Acute Coronary Syndrome (ACS) encompasses a spectrum of life-threatening conditions, including unstable angina, NSTEMI, and STEMI, all resulting from acute myocardial ischemia. Prompt recognition, accurate diagnosis, and rapid, evidence-based management are critical to improving patient outcomes by limiting infarct size, preserving cardiac function, and preventing recurrent ischemic events. For PharmD students, a thorough understanding of the multifaceted management strategies for ACS—from initial emergency care and risk stratification to reperfusion therapies, antiplatelet/anticoagulant regimens, and long-term secondary prevention—is paramount for effective interprofessional collaboration and optimizing pharmacotherapy. This MCQ quiz will test your knowledge on the comprehensive management of patients presenting with Acute Coronary Syndrome.
1. Acute Coronary Syndrome (ACS) typically results from:
- A. Gradual progression of stable angina
- B. Rupture or erosion of an atherosclerotic plaque followed by intracoronary thrombus formation
- C. Severe, uncontrolled hypertension leading to aortic dissection
- D. Congenital abnormalities of the coronary arteries
Answer: B. Rupture or erosion of an atherosclerotic plaque followed by intracoronary thrombus formation
2. Which of the following is a key diagnostic tool used to differentiate between STEMI, NSTEMI, and Unstable Angina in the initial assessment of a patient with suspected ACS?
- A. Chest X-ray
- B. Echocardiogram
- C. 12-lead Electrocardiogram (ECG) and cardiac troponin levels
- D. Serum lipid panel
Answer: C. 12-lead Electrocardiogram (ECG) and cardiac troponin levels
3. ST-segment elevation on the ECG in a patient with ischemic chest pain is most characteristic of:
- A. Unstable Angina (UA)
- B. Non-ST-segment Elevation Myocardial Infarction (NSTEMI)
- C. ST-segment Elevation Myocardial Infarction (STEMI)
- D. Stable angina
Answer: C. ST-segment Elevation Myocardial Infarction (STEMI)
4. Elevated cardiac troponin levels (I or T) indicate:
- A. Only severe myocardial ischemia without necrosis
- B. Myocardial necrosis (infarction), and are seen in both NSTEMI and STEMI
- C. A high risk of developing atherosclerosis
- D. The presence of stable coronary artery disease
Answer: B. Myocardial necrosis (infarction), and are seen in both NSTEMI and STEMI
5. Initial management of a patient with suspected ACS often includes the “MONA” mnemonic components (though not all are always given or in this order). Morphine is primarily administered for:
- A. Its antiplatelet effects
- B. Relief of severe chest pain unresponsive to nitrates, and for anxiolysis/venodilation
- C. Lowering blood glucose
- D. Its fibrinolytic properties
Answer: B. Relief of severe chest pain unresponsive to nitrates, and for anxiolysis/venodilation
6. What is the recommended initial dose of non-enteric coated aspirin for a patient with suspected ACS?
- A. 81 mg chewed
- B. 162-325 mg chewed
- C. 500 mg intravenously
- D. Aspirin is contraindicated in ACS
Answer: B. 162-325 mg chewed
7. Nitroglycerin is administered in ACS for its ability to:
- A. Increase myocardial contractility
- B. Dilate coronary arteries and reduce myocardial preload through venodilation, alleviating ischemic pain
- C. Irreversibly inhibit platelet aggregation
- D. Stabilize atherosclerotic plaques
Answer: B. Dilate coronary arteries and reduce myocardial preload through venodilation, alleviating ischemic pain
8. The primary goal of reperfusion therapy in STEMI is to:
- A. Relieve chest pain only
- B. Restore blood flow to the infarct-related artery as quickly as possible to salvage viable myocardium
- C. Prevent arrhythmias
- D. Lower LDL cholesterol
Answer: B. Restore blood flow to the infarct-related artery as quickly as possible to salvage viable myocardium
9. Which reperfusion strategy is generally preferred for STEMI if it can be performed in a timely fashion (e.g., door-to-balloon time <90-120 minutes)?
- A. Fibrinolytic therapy
- B. Primary Percutaneous Coronary Intervention (PCI)
- C. Urgent Coronary Artery Bypass Graft (CABG) surgery
- D. Intensive anticoagulation alone
Answer: B. Primary Percutaneous Coronary Intervention (PCI)
10. Dual Antiplatelet Therapy (DAPT) in ACS typically involves aspirin plus which other class of antiplatelet agent?
- A. A phosphodiesterase inhibitor (e.g., cilostazol)
- B. A P2Y12 receptor inhibitor (e.g., clopidogrel, prasugrel, ticagrelor)
- C. A Vitamin K antagonist (e.g., warfarin)
- D. A direct thrombin inhibitor (e.g., bivalirudin)
Answer: B. A P2Y12 receptor inhibitor (e.g., clopidogrel, prasugrel, ticagrelor)
11. In patients with NSTE-ACS, an “early invasive strategy” (angiography with intent to revascularize) is generally preferred for patients who are:
- A. At very low risk with no recurrent symptoms.
- B. At high ischemic risk (e.g., elevated troponins, dynamic ST changes, high GRACE/TIMI score).
- C. Presenting with STEMI.
- D. Allergic to aspirin.
Answer: B. At high ischemic risk (e.g., elevated troponins, dynamic ST changes, high GRACE/TIMI score).
12. Which anticoagulant is commonly used for NSTE-ACS, particularly if an invasive strategy is planned, and offers predictable pharmacokinetics without routine monitoring?
- A. Warfarin
- B. Unfractionated Heparin (UFH) infusion
- C. Enoxaparin (a Low-Molecular-Weight Heparin)
- D. Dabigatran
Answer: C. Enoxaparin (a Low-Molecular-Weight Heparin)
13. Beta-blockers should generally be initiated within 24 hours in ACS patients (if no contraindications) because they:
- A. Increase myocardial oxygen supply significantly.
- B. Reduce myocardial oxygen demand, decrease arrhythmias, and may limit infarct size/improve long-term survival.
- C. Have potent fibrinolytic effects.
- D. Are the primary treatment for pain.
Answer: B. Reduce myocardial oxygen demand, decrease arrhythmias, and may limit infarct size/improve long-term survival.
14. High-intensity statin therapy should be initiated or continued in all patients with ACS, regardless of baseline LDL-C levels, because statins:
- A. Only lower LDL-C and have no other benefits.
- B. Provide plaque stabilization, anti-inflammatory effects, and improve endothelial function, in addition to LDL-C lowering.
- C. Primarily act as antiplatelet agents in ACS.
- D. Dissolve existing coronary thrombi.
Answer: B. Provide plaque stabilization, anti-inflammatory effects, and improve endothelial function, in addition to LDL-C lowering.
15. ACE inhibitors (or ARBs if ACEI intolerant) are recommended post-ACS, especially in patients with:
- A. Normal left ventricular function and no other comorbidities.
- B. Left ventricular ejection fraction (LVEF) ≤ 40%, hypertension, diabetes, or chronic kidney disease.
- C. A high bleeding risk.
- D. Severe bradycardia.
Answer: B. Left ventricular ejection fraction (LVEF) ≤ 40%, hypertension, diabetes, or chronic kidney disease.
16. The GRACE risk score is used in ACS to estimate:
- A. The likelihood of successful PCI.
- B. The risk of in-hospital and post-discharge mortality.
- C. The optimal duration of DAPT.
- D. The degree of coronary artery stenosis.
Answer: B. The risk of in-hospital and post-discharge mortality.
17. For STEMI patients receiving fibrinolytic therapy, which anticoagulant is often co-administered to prevent re-thrombosis?
- A. Warfarin initiated concurrently.
- B. Parenteral anticoagulation (e.g., UFH, enoxaparin, or fondaparinux) for at least 48 hours or until revascularization.
- C. No anticoagulant is needed with fibrinolytics.
- D. Aspirin monotherapy is sufficient.
Answer: B. Parenteral anticoagulation (e.g., UFH, enoxaparin, or fondaparinux) for at least 48 hours or until revascularization.
18. Which P2Y12 inhibitor is generally NOT recommended for patients with a history of stroke or TIA due to an increased risk of intracranial hemorrhage?
- A. Clopidogrel
- B. Ticagrelor
- C. Prasugrel
- D. Cangrelor
Answer: C. Prasugrel
19. Glycoprotein IIb/IIIa inhibitors are potent antiplatelet agents typically used in ACS:
- A. As routine oral therapy for all ACS patients.
- B. In high-risk patients undergoing PCI, particularly those with large thrombus burden or inadequate P2Y12 loading.
- C. For long-term secondary prevention.
- D. In patients with active bleeding.
Answer: B. In high-risk patients undergoing PCI, particularly those with large thrombus burden or inadequate P2Y12 loading.
20. What is a key difference in the management approach between NSTEMI and Unstable Angina based on cardiac biomarkers?
- A. NSTEMI is managed with antiplatelets, while UA is not.
- B. Cardiac troponins are elevated in NSTEMI (indicating necrosis), but not in UA.
- C. Reperfusion therapy is always indicated for UA.
- D. Beta-blockers are contraindicated in NSTEMI but indicated in UA.
Answer: B. Cardiac troponins are elevated in NSTEMI (indicating necrosis), but not in UA.
21. The recommended “door-to-balloon” time for primary PCI in STEMI patients is ideally within:
- A. 6 hours
- B. 3 hours
- C. 90 minutes (at a PCI-capable hospital) or 120 minutes (if transfer needed)
- D. 24 hours
Answer: C. 90 minutes (at a PCI-capable hospital) or 120 minutes (if transfer needed)
22. If a patient with STEMI presents to a non-PCI capable hospital and cannot be transferred to a PCI-capable hospital within 120 minutes, what is the recommended reperfusion strategy?
- A. Administer fibrinolytic therapy (if no contraindications) within 30 minutes of arrival (“door-to-needle” time).
- B. Wait for transfer regardless of the delay.
- C. Initiate DAPT and anticoagulation and observe.
- D. Perform emergency CABG surgery at the non-PCI hospital.
Answer: A. Administer fibrinolytic therapy (if no contraindications) within 30 minutes of arrival (“door-to-needle” time).
23. Aldosterone antagonists (e.g., spironolactone, eplerenone) are recommended post-MI in patients who:
- A. Have normal LVEF and no other risk factors.
- B. Have LVEF ≤ 40% AND either symptomatic heart failure or diabetes mellitus, provided no hyperkalemia or significant renal dysfunction.
- C. Are intolerant to beta-blockers.
- D. Have a high risk of bleeding.
Answer: B. Have LVEF ≤ 40% AND either symptomatic heart failure or diabetes mellitus, provided no hyperkalemia or significant renal dysfunction.
24. Long-term secondary prevention after ACS includes all of the following lifestyle modifications EXCEPT:
- A. Smoking cessation
- B. Regular physical activity
- C. A diet high in saturated and trans fats
- D. Weight management
Answer: C. A diet high in saturated and trans fats
25. Which statement is TRUE regarding the use of fondaparinux in ACS?
- A. It is the preferred anticoagulant for all STEMI patients undergoing primary PCI.
- B. It has been associated with an increased risk of catheter thrombosis if used as sole anticoagulant during PCI.
- C. It requires routine aPTT monitoring.
- D. It is administered orally.
Answer: B. It has been associated with an increased risk of catheter thrombosis if used as sole anticoagulant during PCI.
26. A patient with NSTE-ACS is managed with an ischemia-guided (conservative) strategy. This means:
- A. They will receive immediate coronary angiography and PCI.
- B. They will be managed with medical therapy (antiplatelets, anticoagulants, anti-ischemics), and angiography is reserved for recurrent ischemia or positive stress test.
- C. Fibrinolytic therapy is the primary treatment.
- D. No antithrombotic therapy is required.
Answer: B. They will be managed with medical therapy (antiplatelets, anticoagulants, anti-ischemics), and angiography is reserved for recurrent ischemia or positive stress test.
27. Which of the following is a contraindication to beta-blocker therapy in the acute phase of ACS?
- A. Sinus tachycardia
- B. Hypertension
- C. Signs of acute heart failure/cardiogenic shock or severe bradycardia
- D. History of prior MI
Answer: C. Signs of acute heart failure/cardiogenic shock or severe bradycardia
28. The choice of P2Y12 inhibitor (clopidogrel vs. ticagrelor vs. prasugrel) in ACS management depends on:
- A. Patient’s hair color
- B. Clinical presentation (STEMI vs. NSTE-ACS), planned strategy (invasive vs. conservative), patient characteristics (age, weight, bleeding risk, history of stroke/TIA), and local guidelines.
- C. Cost alone.
- D. Availability of genetic testing results for all patients.
Answer: B. Clinical presentation (STEMI vs. NSTE-ACS), planned strategy (invasive vs. conservative), patient characteristics (age, weight, bleeding risk, history of stroke/TIA), and local guidelines.
29. What is the primary role of oxygen therapy in the initial management of ACS?
- A. To be administered to all patients regardless of oxygen saturation.
- B. To correct hypoxemia (e.g., SaO2 < 90%) and alleviate ischemia related to it.
- C. To act as an antiplatelet agent.
- D. To reduce blood pressure.
Answer: B. To correct hypoxemia (e.g., SaO2 < 90%) and alleviate ischemia related to it.
30. Why are nitrates contraindicated in ACS patients with suspected right ventricular infarction or severe aortic stenosis?
- A. They cause severe hypertension in these patients.
- B. They can cause profound hypotension due to preload dependency (RV infarct) or fixed outflow obstruction (AS).
- C. They increase myocardial oxygen demand excessively.
- D. They interact negatively with aspirin.
Answer: B. They can cause profound hypotension due to preload dependency (RV infarct) or fixed outflow obstruction (AS).
31. The typical duration of parenteral anticoagulation in NSTE-ACS patients managed with an ischemia-guided strategy is:
- A. For 1 hour only.
- B. For the duration of hospitalization or until PCI is performed (if planned), often for at least 48 hours.
- C. Indefinitely.
- D. Not indicated.
Answer: B. For the duration of hospitalization or until PCI is performed (if planned), often for at least 48 hours.
32. After fibrinolytic therapy for STEMI, if there is evidence of failed reperfusion, what is the recommended next step?
- A. Administer a second dose of the fibrinolytic.
- B. Arrange for urgent/rescue PCI.
- C. Switch to oral anticoagulation immediately.
- D. Observe and manage medically only.
Answer: B. Arrange for urgent/rescue PCI.
33. Which of the following is a component of the TIMI (Thrombolysis In Myocardial Infarction) risk score for NSTE-ACS?
- A. Presence of left bundle branch block
- B. Age ≥ 65 years, ≥ 3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation, ≥2 anginal events in prior 24h, aspirin use in prior 7 days, elevated cardiac markers.
- C. Blood glucose level at presentation
- D. Ejection fraction < 30%
Answer: B. Age ≥ 65 years, ≥ 3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation, ≥2 anginal events in prior 24h, aspirin use in prior 7 days, elevated cardiac markers.
34. Long-term management after ACS aims to modify risk factors. This includes achieving target levels for:
- A. Only blood pressure
- B. Blood pressure, LDL-C, and glycemic control (in diabetics)
- C. Only LDL-C
- D. Only body weight
Answer: B. Blood pressure, LDL-C, and glycemic control (in diabetics)
35. If a patient experiences recurrent ischemic chest pain despite optimal medical therapy after ACS, what is often considered?
- A. Discontinuation of all medications
- B. Repeat coronary angiography with possible revascularization (PCI or CABG)
- C. Increase in aspirin dose only
- D. Long-term oxygen therapy
Answer: B. Repeat coronary angiography with possible revascularization (PCI or CABG)
36. What is the role of cardiac rehabilitation programs in post-ACS management?
- A. To primarily provide vocational training.
- B. To provide supervised exercise, education on risk factor modification, and psychosocial support.
- C. To administer anticoagulation therapy.
- D. To perform routine ECG monitoring only.
Answer: B. To provide supervised exercise, education on risk factor modification, and psychosocial support.
37. In the management of ACS, when is bivalirudin (a direct thrombin inhibitor) most commonly used as an anticoagulant?
- A. For long-term oral therapy post-discharge.
- B. As an alternative to UFH/LMWH during PCI, particularly if there’s a high risk of HIT or bleeding.
- C. For all patients with unstable angina managed conservatively.
- D. In combination with fibrinolytic therapy.
Answer: B. As an alternative to UFH/LMWH during PCI, particularly if there’s a high risk of HIT or bleeding.
38. Patients presenting with cocaine-associated chest pain and ST elevation should initially be managed with:
- A. Beta-blockers as first-line therapy
- B. Benzodiazepines and nitrates; beta-blockers should be used with caution or avoided due to risk of unopposed alpha-stimulation.
- C. Immediate fibrinolysis without angiography
- D. High-dose aspirin only
Answer: B. Benzodiazepines and nitrates; beta-blockers should be used with caution or avoided due to risk of unopposed alpha-stimulation.
39. The transition from parenteral anticoagulation to oral anticoagulation (if indicated long-term, e.g., for AFib) after ACS requires careful consideration of:
- A. Only the patient’s preference for oral medication.
- B. Overlap of therapy if using warfarin, appropriate timing, and risk of bleeding with concomitant DAPT.
- C. The color of the oral anticoagulant.
- D. Discontinuing all parenteral anticoagulants 24 hours before starting oral.
Answer: B. Overlap of therapy if using warfarin, appropriate timing, and risk of bleeding with concomitant DAPT.
40. Which of the following is a common mechanical complication of acute MI?
- A. Atrial fibrillation
- B. Ventricular septal rupture or papillary muscle rupture
- C. Pericarditis
- D. Deep vein thrombosis
Answer: B. Ventricular septal rupture or papillary muscle rupture
41. For how long is aspirin typically continued after an ACS event, unless contraindicated?
- A. For 1 month
- B. For 1 year
- C. Indefinitely
- D. For 3 months
Answer: C. Indefinitely
42. The decision to use a proton pump inhibitor (PPI) in ACS patients on DAPT is typically based on:
- A. Routine use for all patients to prevent dyspepsia.
- B. The patient’s risk of gastrointestinal bleeding (e.g., history of GI bleed, advanced age, concomitant warfarin/steroids/NSAIDs).
- C. The type of P2Y12 inhibitor used.
- D. The patient’s LDL-C level.
Answer: B. The patient’s risk of gastrointestinal bleeding (e.g., history of GI bleed, advanced age, concomitant warfarin/steroids/NSAIDs).
43. In NSTE-ACS, if an ischemia-guided strategy is chosen, and the patient remains symptom-free with no high-risk features, what is often done before hospital discharge?
- A. All medications are discontinued.
- B. A stress test (pharmacological or exercise) is performed to assess for inducible ischemia.
- C. Immediate CABG surgery.
- D. Lifelong oxygen therapy is initiated.
Answer: B. A stress test (pharmacological or exercise) is performed to assess for inducible ischemia.
44. What is the “time zero” for calculating door-to-balloon time in STEMI?
- A. Time of symptom onset
- B. Time of arrival at the emergency department (first medical contact if EMS, or hospital arrival)
- C. Time of troponin result
- D. Time of cardiologist consultation
Answer: B. Time of arrival at the emergency department (first medical contact if EMS, or hospital arrival)
45. Which of the following antiplatelet loading dose regimens is appropriate for a patient with NSTE-ACS planned for an invasive strategy?
- A. Aspirin 81 mg PO only
- B. Aspirin 162-325 mg PO plus a P2Y12 inhibitor (e.g., clopidogrel 300-600 mg, or ticagrelor 180 mg)
- C. Clopidogrel 75 mg PO only
- D. No antiplatelet therapy is needed if anticoagulation is given.
Answer: B. Aspirin 162-325 mg PO plus a P2Y12 inhibitor (e.g., clopidogrel 300-600 mg, or ticagrelor 180 mg)
46. Management of pain in ACS should prioritize nitrates. If pain persists despite nitrates, morphine can be used. However, morphine use has been associated with:
- A. Increased efficacy of P2Y12 inhibitors.
- B. Potential for delayed absorption and reduced antiplatelet effect of oral P2Y12 inhibitors.
- C. A reduction in infarct size in all patients.
- D. No significant drug interactions.
Answer: B. Potential for delayed absorption and reduced antiplatelet effect of oral P2Y12 inhibitors.
47. A patient presenting with chest pain, ST depressions in leads V1-V3, and tall R waves in these leads may be having a:
- A. Right ventricular infarction
- B. Posterior wall STEMI (requiring posterior leads for confirmation of ST elevation)
- C. Pericarditis
- D. Pulmonary embolism
Answer: B. Posterior wall STEMI (requiring posterior leads for confirmation of ST elevation)
48. The pharmacist’s role in managing ACS patients upon discharge includes:
- A. Recommending discontinuation of all cardiac medications.
- B. Counseling on medication adherence, proper use, potential side effects, and importance of lifestyle changes.
- C. Scheduling the follow-up PCI.
- D. Advising against cardiac rehabilitation.
Answer: B. Counseling on medication adherence, proper use, potential side effects, and importance of lifestyle changes.
49. Which of the following is a key component of the initial stabilization for a patient presenting with ACS symptoms in the emergency department?
- A. Immediate administration of a beta-agonist
- B. Continuous ECG monitoring
- C. Withholding aspirin until a definitive diagnosis is made
- D. Encouraging strenuous physical activity
Answer: B. Continuous ECG monitoring
50. In patients with ACS and renal dysfunction, dosing adjustments are particularly important for which medications?
- A. Aspirin
- B. Nitroglycerin
- C. Many anticoagulants (e.g., enoxaparin, fondaparinux, bivalirudin, some DOACs) and some P2Y12 inhibitors (though less commonly for P2Y12s unless severe).
- D. Statins
Answer: C. Many anticoagulants (e.g., enoxaparin, fondaparinux, bivalirudin, some DOACs) and some P2Y12 inhibitors (though less commonly for P2Y12s unless severe).