On this page
Study tools
Write your answer
Saved on this device. No marking — you are the marker.
Q1: Definitions (2 min)
"A patient's troponin is elevated. Does that mean they've had an MI?"
- Not necessarily. Myocardial infarction requires a troponin rise/fall with at least one value above the 99th percentile, plus clinical evidence of acute ischaemia — symptoms, new ECG changes, imaging evidence of new loss of viable myocardium, or an identified thrombus.
- Troponin elevation without an ischaemic context is myocardial injury, not infarction — sepsis, tachyarrhythmia, renal failure, and pulmonary embolism can all raise troponin without a coronary event.
- Distinguish Type 1 MI (plaque rupture/thrombosis) from Type 2 MI (supply-demand mismatch without acute coronary atherothrombosis — e.g. severe anaemia or tachyarrhythmia in a patient with fixed coronary disease); management differs — Type 2 is treated by fixing the precipitant, not by reflexively starting dual antiplatelet therapy.[2]
Q2: ECG localisation (2 min)
"An ECG shows ST elevation in II, III, and aVF. Which artery is occluded, and what do you check next?"
- Inferior leads (II, III, aVF) localise to the right coronary artery territory in most patients.
- Check for right ventricular involvement — record right-sided leads (V3R–V4R); if RV infarction is present, the patient will show hypotension, clear lung fields, and a raised JVP.
- Critical management point: avoid nitrates and diuretics in RV infarction — they drop preload-dependent right ventricular output and can cause severe hypotension. Give fluids instead.
- Also check for posterior extension — tall R waves and ST depression in V1–V2, with posterior leads V7–V9 confirming ST elevation (a 0.5 mm cut-off in V7–V9; 1 mm in men under 40).[2]
Q3: Reperfusion decision-making (3 min)
"A STEMI patient presents to a rural hospital with no cath lab. The nearest PCI centre is 3 hours away. What do you do?"
- Primary PCI is preferred only if deliverable within 120 minutes of the STEMI diagnosis — a 3-hour transfer clearly exceeds this.
- Give fibrinolysis (e.g. weight-based tenecteplase bolus) as soon as the diagnosis is made — the ESC target is the lytic bolus within 10 minutes of the STEMI diagnosis — provided there is no contraindication (any previous intracranial haemorrhage, a known structural cerebral vascular lesion or intracranial neoplasm, suspected aortic dissection, active bleeding, recent major trauma or intracranial surgery, severe uncontrolled hypertension).
- Load aspirin 300 mg + a P2Y12 inhibitor + a parenteral anticoagulant regardless of reperfusion strategy.
- Transfer immediately after the lytic bolus: rescue PCI urgently if lysis fails (ST resolution under 50 percent or persisting pain at 60–90 minutes), otherwise routine early angiography 2–24 hours after lysis.[3][4]
Q4: The GRACE and TIMI scores (2 min)
"Reproduce the GRACE score. What is it used for?"
- GRACE estimates in-hospital and 6-month mortality from: age, heart rate, systolic BP, creatinine, Killip class, cardiac arrest at admission, ST-segment deviation, and elevated cardiac biomarkers.
- It is used in NSTE-ACS (NSTEMI/unstable angina) to decide the timing of invasive angiography — a higher score (classically >140) supports an early invasive strategy.
- Contrast with TIMI risk score (7 components: age ≥65, ≥3 risk factors, known ≥50% coronary stenosis, aspirin use in the last 7 days, severe angina ≥2 episodes/24h, ST deviation ≥0.5mm, elevated biomarker) — a simpler bedside tool; the 14-day rate of death, MI or urgent revascularisation rose from 4.7% at 0–1 points to 40.9% at 6–7 in the derivation cohort.[5][1]
Q5: Complications and pitfalls (3 min)
"Five days after an anterior MI, a patient develops a new pansystolic murmur and sudden pulmonary oedema. What's happened, and what do you do?"
- This is the classic presentation of acute mitral regurgitation from papillary muscle rupture (or, if the murmur is harsher with a thrill and biventricular failure, consider ventricular septal rupture instead).
- Both are mechanical complications: papillary muscle rupture peaks at 2–7 days post-MI, while ventricular septal rupture usually declares itself within the first 24 hours of a STEMI.[6]
- Management: urgent bedside echocardiography to confirm and characterise the lesion, haemodynamic stabilisation (afterload reduction, possibly mechanical support), and urgent cardiothoracic surgical referral — these are surgical emergencies.
- Mention free-wall rupture as the most catastrophic mechanical complication (sudden tamponade, often fatal, typically from 24–48 hours out to the first week) and Dressler syndrome as a later (weeks), autoimmune, non-mechanical complication (fever, pleuritic pain, pericardial rub — managed medically with NSAIDs/colchicine, not surgery).[6]
Q6: Secondary prevention (2 min)
"The patient is being discharged after successful primary PCI. What do you send them home on?"
- Dual antiplatelet therapy for 12 months — aspirin indefinitely + a P2Y12 inhibitor (prasugrel or ticagrelor by default after PCI).
- High-intensity statin (e.g. atorvastatin 80 mg).
- Beta-blocker, especially with reduced ejection fraction.
- ACE-inhibitor or ARB, especially with reduced ejection fraction or anterior infarction.
- Smoking cessation counselling and cardiac rehabilitation referral.
- These five pillars reduce recurrent events and mortality — secondary prevention is lifelong, not a discharge checkbox.[1]
References6ShowHide
- [1]Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes Eur Heart J, 2023.PMID 37622654
- [2]Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018) J Am Coll Cardiol, 2018.PMID 30153967
- [3]Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) Eur Heart J, 2018.PMID 28886621
- [4]Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Circulation, 2025.PMID 40014670
- [5]Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making JAMA, 2000.PMID 10938172
- [6]Meza-González YA, Manzur-Barbur MC, Ochoa-Díaz AF, et al. Untangling Mechanical Complications of Acute Myocardial Infarction JACC Case Rep, 2025.PMID 40185591