ACS MCQs (NEET-SS / DM Cardiology level)
ACS MCQs (NEET-SS / DM Cardiology level)
1. In a patient with chest pain of 90 minutes’ duration and persistent ST-elevation on ECG, the next best step is:
STEMI with ongoing ischemia requires immediate reperfusion—primary PCI is preferred when timely.
2. Which of the following is an absolute contraindication to fibrinolysis?
Prior ICH is an absolute contraindication to thrombolysis due to high risk of catastrophic bleeding.
3. Door-to-balloon time target recommended for primary PCI is:
Guidelines recommend door-to-balloon within 90 minutes to improve outcomes.
4. A 68-year-old with inferior STEMI is hypotensive. Which statement is correct regarding nitrates?
Right ventricular infarction produces preload dependence—nitrates can precipitate severe hypotension and should be avoided.
5. Which P2Y12 inhibitor showed mortality benefit over clopidogrel in ACS patients undergoing invasive strategy?
Ticagrelor demonstrated reduced mortality vs clopidogrel in the PLATO trial in ACS patients.
6. After successful fibrinolysis for STEMI, the recommended timing for coronary angiography (pharmaco-invasive strategy) is:
A routine early angiography (3–24 h) after successful lysis optimizes outcomes by identifying residual lesions amenable to PCI.
7. A patient with NSTEMI should be risk-stratified using GRACE score primarily to determine:
GRACE score predicts mortality and helps decide early (≤24 h) vs delayed invasive strategy in NSTEMI.
8. Which anticoagulant is preferred during PCI in a patient at high bleeding risk?
Bivalirudin reduces procedural bleeding in some settings and is considered when bleeding risk is high.
9. Which ECG finding suggests posterior wall MI when anterior leads are non-diagnostic?
Posterior MI often shows ST depression with tall R waves in V1–V3—reciprocal changes to posterior ST elevation.
10. In ACS, high-intensity statin therapy (atorvastatin 80 mg) should be started:
High-intensity statin therapy begun early reduces recurrent ischemic events after ACS.
11. Which statement about primary PCI vs fibrinolysis is correct?
Primary PCI provides better patency and lower mortality than fibrinolysis when performed rapidly.
12. A patient has chest pain and an ECG showing diffuse PR depression with ST elevation in most leads—this is most consistent with:
Diffuse ST elevation with PR depression is classical for pericarditis, not localized STEMI changes.
13. Which of the following increases mortality if given routinely in uncomplicated STEMI?
Routine morphine is not recommended for all—use for refractory severe pain; it may delay P2Y12 absorption and has mixed outcome data.
14. The best initial test to assess left ventricular function at bedside after MI is:
Echocardiography is the initial, bedside tool for EF assessment and detection of mechanical complications.
15. Which drug combination should be used cautiously (higher bleeding) in a patient requiring triple therapy (AF + recent PCI)?
Concurrent DOAC with DAPT markedly increases bleeding; strategies favor minimizing duration of triple therapy and using single antiplatelet with DOAC when appropriate.
16. In a patient with cardiogenic shock complicating STEMI, which is recommended as initial mechanical support when available?
Mechanical circulatory support (Impella/VA-ECMO) may be considered for refractory shock as bridge to revascularization or recovery; IABP is no longer routine.
17. In the setting of NSTEMI, which is the least appropriate?
Fibrinolysis is not indicated in NSTEMI; management is guided by risk stratification and timing of invasive strategy.
18. Which lesion is an indication for urgent CABG rather than PCI in ACS?
Left main disease with multivessel involvement generally favors CABG for survival benefit, depending on SYNTAX score and surgical risk.
19. A patient with chest pain has a normal ECG but rising troponin—this is classified as:
Elevated cardiac biomarkers with no ST elevation classify as NSTEMI (subendocardial myocardial infarction).
20. Which antiplatelet agent is contraindicated in patients with prior stroke/TIA?
Prasugrel increases intracranial bleeding risk and is contraindicated in prior stroke/TIA.
21. Post-PCI, when is it reasonable to consider de-escalation from ticagrelor to clopidogrel in ACS?
Guided de-escalation (genotype or platelet function testing) may be used to switch to clopidogrel in high bleeding risk patients.
22. Which of the following is the most common mechanical complication 3–5 days after transmural MI?
Papillary muscle rupture causing acute severe MR often occurs within days after MI; free wall rupture commonly causes sudden death around the same period but pap muscle rupture is a well-known early mechanical complication.
23. In a STEMI patient receiving tenecteplase, which anticoagulant is preferred during and after thrombolysis?
Enoxaparin has evidence of efficacy and is commonly used adjunctively with fibrinolysis unless contraindicated.
24. Which is true regarding high-sensitivity troponin (hs-cTn) testing in suspected ACS?
High-sensitivity assays permit accelerated diagnostic pathways (0/1h or 0/3h) to rule in/out MI when combined with clinical assessment.
25. Which strategy reduces early recurrent ischemic events after PCI for ACS:
Evidence supports staged or in-hospital complete revascularization in selected patients with multivessel disease to reduce events.
26. A 55-year-old with anterior STEMI is in cardiogenic shock; coronary anatomy shows left main occlusion. Best immediate step is:
Left main occlusion in shock mandates urgent revascularization; choice between PCI and CABG depends on anatomy and surgical risk.
27. For acute ST-elevation MI, tenecteplase is preferred over alteplase because:
Tenecteplase is bolus-administered (weight-based), facilitating rapid administration in pre-hospital or non-PCI settings.
28. A patient with recurrent ventricular tachycardia 2 days after MI should be managed with:
Early VT after MI requires acute management; primary prevention ICD is normally deferred (~40 days) to allow recovery of EF.
29. Which of the following biomarkers is most specific for myocardial necrosis?
Cardiac troponins are the most specific and sensitive biomarkers for myocardial injury.
30. Which feature on ECG makes early reperfusion mandatory rather than conservative therapy?
Persistent ST elevation indicates transmural ischemia and is an indication for immediate reperfusion (STEMI).
31. Which of the following is the best management for no-reflow during PCI?
No-reflow is treated with intracoronary vasodilators, thrombectomy (if indicated), and supportive measures.
32. Which finding suggests successful reperfusion after fibrinolysis?
ST-segment resolution (>50%) within 60–90 minutes is a clinical indicator of reperfusion success after lysis.
33. In ACS with cardiogenic shock, which vasopressor is preferred as first-line to maintain perfusion?
Norepinephrine is recommended as first-line vasopressor in cardiogenic shock to maintain perfusion with fewer arrhythmias than dopamine.
34. The recommended duration of DAPT after ACS treated with drug-eluting stent is usually:
Guidelines recommend at least 12 months of DAPT after ACS unless bleeding risk mandates shorter duration.
35. Which of the following is a predictor of poor outcome after MI?
Hypotension and higher Killip class indicate hemodynamic compromise and predict worse prognosis.
36. Which of the following is most appropriate for antithrombotic therapy in a patient with NSTEMI scheduled for early PCI?
Fondaparinux needs UFH bolus during PCI to avoid catheter thrombosis; UFH is commonly used during the procedure.
37. Which feature is most suggestive of reinfarction while in hospital after an MI?
New ischemic symptoms with ECG changes and biomarker rise indicate reinfarction and prompt urgent evaluation.
38. Which of the following agents is recommended to reduce remodeling and mortality in patients with reduced EF after MI?
ACE inhibitors (or ARNI/ARB when indicated) reduce remodeling and improve survival in patients with LV dysfunction post-MI.
39. Which therapy is indicated for ST-elevation MI and is associated with chewed-loading immediately?
Early aspirin loading (chewed) reduces early thrombotic complications and should be given immediately in suspected ACS.
40. In a patient with suspected ACS and recent use of sildenafil, nitrates should be avoided for at least:
Sildenafil potentiates nitrates—contraindicated within 24 hours of PDE-5 inhibitor use due to severe hypotension risk.
41. Coronary artery embolism causing MI should prompt evaluation for which condition?
Cardioembolic MI warrants search for atrial fibrillation, left ventricular thrombus, or other embolic sources.
42. Which metric best identifies high bleeding risk when considering DAPT duration?
HAS-BLED and PRECISE-DAPT scores help quantify bleeding risk to individualize DAPT duration.
43. Which procedure is indicated for mechanical complication of MI such as papillary muscle rupture with severe MR?
Mechanical complications such as pap muscle rupture require urgent surgical correction.
44. Early invasive strategy in NSTEMI is most strongly indicated by which of the following?
Active ischemia (ongoing pain, dynamic ECG changes) indicates immediate/early invasive management.
45. Which of these is true regarding use of glycoprotein IIb/IIIa inhibitors in contemporary PCI for ACS?
GPIIb/IIIa inhibitors are now mainly used selectively for high thrombus burden or bailout; not routine for all PCI.
46. Which of the following is the recommended initial beta-blocker approach in uncomplicated STEMI?
Early oral beta-blockade is recommended unless there are contraindications like hypotension, shock, bradycardia, or acute HF.
47. Which ECG change is most characteristic of early transmural ischemia?
Localised ST elevation reflects transmural ischemia from coronary occlusion.
48. Which medication should be started in all patients with LVEF ≤ 40% after MI to improve outcomes?
ACE inhibitors (or ARNI where appropriate) reduce mortality and remodeling in systolic dysfunction post-MI.
49. Which complication is MOST likely to present with sudden hypotension and electromechanical dissociation post-MI?
Free wall rupture causes hemopericardium and tamponade, leading to sudden collapse and often electromechanical dissociation.
50. In primary PCI for a large thrombus burden, which adjunctive therapy may be considered?
Thrombectomy and bailout GPIIb/IIIa inhibitors can be used selectively for large thrombus burden, though routine thrombectomy is not universally recommended.
51. Which is true concerning reperfusion injury during MI?
Reperfusion can paradoxically cause additional myocyte injury mediated by oxidative stress, calcium overload, and inflammation.
52. For which subgroup is prasugrel specifically NOT recommended?
Prasugrel increases intracranial hemorrhage risk and is contraindicated in those with prior stroke/TIA.
53. Which imaging modality is most useful to detect left ventricular free-wall rupture if suspected?
Bedside echocardiography rapidly detects pericardial effusion/tamponade from free-wall rupture and guides emergent management.
54. Which factor is most determinant in choosing between PCI and CABG for multivessel disease after ACS?
SYNTAX score and comorbidities guide revascularization strategy; high SYNTAX favors CABG for complex disease.
55. A patient with ACS on dual antiplatelet therapy requires urgent non-cardiac surgery. Best immediate step is:
Urgent surgery requires individualized decisions balancing bleeding and ischemic risk; multidisciplinary planning and delaying surgery where feasible is preferred.
56. Which of the following best describes the Killip classification’s clinical use after MI?
Killip class (I–IV) assesses heart failure signs post-MI and correlates with prognosis, complementing risk scores.
57. Which antihyperglycemic class has demonstrated benefit in heart failure and may be considered post-ACS in patients with diabetes?
SGLT2 inhibitors reduce HF hospitalizations and are considered in diabetic patients with or at risk of heart failure post-ACS when appropriate.
58. Which laboratory abnormality increases bleeding risk and impacts antithrombotic choices post-ACS?
Severe renal impairment increases bleeding risk and affects dosing and selection of anticoagulants and some antiplatelet agents.
59. Which is the most appropriate discharge follow-up for medication and LV function assessment after MI?
Early clinical review (1–2 weeks) and reassessment of LV function after remodeling (6–12 weeks) guide ongoing therapy and device decisions.
60. Which is the single most effective immediate intervention to reduce mortality in acute STEMI?
Rapid reperfusion is the primary life-saving intervention in STEMI by restoring coronary perfusion and limiting infarct size.
