Ischemic Heart Disease (Presentation, ECG, Complications, Management) MCQs

Medicine · 156 free questions with answers & explanations.

  1. A 62-year-old man presents with 45 minutes of severe substernal chest pain radiating to the left arm, diaphoresis, and nausea. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. Which artery is most likely occluded?
  2. A 70-year-old man develops bradycardia and hypotension 8 hours after an inferior STEMI. ECG shows P waves occurring at a rate of 80/min with QRS complexes at 36/min. P waves bear no consistent relationship to QRS complexes. QRS duration is 0.08 sec. What is the most appropriate immediate management?
  3. A 65-year-old man is admitted with NSTEMI. Troponin I is elevated at 3.8 ng/mL. He is started on aspirin, ticagrelor, and low-molecular-weight heparin. On day 3, he develops a new harsh holosystolic murmur at the lower left sternal border, worsening dyspnea, and a right heart catheterization shows a step-up in oxygen saturation from right atrium to right ventricle. What is the most likely complication?
  4. A 55-year-old woman with stable angina undergoes coronary angiography showing 65% stenosis of the LAD. Her symptoms are well controlled on atenolol, amlodipine, and sublingual nitrate PRN. According to evidence-based management of stable ischemic heart disease, the next step is:
  5. A 62-year-old man presents 90 minutes after onset of crushing chest pain. ECG shows ST elevation in leads II, III, and aVF, with reciprocal ST depression in I and aVL. Bedside echocardiography shows right ventricular dilation with right ventricular wall motion abnormality. He is hypotensive at 85/55 mmHg despite IV fluids. Which drug is CONTRAINDICATED in this setting?
  6. A 58-year-old woman with NSTEMI undergoes coronary angiography showing 70% stenosis of the left anterior descending artery with TIMI-2 flow. Her GRACE score is 145. Troponin-I is 4.2 ng/mL. According to current guidelines, what is the optimal invasive strategy timing?
  7. Ten days after an anterior MI, a 66-year-old man develops a new holosystolic murmur at the left sternal border with a thrill, worsening dyspnea, and a prominent V wave on wedge pressure tracing. Echocardiography shows a left-to-right shunt. What is the most likely diagnosis?
  8. A 70-year-old man with a prior anterior MI 5 years ago presents for routine follow-up. ECG shows persistent ST elevation in V1–V4 and Q waves. Echocardiogram reveals an akinetic, dyskinetic region in the anterior wall with a 4.2 cm LV aneurysm. He reports no chest pain but has episodic ventricular tachycardia. Which long-term complication is this patient MOST at risk for from the aneurysm?
  9. A 65-year-old man presents with an NSTEMI. Risk stratification using the TIMI score shows 5 out of 7. According to current ACC/AHA guidelines (ESC/ACC 2023 updates), what is the recommended reperfusion strategy?
  10. A 70-year-old woman 3 days after anterior STEMI develops a new pansystolic murmur loudest at the lower left sternal border with a systolic thrill. Echocardiography shows a defect in the interventricular septum. Which of the following best describes the pathophysiology of this complication?
  11. According to the PLATO trial, ticagrelor compared to clopidogrel in ACS demonstrated which of the following key findings?
  12. A 55-year-old man presents with chest pain. ECG shows ST elevation in V1-V4 with ST depression in II, III, and aVF. Primary PCI is performed and stent placed in the LAD. Which coronary anatomy pattern is suggested by this ECG pattern?
  13. In the ISIS-2 trial, the combination of aspirin and streptokinase in STEMI reduced 35-day vascular mortality by approximately 42% compared with placebo. The individual contribution of aspirin alone was approximately:
  14. A 65-year-old diabetic male develops a large anterior STEMI and undergoes primary PCI. Forty-eight hours later, a new loud pansystolic murmur is heard at the left sternal border; blood pressure drops to 80/50 mmHg. Oxygen step-up is confirmed on right heart catheterisation. Which mechanical complication is most likely?
  15. De Winter ST-segment pattern on ECG — upsloping ST depression at the J-point with tall, peaked T waves in precordial leads V1–V6 — is equivalent to STEMI and indicates occlusion of which vessel?
  16. The PLATO trial showed ticagrelor superior to clopidogrel in ACS. Unlike clopidogrel, ticagrelor exhibits which unique pharmacological property relevant to its side effect of dyspnoea?
  17. A 65-year-old man presents with STEMI in leads II, III, and aVF. His blood pressure drops to 80/50 mmHg despite 1 L IV fluid. ECG shows ST elevation in V4R. The MOST likely diagnosis and immediate management is:
  18. The ISCHEMIA trial (2019) compared initial invasive strategy versus conservative strategy in patients with stable coronary artery disease and moderate-to-severe ischemia on stress testing. Its key finding was:
  19. A patient develops ventricular septal rupture 5 days after a large anterior STEMI. On examination there is a new harsh pansystolic murmur at the lower sternal border. Which haemodynamic parameter pattern is expected on Swan-Ganz catheterisation?
  20. A 62-year-old man with NSTEMI (troponin positive) has GRACE score >140. Coronary angiography shows 70% stenosis in the proximal LAD. His LV ejection fraction is 35%. According to current ESC/AHA guidelines, what is the preferred revascularization strategy?
  21. A 68-year-old man develops cardiogenic shock 4 hours after anterior STEMI. Despite primary PCI to the LAD, he remains hypotensive (BP 82/50 mmHg) with cold extremities and pulmonary edema. The IABP-SHOCK II trial showed that intra-aortic balloon pump (IABP) in this setting:
  22. A 55-year-old woman presents 10 days after an anterior MI with a new holosystolic murmur at the apex, loud S3, worsening dyspnea, and pulmonary congestion on X-ray. Echocardiography shows posterior mitral leaflet flap with severe MR. The most likely mechanism of this acute MR is:
  23. In patients with stable angina and multivessel coronary artery disease (3 vessels) and diabetes mellitus, the FREEDOM trial demonstrated that compared to PCI with drug-eluting stents:
  24. A 60-year-old man presents 6 hours after onset of anterior STEMI. He undergoes primary PCI and stenting of LAD. Two days later, he develops a new pansystolic murmur at the left sternal border with a thrill. Echo shows a left-to-right shunt at the interventricular septum. What is the most appropriate management?
  25. The COURAGE trial (2007) compared optimal medical therapy (OMT) alone versus PCI plus OMT in stable ischemic heart disease. What was the primary finding?
  26. A 55-year-old man with NSTEMI has a GRACE score of 145 (high risk). He is on aspirin, ticagrelor, heparin, and statin. Echocardiography shows EF of 35%. According to current ACC/AHA guidelines, what is the optimal timing for coronary angiography?
  27. Dressler syndrome (post-MI pericarditis) typically presents how many weeks after myocardial infarction, and which is the MOST appropriate first-line treatment?
  28. A 60-year-old man with NSTEMI is risk-stratified using the GRACE 2.0 score and found to be high risk. According to current ESC NSTEMI guidelines (2020), within what timeframe should coronary angiography be performed?
  29. A 65-year-old man develops acute MI. Echocardiogram 3 days later shows a thin-walled left ventricular aneurysm with mural thrombus at the apex. Which ECG finding best correlates with this complication?
  30. In the ISCHEMIA trial, patients with stable coronary artery disease and moderate-to-severe ischaemia were randomized to routine invasive versus conservative management. What was the primary outcome finding?
  31. A 62-year-old man with STEMI undergoes primary PCI at 90 minutes. Post-PCI ECG shows >50% resolution of ST elevation and TIMI-3 flow. Six hours later he develops sudden hypotension, elevated JVP, clear lungs, and a new pansystolic murmur at the lower left sternal border. The most likely diagnosis is:
  32. In the ISCHEMIA trial (2019), patients with stable ischemic heart disease and moderate-to-severe ischemia on stress testing were randomized to an invasive strategy (early PCI/CABG) versus conservative medical therapy. The primary finding was:
  33. A 71-year-old man had STEMI 3 weeks ago treated with primary PCI and stenting of the LAD. He is on aspirin, ticagrelor, atorvastatin, metoprolol, and ACE inhibitor. Echocardiography shows LVEF 32%. According to current heart failure guidelines, the next medication to add is:
  34. According to the 2022 ACC/AHA Chest Pain Guidelines, a patient presenting with possible ACS whose HEART score is 6 (high risk) should be managed as:
  35. A 65-year-old man presents 2 hours after sudden severe chest pain with diaphoresis. ECG shows ST elevation in V1–V4 with reciprocal changes in II, III, aVF. He arrives at a hospital without PCI capability. Door-to-balloon time if transferred would be 110 minutes. Door-to-needle time for thrombolysis would be 25 minutes. What is the most appropriate reperfusion strategy?
  36. A 70-year-old man 4 days post-STEMI develops a new harsh holosystolic murmur at the lower left sternal border with a palpable thrill. BP drops to 90/60 mmHg. Jugular venous pressure is elevated. Which diagnosis does this presentation indicate?
  37. A 60-year-old woman with stable angina has left main coronary artery stenosis of 62% on invasive angiography. Left ventricular ejection fraction is 55%. She has no diabetes. Which revascularization strategy is preferred?
  38. On an ECG, a patient with acute inferior STEMI (ST elevation II, III, aVF) also shows ST elevation in V4R. This finding indicates involvement of which vessel?
  39. A 58-year-old man with NSTEMI undergoes coronary angiography. He has a 90% stenosis in the proximal LAD and a 75% stenosis in the mid-RCA. His SYNTAX score is 16. What does this SYNTAX score determine regarding revascularisation strategy?
  40. A 64-year-old woman presents 2 hours after onset of crushing chest pain. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. She develops hypotension (BP 80/50), raised JVP, clear lung fields, and no S3. The right-sided ECG shows ST elevation in V4R. What is the most appropriate immediate next step?
  41. The ISCHEMIA trial (2019) randomised stable patients with moderate-severe ischaemia on stress testing to initial invasive strategy vs. optimal medical therapy. What was its primary finding relevant to clinical decision-making?
  42. A 55-year-old man with anterior STEMI treated with primary PCI 48 hours ago has an echocardiogram showing EF 35%, anterior wall akinesis, and an apical thrombus. He is in sinus rhythm. What is the recommended anticoagulation strategy?
  43. The PLATO trial demonstrated superior outcomes with ticagrelor over clopidogrel in ACS patients. The mechanism by which ticagrelor differs from clopidogrel is:
  44. A 65-year-old man presents 90 minutes after onset of anterior STEMI. Primary PCI is available within 30 minutes. He is on warfarin with INR 2.8. The MOST appropriate anticoagulation strategy during primary PCI is:
  45. Ventricular free wall rupture complicating STEMI most commonly occurs at what time interval after the index infarction?
  46. The ISCHEMIA trial (2019) enrolled stable CAD patients with moderate-to-severe ischaemia on stress testing. Its KEY finding compared to earlier assumptions was:
  47. The ISCHEMIA trial (2020) challenged routine invasive strategy in stable ischemic heart disease. Which conclusion was demonstrated in patients with moderate-to-severe ischemia on non-invasive testing?
  48. A 65-year-old man presents with anterior STEMI and undergoes successful primary PCI. On day 2, he develops sudden hypotension, a new loud pan-systolic murmur at the left sternal border, and bilateral pulmonary oedema. Echocardiography shows a 1.5 cm defect in the interventricular septum with left-to-right shunt. What is the most appropriate management?
  49. PLATO trial demonstrated superiority of ticagrelor over clopidogrel in ACS. Which unique pharmacodynamic property distinguishes ticagrelor from clopidogrel?
  50. Wellens' syndrome on ECG indicates critical stenosis of the proximal left anterior descending artery. Which ECG pattern is characteristic of Type B (more common) Wellens' syndrome?
  51. A 60-year-old woman presents 2 hours after chest pain onset. ECG shows 3 mm ST elevation in V1–V4. She is taken for primary PCI. Which P2Y12 inhibitor is preferred over clopidogrel in this setting according to ESC STEMI guidelines?
  52. A 68-year-old man develops severe mitral regurgitation with pulmonary edema 4 days after anterior STEMI. Echocardiography reveals a flail posterior mitral leaflet. The MOST likely underlying mechanism is:
  53. A 55-year-old man with stable angina has undergone coronary angiography showing 70% stenosis in the left anterior descending artery. His symptoms are controlled on medical therapy. The ISCHEMIA trial demonstrated that in this setting, routine invasive revascularization versus optimal medical therapy resulted in:
  54. A 70-year-old woman with STEMI undergoes primary PCI at 90 minutes. On day 3, she develops fever (38.5°C), pleuritic chest pain, and a pericardial friction rub. ECG shows diffuse ST elevation. The MOST appropriate treatment is:
  55. A 60-year-old man presents 3 hours after onset of crushing chest pain. ECG shows ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. He is taken for primary PCI. Which coronary artery is most likely occluded?
  56. Following a successful primary PCI for anterior STEMI, a 55-year-old man develops a new holosystolic murmur at the lower left sternal border on day 5. He is hypotensive and tachycardic. Echocardiography shows a left-to-right shunt. What is the most likely diagnosis and initial stabilizing intervention?
  57. A 62-year-old man with anterior STEMI, now day 2 post-primary PCI, is found on echo to have an LV ejection fraction of 32% and anterior wall akinesis. He has no symptoms of heart failure at rest. According to current guidelines, which therapy should be initiated before discharge to reduce mortality?
  58. In the ISCHEMIA trial, which finding was demonstrated regarding revascularization versus optimal medical therapy in stable ischemic heart disease with moderate-to-severe ischemia on stress testing?
  59. A 60-year-old man presents with STEMI of the inferior wall 90 minutes after symptom onset. Primary PCI is performed successfully. On day 3 he develops sudden hypotension, new pansystolic murmur loudest at the lower left sternal border, and a left-to-right shunt on echocardiography. The MOST likely diagnosis is:
  60. In the PLATO trial, ticagrelor compared to clopidogrel in ACS patients showed which PRIMARY outcome benefit?
  61. A patient presents with anterior STEMI and undergoes primary PCI with drug-eluting stent placement. Dual antiplatelet therapy (DAPT) with aspirin and ticagrelor is prescribed. When is it appropriate to discontinue the P2Y12 inhibitor in an uncomplicated patient at standard bleeding risk?
  62. A 55-year-old man has stable angina with significant LAD stenosis on coronary angiogram. He is on optimal medical therapy (beta-blocker, statin, aspirin, nitrates). The ISCHEMIA trial's principal finding relevant to deciding between PCI and continued medical therapy in stable CAD is:
  63. On ECG of an inferior STEMI patient, ST elevation is seen in leads II, III and aVF with reciprocal depression in I and aVL. Additionally, there is ST elevation of 1 mm in lead V4R. What does the V4R finding indicate and how does it change management?
  64. A 62-year-old man presents with NSTEMI. His TIMI risk score for NSTEMI is calculated to be 5. According to current ACC/AHA guidelines, what is the recommended strategy?
  65. A 70-year-old man who had an anterior STEMI 3 weeks ago develops increasing dyspnea and a loud pansystolic murmur at the apex radiating to the axilla. Echo shows an ejection fraction of 30% with no VSD. What is the most likely complication?
  66. A 65-year-old man with STEMI undergoes primary PCI. After stenting the LAD, his BP drops to 80/50 mmHg, HR is 50 bpm, JVP is elevated, and clear lung fields are noted. ECG shows ST elevation in leads II, III, aVF and ST depression in V1–V3. Which additional territory is most likely infarcted?
  67. The ISCHEMIA trial (2019) enrolled patients with stable coronary artery disease and moderate-to-severe ischemia on stress testing. Its major finding was:
  68. A 62-year-old man presents with 2 hours of chest pain. ECG shows 3 mm ST elevation in leads II, III, and aVF with reciprocal ST depression in I and aVL. He arrives at a hospital without PCI capability. Door-to-balloon time via transfer would be 3.5 hours. Per current ACC/AHA STEMI guidelines, the preferred reperfusion strategy is:
  69. Five days after an anterior STEMI, a 65-year-old man develops sudden onset dyspnoea and hypotension. Examination reveals a loud harsh pansystolic murmur at the left sternal border with a systolic thrill. Echocardiography shows a left-to-right shunt. The most likely complication and definitive management are:
  70. The ISCHEMIA trial (2020) changed practice regarding the management of stable ischaemic heart disease. Its principal finding was:
  71. A patient with NSTEMI is started on dual antiplatelet therapy with aspirin and ticagrelor. He has a prior history of ischaemic stroke 8 months ago. Which statement is most accurate regarding ticagrelor use in this patient?
  72. A 62-year-old man is admitted with NSTEMI. He is treated with aspirin, ticagrelor, anticoagulation, and an early invasive strategy. Coronary angiography reveals a 95% stenosis of the proximal LAD. PCI is performed with a drug-eluting stent. What is the minimum recommended duration of dual antiplatelet therapy (DAPT) per current ESC guidelines after DES implantation for ACS?
  73. On the third day after an acute anterior STEMI treated with primary PCI, a patient develops sudden severe dyspnoea, a new loud pan-systolic murmur at the left sternal border, and rapid haemodynamic deterioration. Echocardiography shows a left-to-right shunt. What is the MOST likely diagnosis?
  74. Which of the following statements BEST describes the finding that supports diagnosing right ventricular myocardial infarction in the setting of inferior STEMI?
  75. The ISCHEMIA trial (2019) studied patients with stable coronary artery disease and moderate-to-severe ischaemia on stress testing. Compared with medical therapy alone, routine invasive strategy with revascularisation showed which outcome?
  76. A 62-year-old man presents with STEMI. Primary PCI is performed within 60 minutes. Post-PCI ECG shows >50% resolution of ST elevation. On day 2, he develops hypotension, elevated JVP, clear lung fields, and a new harsh pansystolic murmur at the left lower sternal border. What is the most likely diagnosis?
  77. A patient with anterior STEMI is treated with thrombolytics as primary PCI was not available within 120 minutes. Pharmacoinvasive strategy is planned. According to current guidelines, at what window post-thrombolysis should routine coronary angiography be performed?
  78. Which ECG finding is most specific for posterior wall myocardial infarction?
  79. In NSTEMI management, which clinical finding categorises a patient as 'very high risk' mandating immediate invasive strategy (within 2 hours) per ESC 2023 guidelines?
  80. A 61-year-old man presents 3 hours after onset of anterior chest pain. ECG shows ST elevation in leads V1–V4. He undergoes primary PCI successfully. On day 3, he develops sudden hypotension, a new loud holosystolic murmur at the left sternal border, and a thrill. Oxygen saturation step-up is noted from right atrium to right ventricle on Swan-Ganz catheterisation. The complication is:
  81. A 55-year-old diabetic woman presents with 2 hours of jaw pain and nausea but no chest pain. Troponin I at 4 hours is 2.8 ng/mL (URL 0.04). ECG shows no ST changes. Based on current ESC 0h/1h hs-cTnI algorithm, this presentation is classified as:
  82. The ISCHEMIA trial (2020) demonstrated which major finding regarding the management of stable ischaemic heart disease with moderate-to-severe ischaemia?
  83. A 68-year-old woman post anterior MI 6 weeks ago has a repeat echo showing EF of 30% and a large apical thrombus on imaging. She has no contraindications to anticoagulation. The preferred anticoagulation strategy for the left ventricular thrombus is:
  84. A 60-year-old man presents with NSTEMI. Coronary angiography reveals triple-vessel disease with proximal LAD involvement. His SYNTAX score is 28. According to current ESC NSTEMI guidelines (2023), what is the preferred revascularisation strategy?
  85. The ISCHEMIA trial (2019–2020) randomised stable ischaemic heart disease patients to initial invasive strategy versus optimal medical therapy. The trial's primary finding was:
  86. A 65-year-old man with STEMI undergoes primary PCI successfully. On day 3, he develops sudden hypotension, elevated JVP, clear lung fields, and a new loud holosystolic murmur at the left sternal border that increases on inspiration. Which complication is most likely?
  87. Following STEMI treated with primary PCI, which P2Y12 inhibitor has shown superior mortality benefit in the PLATO trial compared to clopidogrel?
  88. A 60-year-old man with anterior STEMI undergoes primary PCI successfully. Two days later, he develops new harsh holosystolic murmur at the left sternal border with thrill, and acute pulmonary edema. Echocardiography is most likely to show:
  89. A 55-year-old man with NSTEMI (GRACE score 148) is started on dual antiplatelet therapy and anticoagulation. According to current ESC guidelines, when should invasive angiography ideally be performed?
  90. A 61-year-old man presents 90 minutes after chest pain onset with ST elevation in leads II, III, aVF. He is at a primary PCI-capable centre. Door-to-balloon time is currently estimated at 85 minutes. What is the most appropriate management?
  91. Following an anterior STEMI, an ECG on day 3 shows persistent ST elevation with Q waves in V1–V4. Echocardiography reveals a thin akinetic segment with a layered thrombus in the left ventricular apex. The most appropriate additional therapy is:
  92. A 68-year-old woman with stable angina has an FFR (fractional flow reserve) of 0.79 on invasive angiography of a 60% LAD stenosis. She is on optimal medical therapy. What does this FFR value indicate and what is the next step?
  93. Which landmark trial demonstrated that routine early invasive strategy (within 24 hours) was superior to selective invasive strategy in high-risk NSTEMI patients, leading to current NSTEMI guidelines recommending early angiography?
  94. A patient with NSTEMI is started on ticagrelor 180 mg loading dose plus aspirin. After PCI with drug-eluting stent, which of the following is the correct duration of dual antiplatelet therapy (DAPT) according to current ESC guidelines?
  95. A 62-year-old man presents with STEMI (anterior). Door-to-balloon time is currently 50 minutes. Cath lab is available in the hospital. Which reperfusion strategy is the standard of care per ACC/AHA guidelines?
  96. A 70-year-old man with anterior STEMI 3 days ago develops sudden severe chest pain, new systolic murmur, and cardiogenic shock. Echo shows free-wall rupture versus ventricular septal defect. Which bedside finding would MOST reliably differentiate ventricular septal rupture from acute mitral regurgitation?
  97. The ISCHEMIA trial (2019) demonstrated that in stable coronary artery disease with moderate-to-severe ischemia, compared to conservative (optimal medical therapy alone), the routine invasive strategy (PCI/CABG):
  98. A 58-year-old man post-STEMI is started on dual antiplatelet therapy (aspirin + ticagrelor). His cardiologist considers adding low-dose rivaroxaban (2.5 mg twice daily) per the COMPASS trial. This combination is specifically indicated for:
  99. A 62-year-old man is brought with 2-hour chest pain and ST elevation in leads II, III, aVF with reciprocal ST depression in I and aVL. Door-to-balloon time is projected to be 110 minutes. PCI laboratory is not immediately available. What is the preferred management strategy?
  100. A patient develops a new holosystolic murmur 4 days after an inferior STEMI. Bedside echocardiography shows a left-to-right shunt at the ventricular level with moderate-to-severe haemodynamic compromise. What is the definitive treatment?
  101. In the ISCHEMIA trial, which finding was demonstrated regarding stable ischaemic heart disease with moderate-to-severe ischaemia on stress testing?
  102. A 55-year-old man is diagnosed with NSTEMI (troponin I 4.2 ng/mL, TIMI risk score 5). Which antiplatelet strategy, in addition to aspirin, is preferred per current guidelines for patients managed invasively?
  103. A 64-year-old man develops an anterior STEMI. He is taken for primary PCI at 90 minutes. Post-procedure, angiography shows TIMI-3 flow, but his ECG shows persistent ST elevation and he develops new right bundle branch block with QRS duration 140 ms. What does this ECG finding indicate?
  104. A 70-year-old woman has an NSTEMI and is found to have three-vessel coronary artery disease with preserved LV ejection fraction (55%). Her SYNTAX score is 32. Which revascularization strategy is preferred per current guidelines?
  105. Five days after an anterior STEMI, a 58-year-old man develops sudden severe dyspnoea. Examination reveals a new pansystolic murmur loudest at the lower left sternal border with a thrill. BP is 88/60 mmHg. Which complication has occurred and what is the distinguishing feature from papillary muscle rupture?
  106. Which statement about high-sensitivity troponin (hs-cTnT/cTnI) in the diagnosis of NSTEMI is most accurate?
  107. The ISCHEMIA trial (2019) showed that, compared to conservative medical therapy alone in stable coronary artery disease with moderate-to-severe ischaemia, routine revascularisation (PCI or CABG):
  108. A 65-year-old man develops sudden hypotension and new pansystolic murmur loudest at the apex 5 days after an inferior STEMI managed with primary PCI. An echocardiogram shows severe mitral regurgitation with rupture of the posteromedial papillary muscle. The MOST appropriate immediate management is:
  109. A patient with NSTEMI has a GRACE score of 148 (>140 = high risk). According to current ESC guidelines, the optimal timing for coronary angiography is:
  110. Wellens' syndrome type B ECG pattern in a pain-free patient who was previously having typical anginal chest pain is characterised by:
  111. In the PLATO trial, ticagrelor compared to clopidogrel in ACS showed:
  112. A 58-year-old diabetic man presents 90 minutes after onset of crushing chest pain. ECG shows ST elevation in V2-V5. He is taken for primary PCI. On opening the LAD, a large thrombus burden is found with TIMI 0 flow. After aspiration thrombectomy and stent placement, TIMI 3 flow is restored but the patient develops acute hypotension and raised JVP 40 minutes later. Bedside echo shows RV dilatation with septal D-sign and moderate pericardial effusion. The MOST likely diagnosis is:
  113. The PLATO trial compared ticagrelor vs clopidogrel in ACS patients. The significant survival benefit of ticagrelor was partly attributed to an off-target mechanism. Which of the following correctly identifies this off-target effect?
  114. A 65-year-old man with NSTEMI has a GRACE score of 155. He is on aspirin, ticagrelor, fondaparinux, and a beta blocker. Which statement about the timing of coronary angiography in this patient is MOST aligned with current ESC NSTEMI guidelines?
  115. In chronic stable ischaemic heart disease, the ISCHEMIA trial (2019) compared complete revascularisation plus OMT versus OMT alone. The MAIN finding of the trial was:
  116. A 55-year-old man post-anterior STEMI develops sustained monomorphic ventricular tachycardia (VT) on day 3. His LVEF is 30%. He is haemodynamically stable. The VT terminates with IV amiodarone. What is the MOST appropriate long-term management?
  117. A 65-year-old man presents 90 minutes after STEMI onset. Primary PCI is not achievable within 120 minutes. He receives tenecteplase. At 90 minutes post-thrombolysis, his ST segments have resolved >50% and he is pain-free. Per current ESC/ACC guidelines, what is the next best step?
  118. A 70-year-old man 48 hours post-inferior STEMI develops a new pansystolic murmur at the left sternal border with a thrill, and acute decompensated heart failure. Echocardiogram shows a 1.5 cm VSD in the basal interventricular septum with left-to-right shunt. Which statement about the management of post-MI VSD is correct?
  119. A 58-year-old woman with anterior STEMI undergoes primary PCI to the LAD. Day 3, she develops low-grade fever, pleuritic chest pain, and diffuse saddle-shaped ST elevation without reciprocal changes. Echo shows a small pericardial effusion with no hemodynamic compromise. What is the correct treatment?
  120. In the PLATO trial, ticagrelor versus clopidogrel in ACS patients showed a mortality benefit. Which specific mechanism accounts for ticagrelor's mortality benefit beyond platelet inhibition?
  121. A 72-year-old diabetic woman has multivessel coronary artery disease with SYNTAX score of 33 and preserved LVEF. She is otherwise operable. According to SYNTAX trial data and current guidelines, what revascularization strategy is recommended?
  122. A 64-year-old man presents with NSTEMI. Risk stratification using the GRACE score gives him a score of 148. Per current ESC 2023 NSTEMI guidelines, the recommended invasive strategy is:
  123. A patient develops a new pansystolic murmur at the apex 4 days after a large anterior STEMI. Echocardiography shows a flail posterior mitral leaflet with severe MR. This mechanical complication is most likely caused by:
  124. The ISCHEMIA trial (2019) compared initial conservative management versus invasive coronary revascularisation in stable ischaemic heart disease with moderate-severe ischaemia. Which statement BEST reflects the key finding?
  125. In the ISCHEMIA trial, which key finding challenged the traditional approach to stable ischemic heart disease with significant ischemia on stress testing?
  126. A 68-year-old man is 72 hours post-STEMI with persistent fever, pleuritic chest pain, and a new pericardial friction rub. ECG shows diffuse ST elevation without reciprocal changes. This presentation is MOST consistent with:
  127. According to the 4th Universal Definition of MI, a rise and fall in troponin with at least one value above the 99th percentile URL is required. Which MI type is defined by biomarker elevation following CABG?
  128. A 61-year-old woman presents 90 minutes after STEMI onset. Primary PCI is performed successfully. She is now considered for dual antiplatelet therapy (DAPT) duration. Per current AHA/ACC guidelines, the recommended minimum DAPT duration post-drug-eluting stent (DES) in stable patients without high bleeding risk is:
  129. Which mechanism best explains why nitrates are CONTRAINDICATED within 24 hours of sildenafil use in a patient with ischemic chest pain?
  130. A 65-year-old man with NSTEMI is managed conservatively. His GRACE score is 148. According to the ESC 2023 NSTEMI guidelines, what is the recommended timing for coronary angiography?
  131. A patient with acute STEMI develops a new pansystolic murmur loudest at the left sternal border 5 days post-infarction. Echocardiography reveals a left-to-right shunt. Which intervention is most appropriate?
  132. The ISCHEMIA trial (2019) enrolled stable ischaemic heart disease patients with moderate-to-severe ischaemia on stress testing. What was its key finding regarding routine invasive strategy versus conservative management?
  133. A 62-year-old man develops cardiogenic shock 6 hours after anterior STEMI treated by primary PCI. His BP is 70/40 mmHg with vasopressin and norepinephrine, pulmonary capillary wedge pressure 24 mmHg, cardiac index 1.5 L/min/m². The IABP-SHOCK II trial fundamentally changed management of this condition. Which conclusion did it establish?
  134. In the COMPLETE trial design for patients with STEMI and multivessel coronary artery disease, what was the primary finding regarding complete revascularisation vs. culprit-only PCI?
  135. A 70-year-old woman 72 hours after inferior STEMI develops sudden haemodynamic collapse with a new harsh pansystolic murmur best heard at the lower left sternal border and a step-up in oxygen saturation from right atrium to right ventricle on pulmonary artery catheterisation. ECG shows AV dissociation. Which statement is most correct about the surgical timing for the most likely diagnosis?
  136. A patient with chronic stable angina has an FFR of 0.79 across a 65% stenosis in the LAD on invasive coronary angiography. Optimal medical therapy (statin, beta-blocker, aspirin, ranolazine) has been maximised. What does the ISCHEMIA trial indicate about the next best step?
  137. A 55-year-old diabetic male post-NSTEMI is being considered for dual antiplatelet therapy. He had a GI bleed 8 months ago. The PEGASUS-TIMI 54 trial evaluated which specific therapeutic strategy?
  138. The PLATO trial demonstrated superiority of ticagrelor over clopidogrel in ACS management. Which pharmacokinetic property of ticagrelor makes it distinct from clopidogrel?
  139. A patient develops right ventricular infarction complicating inferior STEMI. She is hypotensive and bradycardic. Which treatment is CONTRAINDICATED in this setting?
  140. A 55-year-old man with anterior STEMI and EF 35% 3 weeks later is being evaluated. The MADIT-II trial informs the decision to implant an ICD. What is the current ACC/AHA guideline recommendation for ICD implantation in this scenario?
  141. In the COURAGE trial, which important conclusion was drawn regarding percutaneous coronary intervention (PCI) for stable ischemic heart disease?
  142. Wellens' syndrome represents a critical ECG finding in an otherwise pain-free patient after a brief episode of chest pain. Which ECG pattern in Wellens' Type A (biphasic T-waves) indicates critical LAD stenosis?
  143. A 62-year-old man with NSTEMI (peak troponin I 8.2 ng/mL) undergoes coronary angiography showing 95% stenosis of the proximal LAD. He is currently on aspirin, ticagrelor, unfractionated heparin, and atorvastatin. Which additional therapy has been shown in the PRAMI trial to reduce recurrent MI in this setting?
  144. A 70-year-old man develops mechanical mitral regurgitation 5 days after a large inferior STEMI. He is in cardiogenic shock with a new holosystolic murmur loudest at the apex. Echocardiogram shows posterior papillary muscle rupture with flail leaflet. What is the definitive management?
  145. In the ISCHEMIA trial, which key finding changed the management paradigm for stable ischemic heart disease with moderate-to-severe ischaemia on non-invasive testing?
  146. A patient 72 hours post-STEMI develops sudden hypotension, elevated JVP, clear lungs, and a new loud holosystolic murmur at the left sternal border with a thrill. ECG shows sinus tachycardia with Q waves in inferior leads. What is the most likely diagnosis?
  147. A 62-year-old male has an anterior STEMI. Primary PCI is performed at 90 minutes. Post-PCI ECG shows persistent ST elevation and the patient develops hypotension and pulmonary oedema on day 2. Echo reveals an EF of 20%. What is the most likely mechanical complication?
  148. In the ISCHEMIA trial, which patients with stable coronary artery disease and moderate-to-severe ischaemia showed a significant benefit from invasive revascularisation strategy over optimal medical therapy alone?
  149. A 55-year-old woman presents with a 3-hour history of crushing chest pain radiating to the jaw. ECG shows ST depression in V1–V4 with tall R waves in V1–V2. Which of the following best explains this ECG pattern?
  150. According to the 2023 ESC guidelines on acute coronary syndromes, what is the recommended dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) implantation for a patient with NSTEMI and no high bleeding risk?
  151. A 58-year-old man presents 2 hours after onset of chest pain. ECG shows ST elevation in leads II, III, aVF with reciprocal depression in I and aVL. He is taken for primary PCI. Which vessel is MOST likely culprit?
  152. According to the ISCHEMIA trial, which of the following is the correct conclusion regarding stable ischemic heart disease with moderate-severe ischemia on non-invasive testing?
  153. A 65-year-old man develops a pansystolic murmur at the left sternal border 5 days after an anterior STEMI. He deteriorates haemodynamically. Echocardiography is MOST likely to show which complication?
  154. In a patient with NSTEMI, which feature MOST strongly mandates early invasive strategy within 2 hours (very high-risk criteria per ESC 2020)?
  155. Which antithrombotic regimen is recommended for a patient undergoing primary PCI for STEMI based on current AHA/ACC/ESC guidelines?
  156. A 58-year-old man presents with NSTEMI. Troponin I peak is 28 ng/mL. He has a GRACE score of 148 (high risk). No hemodynamic instability. He is started on dual antiplatelet therapy (aspirin + ticagrelor) and anticoagulation (fondaparinux). The timing of coronary angiography should be:
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