2014 questions of the moment

2. QUESTIONS

3. QUESTION #1
A 70 year-old non-diabetic otherwise healthy
woman admitted for unstable angina has triple
vessel disease (70% LAD lesion, 70% circumflex, 70%
proximal RCA) and normal LV function. Further
workup included carotid duplex, and this test
reveals an 80% lesion in the right internal carotid
artery. There is no history of CVA or TIA
(asymptomatic carotid lesion).
Would you offer the patient:

4. a. Right carotid stent followed by multi vessel stenting
b. Right carotid stent followed by CABG (staged 2-3 days
later)
c. Right carotid endarterectomy followed immediately by
CABG (concomitant procedure)
d. Right carotid endarterectomy followed by CABG 2-
3 days later (staged)
e. CABG with carotid endarterectomy at a later date

5. RESPONSE
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
0 0
3
1
5
0.0% 0.0%
33.3%
11.1%
A B C D E
55.6%
Responses
Percentage
c. Right carotid endarterectomy followed immediately by
CABG (concomitant procedure)
d. Right carotid endarterectomy followed by CABG 2-
3 days later (staged)
e. CABG with carotid endarterectomy at a later date

6. QUESTION #2
A 72 year-old man is admitted for acute coronary
syndrome (NSTEMI, troponin 5), and is found to have a
tight (90%) left main. His LV function is normal. He is
pain free. He had previous PCI to Cx with bare metal
stent one year ago and is on Plavix.
Would you:

7. a. Perform L main PCI
b. Perform immediate CABG with no Plavix washout
c. Perform CABG after 5 days without Plavix
d. Perform CABG after a “VerifyNow” (or other platelet
inhibition test) demonstrates Plavix washout
e. Other

8. RESPONSE
7
6
5
4
3
2
1
0
1
2
4
7
0
7.1% 14.3%
28.6%
50.0%
A B C D E
0.0%
Responses
Percentage
a. Perform L main PCI
b. Perform immediate CABG with no Plavix washout
c. Perform CABG after 5 days without Plavix
d. Perform CABG after a “VerifyNow” (or other platelet
inhibition test) demonstrates Plavix washout

9. QUESTION #3
A patient with atrial fibrillation taking dabigatran
(pradaxa) requires non-cardiac surgery.
How do you bridge this patient appropriately?

10. a. Stop dabigatran 5 days prior to surgery and restart 5 days later if taking PO
and recovering well. No bridge with heparin or lovenox.
b. Stop dabigatran 2 days prior to surgery and restart as soon as taking
PO and recovering well. No bridge
c. Do not stop dabigatran
d. Stop dabigatran 2 days prior to surgery, admit to hospital and start IV heparin
first day of no dabigatran, stop heparin drip at midnight prior to surgery,
restart dabigatran as soon as patient is taking PO without more heparin.)
e. Stop dabigatran 5 days prior to surgery, admit to hospital and start IV heparin
first day of no dabigatran, stop heparin drip at midnight prior to surgery,
restart heparin when surgeon says it's OK, restart dabigatran when taking PO
and stop heparin
f. Other
“Ideally would either continue the dabigatran, or need to bridge with
heparin, will depend upon the specific type of surgery”

11. RESPONSE
9
8
7
6
5
4
3
2
1
0
2
9
0
1
0.0% 7.7% 0
0.0% 7.7%
1
15.4%
69.2%
A B C D E F
Responses
Percentage
a. Stop dabigatran 5 days prior to surgery and restart 5 days later if
taking PO and recovering well. No bridge with heparin or lovenox.
b. Stop dabigatran 2 days prior to surgery and restart as soon as
taking PO and recovering well. No bridge

12. QUESTION #4
A 56 year old male presents to ER with STEMI and
systolic blood pressure of 90 mmHg, awake alert
and talking. ST elevation in lateral leads.
On the way to the cath lab, do you have ER
physician administer:

13. a. ASA
b. Plavix
c. Effient
d. ASA plus Plavix
e. ASA plus Effient
e. Other

14. RESPONSE
3
2.5
2
1.5
1
0.5
0
3
0 0
1
0 0
75.0%
0.0% 0.0%
25.0%
0.0% 0.0%
A B C D E F
Responses
Percentage
a. ASA
d. ASA plus Plavix

15. QUESTION #5
A 45 year old female with aortic valve endocarditis
(s. aureus), severe AI, and two-day old embolic
infarct to left cerebral hemisphere has new
expressive aphasia (neuro exam otherwise
normal).
Would you:

16. a. Wait four-six weeks if possible prior to AVR
b. Perform AVR during this admission after labs normalize
c. Treat medically only
d. Wait two weeks if possible prior to AVR

17. 1
RESPONSE
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
A B C D
0
1
0
1
0.0%
50.0%
0.0%
50.0%
Responses
Percentage
b. Perform AVR during this admission after labs normalize
d. Wait two weeks if possible prior to AVR