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Chapter 42: Percutaneous Coronary Interventions in Acute Myocardial Infarction and Acute Coronary Syndromes

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Which of the following is not an advantage of primary percutaneous coronary intervention (PCI) over fibrinolytic therapy for ST-segment elevation myocardial infarction (STEMI)?

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A. Primary PCI is associated with a reduced incidence of intracranial hemorrhage

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B. Primary PCI is superior in reducing short-term mortality

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C. Primary PCI has a lower overall risk of major bleeding

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D. Primary PCI is associated with fewer nonfatal reinfarctions

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E. All of the above are correct

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The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 42) Over the past 40 years, improvements in the design and development of highly effective antithrombotic and antiplatelet therapy have made PCI a widely used revascularization strategy. This technique gained particular success as it became apparent that a severe residual stenosis persisted in most patients after successful fibrinolysis treatment. A meta-analysis of 23 randomized trials incorporating 7739 patients compared primary PCI with fibrinolytic therapy for STEMI.1 Primary PCI was superior to fibrinolytic therapy in reducing short-term mortality (option B), nonfatal reinfarction (option D), stroke, and the composite end point of death, nonfatal reinfarction, and stroke. These results were maintained at long-term follow-up and were independent of the type of thrombolytic agent used (streptokinase vs fibrin-specific thrombolytics) and whether patients were directly admitted or transferred emergently for primary PCI. The incidence of intracranial hemorrhage was significantly less with primary PCI (option A), although the overall risk of major bleeding (mostly related to access site bleeding) was not lower with primary PCI (option C).

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A 58-year-old man begins to experience chest pain that radiates to his left arm while jogging. He initially dismisses the symptoms and is admitted to the emergency department 6 hours later with an anterior myocardial infarction (MI) confirmed by ECG. Which of the following may be associated with smaller infarct size?

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A. TIMI grade 1 flow in the infarct artery

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B. Remote ischemic conditioning

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C. Anterior MI location

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D. Reperfusion with PCI at 6 hours

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E. None of the above

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The answer is B. (Hurst’s The Heart, 14th Edition, Chap. 42) Once consensus was reached that primary PCI is the superior reperfusion modality, attention turned to limiting infarction size. The last decade has seen many pharmacologic and mechanical strategies to limit infarct size, which are summarized in Table 42-1. Achieving TIMI grade 3 flow has a major impact on short- and long-term mortality. Indeed, ...

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