BCCCP: Acute Coronary Syndromes Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old man with acute coronary syndrome complicated by cardiogenic shock is admitted to the ICU. He is nonambulatory, requires low-dose norepinephrine for hemodynamic support, and has no active bleeding. Which of the following VTE prophylaxis methods should always be used in conjunction with another prophylactic strategy, rather than as a standalone intervention, in this patient?

Intermittent pneumatic compression
Low molecular weight heparin
Graduated compression stockings
Low-dose unfractionated heparin

Question 2 of 10

2. Question

A 68-year-old man is being cared for in the critical care unit following admission for a non–ST-elevation myocardial infarction. He has been receiving a continuous infusion of unfractionated heparin through a central venous catheter for the past 6 days. During morning rounds, his platelet count is found to have fallen from 280,000/mm³ on admission to 85,000/mm³ today. He remains hemodynamically stable. Heparin-induced thrombocytopenia (HIT) is suspected. Which of the following agents is the most appropriate to initiate for continued anticoagulation?

Enoxaparin
Warfarin
Bivalirudin
Rivaroxaban

Question 3 of 10

3. Question

A 62-year-old man with an ST-elevation myocardial infarction received tenecteplase and enoxaparin (30 mg IV bolus then 1 mg/kg SC every 12 hours). He weighs 80 kg, has a creatinine clearance of 95 mL/min, and last received 80 mg SC 6 hours ago. He now requires urgent percutaneous coronary intervention for persistent ischemia. Which management of his enoxaparin therapy is most appropriate?

Continue enoxaparin 80 mg SC every 12 hours without additional dosing.
Discontinue enoxaparin and start an unfractionated heparin infusion targeting an aPTT of 50–70 seconds.
Give a supplemental IV bolus of enoxaparin 0.3 mg/kg at the time of PCI.
Hold enoxaparin until 12 hours after the last SC dose before proceeding with PCI.

Question 4 of 10

4. Question

A 72-year-old man is admitted to the cardiac intensive care unit following an acute myocardial infarction complicated by refractory cardiogenic shock (SCAI stage E). He is intubated on assist-control ventilation, receiving high-dose norepinephrine and vasopressin infusions via a central venous catheter, and has a pulmonary artery catheter in place for hemodynamic monitoring. Despite aggressive medical management, his mean arterial pressure remains low at 55 mm Hg, and he has severe lactic acidosis (lactate 8.2 mmol/L). The care team is considering initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) due to refractory shock. His family is at the bedside and has expressed significant concerns about his prognosis. Given the patient’s advanced shock and potential need for highly invasive mechanical circulatory support, which of the following is the MOST appropriate next step in his management?

Initiate a multidisciplinary goals of care discussion, including palliative care consultation.
Immediately proceed with VA-ECMO cannulation to prevent further organ damage.
Increase the doses of current vasopressor infusions to achieve a mean arterial pressure above 65 mm Hg.
Initiate an epinephrine infusion for additional inotropic and vasopressor support.

Question 5 of 10

5. Question

A 65-year-old man (80 kg) presents with an ST-elevation myocardial infarction and received enoxaparin 1 mg/kg subcutaneously 9 hours ago. His creatinine clearance is 75 mL/min. He is now being taken for urgent percutaneous coronary intervention (PCI). Which of the following is the MOST appropriate additional anticoagulation dose immediately prior to PCI?

Enoxaparin 0.3 mg/kg IV bolus
Enoxaparin 1 mg/kg IV bolus
No additional anticoagulation dose is needed
Unfractionated heparin 70 units/kg IV bolus

Question 6 of 10

6. Question

A 65-year-old man with an acute anterior STEMI has progressed to SCAI Stage D cardiogenic shock. He is intubated, on norepinephrine 0.1 mcg/kg/min, and remains hypotensive (70/40 mmHg) with a heart rate of 115 bpm and cool, mottled extremities. Hemodynamic monitoring shows a cardiac index of 1.8 L/min/m² and a pulmonary capillary wedge pressure of 28 mmHg. Which mechanical circulatory support device provides the least hemodynamic augmentation and is therefore least suitable as initial sole therapy for this patient?

Intra-Aortic Balloon Pump (hemodynamic support ~0.5–1 L/min)
Impella CP (microaxial pump up to ~3.5 L/min)
Venoarterial ECMO (full cardiopulmonary support ~4–6 L/min)
Impella 5.5 (microaxial pump up to ~5.5 L/min)

Question 7 of 10

7. Question

According to North American cardiac intensive care unit registry data from 2018–2023, which statement best describes the current predominant etiology of cardiogenic shock admissions?

Acute myocardial infarction remains the most common etiology of cardiogenic shock admissions.
Acute decompensation of chronic heart failure is now the most frequent etiology of cardiogenic shock admissions.
ST-elevation myocardial infarction–related cardiogenic shock accounts for over 50% of admissions to CICUs.
Non-ischemic causes, such as myocarditis, have surpassed myocardial infarction as a cause of cardiogenic shock admissions.

Question 8 of 10

8. Question

A 65-year-old man presents with acute substernal chest pain radiating to his left arm, diaphoresis, and shortness of breath. His ECG shows ST-segment elevations in leads II, III, and aVF, and his high-sensitivity troponin I level is markedly elevated. Which of the following is the primary pathophysiologic event leading to his acute ST-segment elevation myocardial infarction?

Coronary artery vasospasm
Rupture of an atherosclerotic plaque with subsequent thrombus formation
Myocarditis causing direct myocardial injury
Increased myocardial oxygen demand due to severe anemia causing a supply–demand mismatch (Type 2 MI)

Question 9 of 10

9. Question

A 72-year-old man with hypertension, dyslipidemia, and Stage IV chronic kidney disease (eGFR 25 mL/min/1.73 m²) is diagnosed with a non–ST-segment elevation myocardial infarction based on ECG changes and elevated troponin. Which of the following is the most important consideration when selecting antithrombotic therapy in this patient?

Reduce doses of renally cleared antithrombotic agents (e.g., eptifibatide, bivalirudin) to mitigate increased bleeding risk.
Administer full-dose eptifibatide without renal dosing adjustment during percutaneous coronary intervention.
Use bivalirudin at standard dosing without adjustment due to its lower bleeding risk compared to heparin.
Prescribe standard 12-month dual antiplatelet therapy irrespective of the patient’s bleeding risk.

Question 10 of 10

10. Question

A 65-year-old man presents with acute chest pain. His 12-lead ECG shows isolated 1 mm ST-segment depression in leads V1–V3. Which condition is most strongly suggested and warrants further diagnostic evaluation?

Acute anterior myocardial infarction
Acute posterior myocardial infarction
Right ventricular myocardial infarction
New left bundle branch block