Acute coronary syndrome: diagnosis and drug management MCQs With Answer

Introduction: This MCQ set on Acute Coronary Syndrome: Diagnosis and Drug Management is designed for M.Pharm students studying Pharmacotherapeutics I (MPP 102T). It emphasizes clinical decision-making, diagnostic criteria, biomarker kinetics, reperfusion strategies, and pharmacology of antiplatelet, anticoagulant and thrombolytic therapies. Questions probe guideline-based targets, contraindications, drug mechanisms, interactions, dosing considerations and high-yield complications encountered in STEMI, NSTEMI and unstable angina. The aim is to deepen understanding beyond memorization, linking pathophysiology to rational drug selection, monitoring and safety — preparing students for both exams and clinical pharmacotherapy consultations in acute cardiac care.

Q1. Which biomarker is considered the most specific indicator of myocardial necrosis for diagnosing acute coronary syndrome?

• Creatine kinase-MB (CK-MB)
• Cardiac troponin I/T
• Myoglobin
• Lactate dehydrogenase (LDH)

Correct Answer: Cardiac troponin I/T

Q2. Which ECG criterion best defines an ST-elevation myocardial infarction (STEMI) in typical adult patients?

• ST elevation ≥0.5 mm in any single lead
• ST elevation ≥1 mm in two contiguous limb leads or ≥2 mm in V2–V3
• ST depression ≥1 mm in two contiguous leads
• Isolated T-wave inversion in precordial leads

Correct Answer: ST elevation ≥1 mm in two contiguous limb leads or ≥2 mm in V2–V3

Q3. Which item is NOT a component of the TIMI risk score for unstable angina/NSTEMI?

• Age ≥65 years
• Use of aspirin in preceding 7 days
• ≥3 traditional coronary risk factors
• Hemodynamic instability (cardiogenic shock)

Correct Answer: Hemodynamic instability (cardiogenic shock)

Q4. What is the recommended maximum door-to-balloon time for primary percutaneous coronary intervention (PCI) in STEMI?

• 30 minutes
• 60 minutes
• 90 minutes
• 120 minutes

Correct Answer: 90 minutes

Q5. Which of the following is an absolute contraindication to fibrinolytic therapy in ACS?

• Recent (within 2 weeks) minor surgery
• Uncontrolled hypertension with systolic BP >180 mmHg
• Pregnancy
• Prior intracranial hemorrhage

Correct Answer: Prior intracranial hemorrhage

Q6. Which oral P2Y12 receptor antagonist binds reversibly to the receptor?

• Clopidogrel
• Prasugrel
• Ticagrelor
• None of the above

Correct Answer: Ticagrelor

Q7. Concurrent administration of which class of drugs with fibrinolytic therapy markedly increases major bleeding risk?

• Low-dose aspirin alone
• Unfractionated heparin at therapeutic dose
• Glycoprotein IIb/IIIa inhibitors
• Oral beta-blockers

Correct Answer: Glycoprotein IIb/IIIa inhibitors

Q8. Which anticoagulant is often used as an alternative to heparin during PCI because it is a direct thrombin inhibitor and is associated with lower bleeding in some settings?

• Unfractionated heparin
• Enoxaparin
• Bivalirudin
• Fondaparinux

Correct Answer: Bivalirudin

Q9. Which of the following is an absolute contraindication to intravenous beta-blocker administration in the acute phase of ACS?

• History of well-controlled asthma
• Second- or third-degree atrioventricular block without a pacemaker
• Age over 75 years
• Prior myocardial infarction

Correct Answer: Second- or third-degree atrioventricular block without a pacemaker

Q10. Which statin strategy is recommended to initiate early after an acute coronary syndrome for plaque stabilization and LDL lowering?

• No statin until lipid panel after 6 weeks
• Low-intensity statin therapy
• Moderate-intensity statin therapy
• High-intensity statin therapy (e.g., atorvastatin 80 mg)

Correct Answer: High-intensity statin therapy (e.g., atorvastatin 80 mg)

Q11. Following placement of a drug-eluting stent for ACS, what is the standard recommended duration of dual antiplatelet therapy (DAPT) in patients without excessive bleeding risk?

• 3 months
• 6 months
• 12 months
• Indefinitely

Correct Answer: 12 months

Q12. What is the recommended pharmacologic reversal agent for excessive anticoagulation from unfractionated heparin?

• Vitamin K
• Protamine sulfate
• Idarucizumab
• Andexanet alfa

Correct Answer: Protamine sulfate

Q13. What is the primary mechanism of action of tissue plasminogen activators (e.g., alteplase, tenecteplase) used in thrombolysis for STEMI?

• Direct inhibition of factor Xa
• Conversion of plasminogen to plasmin, leading to fibrin clot degradation
• Antagonism of P2Y12 receptor on platelets
• Blocking glycoprotein IIb/IIIa receptor

Correct Answer: Conversion of plasminogen to plasmin, leading to fibrin clot degradation

Q14. Which antiplatelet agent is contraindicated in patients with a history of prior stroke or transient ischemic attack due to increased bleeding risk?

• Clopidogrel
• Prasugrel
• Ticagrelor
• Aspirin

Correct Answer: Prasugrel

Q15. Which statement about fondaparinux in acute coronary syndromes is correct?

• It is the preferred sole anticoagulant for primary PCI because it prevents catheter thrombosis
• It is a direct thrombin inhibitor
• Fondaparinux should not be used as the sole anticoagulant during PCI due to risk of catheter thrombosis
• It is contraindicated in patients with normal renal function

Correct Answer: Fondaparinux should not be used as the sole anticoagulant during PCI due to risk of catheter thrombosis

Q16. Regarding cardiac troponin kinetics after myocardial infarction, when does troponin typically become detectable in the blood?

• Within 30–60 minutes
• Approximately 3–4 hours after symptom onset
• 24–48 hours only
• After 5–7 days

Correct Answer: Approximately 3–4 hours after symptom onset

Q17. Glycoprotein IIb/IIIa inhibitors are most appropriately used in which ACS/PCI scenario?

• Routine long-term oral therapy after MI
• Bailout therapy during PCI for large thrombus burden or no-reflow
• Primary prevention in high LDL patients
• As a substitute for dual antiplatelet therapy after stenting

Correct Answer: Bailout therapy during PCI for large thrombus burden or no-reflow

Q18. Which commonly prescribed drug can reduce activation and antiplatelet effect of clopidogrel via CYP2C19 inhibition?

• Aspirin
• Omeprazole
• Atorvastatin
• Metoprolol

Correct Answer: Omeprazole

Q19. In cardiogenic shock complicating an acute myocardial infarction with persistent hypotension, which vasoactive agent is recommended as first-line to restore perfusion pressure?

• Dopamine
• Norepinephrine
• Dobutamine alone
• Epinephrine

Correct Answer: Norepinephrine

Q20. For long-term secondary prevention after an ACS, what LDL cholesterol target is generally recommended as a treatment goal for high-risk patients?

• LDL <130 mg/dL
• LDL <100 mg/dL
• LDL <70 mg/dL
• LDL <150 mg/dL

Correct Answer: LDL <70 mg/dL

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