Acute Coronary Syndromes — MCQs
A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?
Which condition is indicated by ST segment elevation in leads V1-V4?
A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis. ECG shows ST elevation. What is the next best step?
A 55-year-old male presents with severe, crushing chest pain and shortness of breath. ECG shows ST elevation in the inferior leads. What is the most appropriate immediate management?
Which of the following is not a complication of infective endocarditis?
Aetiology of Dressler Syndrome is
Stunning of myocardium without any acute coronary syndrome is:-
Most common cause of death in Rheumatoid Arthritis?
Treatment of choice for prinzmetal's angina
Which one of the following conditions is associated with Kawasaki's syndrome?
Acute Coronary Syndromes Indian Medical PG Practice Questions and MCQs
Question 1: A 40-year-old male patient presents to the Emergency department with central chest pain for 2 hours. The ECG shows ST segment depression and cardiac troponins are elevated. The patient has a positive history of previous PCI 3 months back. He is administered Aspirin, Clopidogrel, Nitrates, and LMWH in the Emergency Department and shifted to the coronary care unit. What is the best recommended course of further action?
- A. Early Revascularization with PCI (Correct Answer)
- B. Continue conservative management and monitoring of cardiac enzymes and ECG
- C. Continue conservative management and plan for outpatient follow-up
- D. Immediate Revascularization with Coronary Angiography
Explanation: ***Early Revascularization with PCI*** - The patient presents with **NSTEMI** (ST depression, elevated troponins) and is already on antiplatelet and anticoagulant therapy. **Early revascularization** (ideally within 24 hours for high-risk NSTEMI) is indicated to restore blood flow and prevent further myocardial damage [1]. - Given the patient's history of prior **PCI** and the current NSTEMI presentation, this suggests possible **in-stent restenosis** or progression of coronary artery disease, making revascularization crucial. *Continue conservative management and monitoring of cardiac enzymes and ECG* - While initial conservative management with medications is appropriate, simply continuing monitoring without definitive intervention is insufficient for a **high-risk NSTEMI** patient. - The elevated troponins and ST depression indicate ongoing myocardial injury that requires active management beyond just observation [1]. *Continue conservative management and plan for outpatient follow-up* - This approach is entirely inappropriate for a patient presenting with an **acute coronary syndrome (NSTEMI)**. - Outpatient follow-up is for stable conditions, not for an ongoing cardiac event that requires urgent hospital-based intervention. *Immediate Revascularization with Coronary Angiography* - **Immediate revascularization** (within 90 minutes) is primarily indicated for **STEMI** (ST elevation myocardial infarction). - While coronary angiography will precede PCI, the term "immediate" in this context usually refers to the urgency seen in STEMI; NSTEMI typically warrants "early" rather than "immediate" intervention (within 12-24 hours for high-risk patients like this one) [1].
Question 2: Which condition is indicated by ST segment elevation in leads V1-V4?
- A. Posterior myocardial infarction
- B. Lateral myocardial infarction
- C. Anterior myocardial infarction (Correct Answer)
- D. Inferior myocardial infarction
Explanation: ***Anterior myocardial infarction*** - **ST segment elevation** in leads **V1-V4** is indicative of an infarction in the **anterior wall** of the left ventricle [1]. - These leads correspond to the distribution of the **left anterior descending (LAD) coronary artery**, which supplies the anterior wall and septum [2]. *Posterior myocardial infarction* - This typically presents with **ST depression** in **V1-V4**, along with tall R waves and prominent T waves in the same leads, due to a reciprocal change. - Definitive diagnosis requires **posterior leads (V7-V9)**, which would show ST elevation. *Lateral myocardial infarction* - Characterized by **ST elevation** in leads **I, aVL, V5, and V6**, reflecting ischemia in the lateral wall of the left ventricle [1]. - These leads are supplied by the **circumflex artery** or a diagonal branch of the LAD. *Inferior myocardial infarction* - Identified by **ST elevation** in leads **II, III, and aVF**, indicating involvement of the inferior wall [1]. - This is typically caused by occlusion of the **right coronary artery (RCA)** or a dominant circumflex artery.
Question 3: A 55-year-old diabetic presents with chest pain, shortness of breath, and diaphoresis. ECG shows ST elevation. What is the next best step?
- A. PCI (Correct Answer)
- B. Nitroglycerin
- C. Thrombolysis
- D. Heparin
Explanation: ***PCI*** - Percutaneous coronary intervention (PCI) is the **preferred reperfusion strategy** for ST-elevation myocardial infarction (STEMI) if it can be performed within 90 minutes (door-to-balloon time) at a PCI-capable hospital, or within 120 minutes if requiring transfer [1]. - This patient's symptoms (chest pain, shortness of breath, diaphoresis) and **ST elevation on ECG** indicate an acute STEMI, making PCI the most effective and definitive treatment [1]. *Nitroglycerin* - While nitroglycerin can help alleviate chest pain by causing **vasodilation** and reducing cardiac preload and afterload, it does not address the underlying coronary artery occlusion in STEMI. - It is often used as an adjunct, but not as the primary or definitive treatment for **reperfusion** in STEMI. *Thrombolysis* - Thrombolysis is an alternative reperfusion strategy for STEMI, primarily used when **primary PCI is not available** within the recommended timeframes [1]. - Given that PCI is typically available and preferred for STEMI, thrombolysis is considered a second-line option due to higher risks of bleeding and potential for re-occlusion compared to PCI [1]. *Heparin* - Heparin is an **anticoagulant** used in STEMI management to prevent further clot formation and propagation. - It is an important adjunctive therapy, but it does not directly restore blood flow to the ischemic myocardium by dissolving or mechanically removing the occluding thrombus like PCI or thrombolysis.
Question 4: A 55-year-old male presents with severe, crushing chest pain and shortness of breath. ECG shows ST elevation in the inferior leads. What is the most appropriate immediate management?
- A. Beta blockers
- B. Oxygen and nitroglycerin
- C. Percutaneous coronary intervention (Correct Answer)
- D. Thrombolysis
Explanation: Percutaneous coronary intervention - The patient's symptoms (severe, crushing chest pain, shortness of breath, ST elevation in inferior leads) are classic for an ST-elevation myocardial infarction (STEMI) [1]. - Primary percutaneous coronary intervention (PCI) is the preferred treatment for STEMI when available within recommended timeframes, as it directly opens the occluded coronary artery to restore blood flow [2]. Beta blockers - While beta blockers are part of long-term STEMI management, they are not the most appropriate immediate intervention when revascularization is paramount. - They can be administrated after reperfusion therapy, typically within 24 hours (unless contraindicated), to reduce myocardial oxygen demand [2]. Oxygen and nitroglycerin - Oxygen is indicated for hypoxia, but routine use in normoxia has not shown benefit; nitroglycerin can relieve chest pain but does not address the underlying coronary occlusion in STEMI. - These therapies are largely supportive and do not treat the root cause of STEMI, which is an occluded coronary artery [1]. Thrombolysis - Thrombolysis is an alternative reperfusion strategy for STEMI when PCI is not available or cannot be performed within the recommended time [2]. - Given that the question does not suggest PCI is unavailable, it is not the most appropriate immediate choice in comparison to PCI for STEMI [2].
Question 5: Which of the following is not a complication of infective endocarditis?
- A. Focal and diffuse glomerulonephritis
- B. Myocardial ring abscess
- C. Suppurative pericarditis
- D. Myocardial infarction (Correct Answer)
Explanation: ***Myocardial infarction*** - While infective endocarditis can lead to various cardiac complications, **myocardial infarction** due to direct coronary artery occlusion by emboli from vegetations is **rare** and not considered a typical complication. [1] - Myocardial infarction is more commonly associated with **atherosclerotic coronary artery disease**. *Myocardial ring abscess* - This is a common and severe local complication of infective endocarditis, often occurring in cases involving **virulent organisms** or **prosthetic valves**. [1] - An abscess can extend into the **myocardium**, conduction system, or pericardium, leading to heart block or valvular dehiscence. *Focal and diffuse glomerulonephritis* - These are **immune-mediated renal complications** of infective endocarditis, caused by the deposition of immune complexes in the glomeruli. [1] - Often presents with **hematuria**, proteinuria, and renal impairment, reflecting the systemic inflammatory response. [1] *Suppurative pericarditis* - This can occur if the infection from the endocarditic vegetation extends into the **pericardial space**, either directly or via a myocardial abscess. - It involves **purulent inflammation** of the pericardium, leading to chest pain, fever, and potentially tamponade.
Question 6: Aetiology of Dressler Syndrome is
- A. Autoimmune (Correct Answer)
- B. Toxin mediated
- C. Viral infection
- D. Idiopathic cause
Explanation: ***Autoimmune*** - Dressler syndrome is a form of **pericarditis** that occurs several days to weeks after myocardial injury (e.g., myocardial infarction, cardiac surgery, trauma). [3] - It is considered an **autoimmune phenomenon** where the body's immune system attacks damaged cardiac tissue. [1] *Viral infection* - While viral infections can cause general pericarditis, Dressler syndrome specifically refers to **post-cardiac injury** inflammation, not direct viral involvement. [2], [3] - Viral pericarditis typically has a more acute presentation without a preceding cardiac event. [2] *Toxin mediated* - There is no evidence to suggest that Dressler syndrome is caused by **toxins** or toxic substances. - The pathogenesis is linked to an immune response to damaged myocardial cells. *Idiopathic cause* - While some forms of pericarditis are idiopathic, Dressler syndrome has a clear **triggering event** (cardiac injury) and a well-understood autoimmune mechanism. [3] - Therefore, it is not classified as idiopathic. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 214-215. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 581-582. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 297-298.
Question 7: Stunning of myocardium without any acute coronary syndrome is:-
- A. Restrictive cardiomyopathy
- B. Subendocardial infarction
- C. Transmural infarction
- D. Takotsubo cardiomyopathy (Correct Answer)
Explanation: ***Takotsubo cardiomyopathy*** - This condition involves **transient systolic dysfunction** of the left ventricle, often triggered by severe emotional or physical stress, mimicking a heart attack but without **coronary artery obstruction**. - The apical and mid-ventricular segments of the left ventricle become akinetic or hypocinetic, causing the heart to take on a shape resembling an octopus trap (**takotsubo**). *Restrictive cardiomyopathy* - This is a condition where the walls of the ventricles become **stiff** and **lose their flexibility**, preventing the heart from filling properly. - It is typically caused by conditions like **amyloidosis** or **sarcoidosis**, leading to impaired diastolic function, not transient stunning. *Subendocardial infarction* - This refers to a **heart attack** that affects only the **inner layer** of the heart muscle (**subendocardium**) due to reduced blood flow [2]. - It is a form of **acute coronary syndrome** where there is irreversible myocardial necrosis, unlike the temporary dysfunction in stunning [1]. *Transmural infarction* - This is a **severe form of heart attack** where the entire thickness of the heart muscle wall is affected, usually due to a **complete blockage of a coronary artery** [2]. - This also represents **acute coronary syndrome** with widespread myocardial necrosis, which is fundamentally different from a reversible stunning of the myocardium [1].
Question 8: Most common cause of death in Rheumatoid Arthritis?
- A. Hepatic failure
- B. ARDS
- C. Pulmonary fibrosis
- D. Ischemic heart disease (Correct Answer)
Explanation: ***Ischemic heart disease*** - Patients with **rheumatoid arthritis (RA)** have a significantly increased risk of developing **cardiovascular diseases**, including ischemic heart disease. [1] - This heightened risk is due to chronic systemic inflammation, accelerated atherosclerosis, and potential side effects of RA treatments contributing to **endothelial dysfunction**. [1] *Hepatic failure* - While certain medications used to treat RA, such as **methotrexate**, can cause liver toxicity, hepatic failure is not the most common cause of death in RA patients. [2] - Regular **liver enzyme monitoring** helps in detecting and managing medication-induced liver issues. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** can occur in severely ill patients, but it is not a direct or most common complication of rheumatoid arthritis nor a primary cause of death. [2] - RA can affect the lungs (e.g., interstitial lung disease), but ARDS is typically a severe, acute event triggered by other conditions like **sepsis** or trauma. *Pulmonary fibrosis* - **Interstitial lung disease (ILD)**, including pulmonary fibrosis, is a known extra-articular manifestation of RA and can be a significant cause of morbidity and mortality. [2] - However, **cardiovascular events**, particularly ischemic heart disease, still surpass pulmonary fibrosis as the leading cause of death in RA patients.
Question 9: Treatment of choice for prinzmetal's angina
- A. Nitroglycerin
- B. Prazosin
- C. Beta-blockers
- D. Calcium Channel Blockers (CCBs) (Correct Answer)
Explanation: ***Calcium Channel Blockers (CCBs)*** - **Dihydropyridine** CCBs like nifedipine or amlodipine, and **non-dihydropyridine** CCBs like diltiazem or verapamil, are the **first-line agents** for Prinzmetal's angina [1]. - They work by **relaxing coronary smooth muscle**, preventing the vasospasm that causes the angina [1]. *Nitroglycerin* - **Nitroglycerin is effective** for acute relief of Prinzmetal's angina symptoms due to its **vasodilatory properties**. - However, it's typically used as **rescue therapy** and not as a long-term preventative treatment. *Beta-blockers* - Beta-blockers are **contraindicated** in Prinzmetal's angina as they can **worsen coronary vasospasm** by blocking beta-2 mediated vasodilation, leaving unopposed alpha-1 vasoconstriction [2]. - They can increase the **frequency and severity of attacks**. *Prazosin* - Prazosin is an **alpha-1 adrenergic blocker** used primarily for **hypertension** and benign prostatic hyperplasia. - While it can cause vasodilation, it is **not the treatment of choice** for Prinzmetal's angina and is less effective than CCBs in preventing coronary spasm.
Question 10: Which one of the following conditions is associated with Kawasaki's syndrome?
- A. Acute rheumatic fever
- B. Pulmonary embolus
- C. Systemic lupus erythematosus
- D. Coronary artery aneurysm (Correct Answer)
Explanation: ***Coronary artery aneurysm*** - **Coronary artery aneurysms** are a major and potentially life-threatening complication, occurring in 15-25% of untreated children with Kawasaki disease [1]. - This is due to the disease's predilection for causing **vasculitis** in medium-sized arteries, particularly the coronary arteries [1]. *Acute rheumatic fever* - Acute rheumatic fever is an **inflammatory disease** that can develop after an infection with Group A Streptococcus (strep throat or scarlet fever) [2]. - It primarily affects the **heart, joints, brain, and skin**, but its pathophysiology and clinical presentation are distinct from Kawasaki disease [2]. *Pulmonary embolus* - A **pulmonary embolus** is a block in one of the pulmonary arteries in your lungs, usually caused by blood clots that travel to the lungs from the legs or, rarely, other parts of the body. - It is not a characteristic feature or complication of **Kawasaki disease**. *Systemic lupus erythematosus* - **Systemic lupus erythematosus (SLE)** is a chronic autoimmune disease that can affect almost any part of the body, leading to a wide range of symptoms. - While it can cause vasculitis, its epidemiology, clinical presentation, and specific organ involvement are distinctly different from **Kawasaki disease**.
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