravenous diuretics (Correct Answer)
- C. Echocardiography
- D. Cardiac stress testing
- E. Intravenous inotropes
STEMI management algorithm Explanation: ***Intravenous diuretics***
- The patient presents with classic signs and symptoms of **acute decompensated heart failure**, such as progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral crackles, S3 gallop, pitting edema, and elevated blood pressure with elevated heart rate due to fluid overload.
- **Intravenous loop diuretics** (e.g., furosemide) are the most appropriate initial therapy to reduce preload, alleviate pulmonary and systemic congestion, and improve oxygenation.
*Intravenous beta blockers*
- While beta-blockers are a cornerstone of chronic heart failure management, **starting or acutely increasing beta-blocker dosage in acute decompensated heart failure** can worsen cardiac output and lead to symptomatic hypotension or cardiogenic shock.
- Beta-blockers should generally be withheld or reduced during acute exacerbations and reinstituted once the patient is stable.
*Echocardiography*
- While an **echocardiogram** is essential for diagnosing the underlying cause and assessing cardiac function in heart failure, it is not the *best next step* in a patient presenting with acute, severe symptoms requiring immediate stabilization.
- The patient's acute respiratory distress and hypoxemia necessitate immediate medical intervention to reduce fluid overload before detailed diagnostic imaging.
*Cardiac stress testing*
- **Cardiac stress testing** is used to evaluate for inducible ischemia in stable patients and is not appropriate in the setting of acute decompensated heart failure.
- Performing a stress test on a patient with signs of fluid overload and respiratory distress would be dangerous and could exacerbate their condition.
*Intravenous inotropes*
- **Intravenous inotropes** (e.g., dobutamine, milrinone) are typically reserved for patients with evidence of **cardiogenic shock** or severe heart failure with persistent hypoperfusion despite optimal fluid management and diuretic therapy.
- This patient, while acutely ill, primarily exhibits signs of fluid overload without clear evidence of severe hypoperfusion compromising end-organ function.
STEMI management algorithm US Medical PG Question 5: 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
STEMI management algorithm 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.
STEMI management algorithm US Medical PG Question 6: 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)
STEMI management algorithm 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**.
STEMI management algorithm US Medical PG Question 7: 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
STEMI management algorithm 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**.
STEMI management algorithm US Medical PG Question 8: 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
STEMI management algorithm 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.
STEMI management algorithm US Medical PG Question 9: A 72-year-old man with inferior STEMI underwent successful PCI 5 days ago. He develops sudden onset dyspnea and hypotension. Blood pressure is 75/50 mmHg with pulsus paradoxus of 20 mmHg. Jugular venous pressure is elevated with prominent x descent. Emergent echocardiography shows large pericardial effusion with right atrial and ventricular diastolic collapse. The patient is on aspirin, clopidogrel, and therapeutic enoxaparin. Analyze the complication and optimal intervention strategy.
- A. Immediate surgical exploration and repair (Correct Answer)
- B. Administer protamine and fresh frozen plasma, then observe
- C. Discontinue anticoagulation and observe with serial echocardiograms
- D. Increase intravenous fluid administration
- E. Urgent pericardiocentesis followed by surgical evaluation
STEMI management algorithm Explanation: ***Immediate surgical exploration and repair***
- The patient presents with **free wall rupture** leading to **cardiac tamponade**, a lethal post-MI complication typically occurring 3 to 7 days after the event.
- Definitive treatment for mechanical rupture requires **emergent surgery** to repair the defect, as conservative management carries a near 100% mortality rate.
*Administer protamine and fresh frozen plasma, then observe*
- While reversing **anticoagulation** is important, observation is inappropriate for a patient with **mechanical rupture** and obstructive shock.
- Delaying surgery for medical reversal will likely result in **cardiac arrest** due to rapid hemodynamic collapse.
*Discontinue anticoagulation and observe with serial echocardiograms*
- Discontinuing medication addresses the risk of hemorrhage but fails to manage the primary **ventricular wall defect**.
- **Serial echocardiograms** are indicated for stable pericarditis, not a patient with **hypotension** and right heart collapse.
*Increase intravenous fluid administration*
- IV fluids can be a temporary bridge to maintain **preload** during tamponade, but they are never a curative or primary strategy.
- Over-reliance on fluid resuscitation delays the necessary **surgical decompression** and defect repair required for survival.
*Urgent pericardiocentesis followed by surgical evaluation*
- While it can relieve pressure, **pericardiocentesis** is often contraindicated in free wall rupture as it can dislodge a clot and **exacerbate bleeding**.
- Immediate transition to the **operating room** is the priority over bedside drainage in the setting of post-MI mechanical complications.
STEMI management algorithm US Medical PG Question 10: A 68-year-old woman with anterior STEMI underwent successful PCI 3 days ago. She now complains of sharp, positional chest pain relieved by sitting forward. Temperature is 38.2°C (100.8°F), blood pressure 105/70 mmHg, heart rate 98/min. Cardiac examination reveals a friction rub. ECG shows diffuse ST-segment elevation with PR depression. Troponin levels are trending down from peak values. Echocardiogram shows small pericardial effusion without tamponade. Analyze the clinical picture to determine management.
- A. High-dose aspirin and colchicine therapy (Correct Answer)
- B. High-dose corticosteroids
- C. Resume dual antiplatelet therapy with clopidogrel
- D. Initiate systemic anticoagulation with heparin
- E. Urgent pericardiocentesis
STEMI management algorithm Explanation: ***High-dose aspirin and colchicine therapy***
- The patient is experiencing **peri-infarction pericarditis**, occurring within days of a STEMI, characterized by **pleuritic chest pain**, a **pericardial friction rub**, and diffuse **ST-segment elevation**.
- **High-dose aspirin** is the preferred anti-inflammatory post-MI as other **NSAIDs** can interfere with myocardial healing and increase the risk of myocardial rupture.
*High-dose corticosteroids*
- **Corticosteroids** are generally avoided in the early post-MI period because they are associated with **impaired scar formation** and an increased risk of **ventricular free wall rupture**.
- They are typically reserved for patients who fail to respond to first-line therapies like aspirin and colchicine.
*Resume dual antiplatelet therapy with clopidogrel*
- While the patient should already be on **dual antiplatelet therapy (DAPT)** following PCI, DAPT alone does not provide the **high-dose anti-inflammatory** effect needed to treat pericarditis.
- Escalating or resuming maintenance doses of clopidogrel will not resolve the **pericardial inflammation** or the associated pain.
*Initiate systemic anticoagulation with heparin*
- Systemic **anticoagulation** is generally avoided in patients with acute pericarditis because it increases the risk of developing **hemorrhagic pericardial effusion**.
- This can lead to rapid **cardiac tamponade**, especially in the setting of recent myocardial injury.
*Urgent pericardiocentesis*
- **Pericardiocentesis** is only indicated for patients with **cardiac tamponade** or for diagnostic purposes in suspected purulent/malignant effusions.
- Since the echocardiogram shows only a **small effusion** without hemodynamic compromise (tamponade), this invasive procedure is not required.
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