STEMI management algorithm — MCQs

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?

Two days after admission for myocardial infarction and subsequent coronary angioplasty, a 65-year-old man becomes distressed and diaphoretic in the cardiac intensive care unit. Suddenly he is no longer responsive. Pulse oximetry does not show a tracing. He has a history of hypertension and depression. Prior to his admission, his medication included ramipril and aripiprazole. Examination shows no carotid pulse. An ECG is shown. After beginning chest compressions, which of the following is the most appropriate step in management of the patient?

A 54-year-old man is brought to the emergency department 1 hour after the sudden onset of shortness of breath, epigastric pain, and sweating. He has no history of similar symptoms. He has hypertension and type 2 diabetes mellitus. Current medications include amlodipine and metformin. He has smoked one pack of cigarettes daily for 20 years. He appears weak and pale. His pulse is 56/min, respirations are 18/min, and blood pressure is 100/70 mm Hg. Cardiac examination shows normal heart sounds. The lungs are clear to auscultation. The skin is cold to the touch. An ECG is shown. Bedside transthoracic echocardiography shows normal left ventricular function. High-dose aspirin is administered. Administration of which of the following is most appropriate next step in management?

A 66-year-old man presents to the emergency department with a 3-hour history of crushing chest pain radiating to the left shoulder and neck. Patient states that the pain began suddenly when he was taking a walk around the block and has not improved with rest. He also mentions difficulty breathing and prefers to sit leaning forward. He denies ever having similar symptoms before. Past medical history is significant for hypertension, diagnosed 10 years ago, and hyperlipidemia diagnosed 8 years ago. Current medications are atorvastatin. Patient is also prescribed hydrochlorothiazide as an antihypertensive but is not compliant because he says it makes him urinate too often. Vitals show a blood pressure of 152/90 mm Hg, pulse of 106/min, respirations of 22/min and oxygen saturation of 97% on room air. On physical exam, patient is profusely diaphoretic and hunched over in distress. Cardiac exam is unremarkable and lungs are clear to auscultation. During your examination, the patient suddenly becomes unresponsive and a pulse cannot be palpated. A stat ECG shows the following (see image). Which of the following is the next best step in management?

A 57-year-old man presents to the emergency department for evaluation of slurred speech and left arm and leg weakness over the last 3 hours. History reveals hypertension that is being treated with hydrochlorothiazide. Vital signs include: blood pressure of 110/70 mm Hg, heart rate 104/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals 2/5 strength in both left upper and lower extremities. After 2 hours, the patient’s symptoms suddenly disappear. An electrocardiogram (ECG) is obtained (see image). Which of the following medications could prevent ischemic attacks in this patient in the future?

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 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 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 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 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.