Regarding pharmacological management of ACS, which ONE of the following statements is TRUE?
Answer: D: Aspirin alone has up to 25% relative risk reduction in mortality.
Large trials have not shown any benefit in the early use of beta-blocker therapy in patients with STEMI. Recognising this, the 2007 focused update to the American College of Cardiology / American Heart Association guidelines for managing patients with ST-segment elevation myocardial infarction now recommends oral (not intravenous) beta-blocker therapy to be initiated during the first 24 hours of care of STEMI patients who have none of the following:
Intravenous beta-blockers may be used with caution in patients with tachycardia, hypertension or both and patients with ongoing chest pain resistant to nitrates and none of the abovementioned contraindications.
The CLARITY-TIMI 28 trial and COMMIT trials outlined the efficacy of clopidogrel in combination with aspirin for non-STEMI patients. Neither study incorporated a loading dose in patients older than 75 years of age. ExTRACT-TIMI 25 identified the benefits of enoxaparin over unfractionated heparin for STEMI patients treated with thrombolysis (RRR of 17%) at the expense of increased major bleeds (2.1%) and no increased ICH.
References:
A 75-year-old man presents to the emergency department (ED) with a gradual new onset dyspnoea on exertion. Regarding assessment for heart failure in this patient, all of the following statements are true EXCEPT:
Answer: B: Although at least 50% of patients with heart failure have a low ejection fraction of 40% or less on echocardiography, approximately one-third of all patients have a normal or near normal ejection fraction. Features such as orthopnoea, paroxysmal nocturnal dyspnoea, raised JVP and third heart sound have a 70–90% specificity for diagnosis when present. However, the sensitivity of those features is low. Diastolic dysfunction defined as abnormalities in diastolic distensibility, filling or relaxation of the left ventricle may cause heart failure with pulmonary venous congestion and oedema in the presence of a normal left ventricular (LV) ejection fraction and in the absence of any valvular abnormalities. Many conditions promote fluid retention with precipitation of heart failure and these include uncontrolled hypertension, AF, myocardial ischaemia, renal failure and use of NSAIDs.
Regarding acute pulmonary oedema, which ONE of the following statements is TRUE?
Answer: B: Systolic heart failure is the most common, caused by a range of diseases such as AMI, valvular pathology, cardiomyopathy, anaemia, toxicological causes, arrhythmias, diet, fluid overload, medications (negative inotropes or noncompliance), myocarditis, or progression of disease. Most normotensive/ hypertensive patients are not fluid overloaded – may in fact be globally underfilled. Hence, the mainstay of management is no longer diuretics, but vasodilators and non-invasive ventilation to decrease preload, systemic vascular resistance and un-load the heart. The value of BNP remains controversial, and mostly unhelpful. Most values fall between 100–500 pg/mL, which is regarded as non-diagnostic. Values <100 make a diagnosis of acute heart failure less likely, whereas values >500 makes the diagnosis more likely. BNP has not been shown to be better than the clinical judgement of an experienced emergency clinician.
Regarding cardiogenic shock, which ONE of the following is TRUE?
Answer: D: Myocardial infarction is the most common cause of cardiogenic shock, with shock complicating about 6–7% of cases of AMI. Other causes include arrhythmia, valvular pathology, cardiomyopathy, toxicological causes, and ventriculoseptal defect (VSD). Older patients with anterior AMI, previous infarction, diabetes and known congestive cardiac failure are at higher risk of cardiogenic shock. Early revascularisation with PCI or coronary artery bypass graft (CABG) has a mortality benefit, with vasopressors, inotropes and intra-aortic balloon pump being useful as a bridge to reperfusion. PCI or CABG is preferable to thrombolysis. Thrombolysis is only really indicated if timely transfer to a facility with PCI or CABG is not available.
Reference:
Regarding cardiogenic shock in AMI, which ONE of the following is FALSE?
Answer: B: Inotropes alone do not alter outcome but may temporise until definitive treatment is arranged. The overall mortality for cardiogenic shock complicating AMI sits at about 80% and depends on the age and comorbidities. However, long-term survival is improved in those patients with AMI who receive urgent revascularisation. Indeed, those patients with LAD occlusion have an almost 100% mortality unless urgent reperfusion is obtained. Intra-aortic balloon counterpulsation is only useful if combined with revascularisation.
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