MI Practice Questions

Q: 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.

Immediate surgical exploration and repair. ***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.

Question 1

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.

Accepted Answer

Proceed with angiography within 24 hours using iso-osmolar contrast and intravenous hydration, hold metformin

Answer

Perform coronary CT angiography as alternative to invasive angiography

Answer

Delay catheterization for 72 hours to optimize renal function with hydration

Answer

Prophylactic hemodialysis before and after catheterization to remove contrast

Answer

Medical management only with dual antiplatelet therapy, avoid catheterization

Question 2

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.

Accepted Answer

Triple therapy for 1 month, then apixaban and clopidogrel for 11 months, then apixaban alone

Answer

Triple therapy with aspirin, ticagrelor, and apixaban indefinitely

Answer

Triple therapy for 6 months, then aspirin and apixaban indefinitely

Answer

Aspirin and ticagrelor only, hold anticoagulation due to bleeding risk

Answer

Warfarin with INR 2-3 plus aspirin, discontinue ticagrelor

Question 3

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.

Accepted Answer

Immediate fibrinolytic therapy followed by transfer

Answer

Helicopter transfer to reduce transfer time, then primary PCI

Answer

Administer half-dose fibrinolytic and transfer for immediate PCI

Answer

Fibrinolytic therapy at rural hospital, transfer only if fails

Answer

Wait for transfer team and proceed directly to PCI facility

Question 4

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.

Accepted Answer

Intra-aortic balloon pump with surgery within 24-48 hours

Answer

Immediate surgical mitral valve repair or replacement

Answer

Aggressive diuresis and ACE inhibitor, reassess in 2 weeks

Answer

Percutaneous mitral valve repair with MitraClip

Answer

Medical management with afterload reduction for 6 weeks, then surgery

Question 5

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.

Accepted Answer

Immediate surgical exploration and repair

Answer

Administer protamine and fresh frozen plasma, then observe

Answer

Discontinue anticoagulation and observe with serial echocardiograms

Answer

Increase intravenous fluid administration

Answer

Urgent pericardiocentesis followed by surgical evaluation

MI — MCQs

MI — MCQs

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