Continuing Medical Education Post-Test Based on the information presented in this monograph, please choose one correct response for each of the following questions or statements. Record your answers on the answer sheet on page 89. To receive Category I credit, complete the post-test and record your responses on the answer sheet. Mail in the return envelope no later than February 1, 2008. A passing grade of 80% is needed to receive credit. A certificate will be sent to you upon your successful completion of this post-test. Management of non-st-segment Elevation Acute Coronary Syndrome (NSTE-ACS) in the ED: State-of-the-Art Anti-platelet Management 1. Which of the following anti-platelet drugs is indicated in the emergency department management of high risk NSTE-ACS? a) Clopidogrel b) Glycoprotein IIb/IIIa inhibitors c) Aspirin 2. Based on the ARMYDA-2 trial, what are the effects of increasing the loading dose of clopidogrel to 600 mg prior to PCI? a) Increase in bleeding complications b) Reduction in death, MI, and target vessel revascularization c) Increase in CABG related bleeding d) Reduction in bleeding complications. 3. According to the ISAR REACT-2 trial, which group of high risk NSTE-ACS patients received the most benefit from the addition of a GP IIb/IIIa inhibitor during PCI? a) Troponin negative patients b) Troponin positive patients c) ECG ST segment depression patients Non-ST-segment Elevation Acute Coronary Syndrome: Optimal Anti-Coagulant Therapy for the Emergency Department 5) For patients with NSTE ACS presenting to the ED, which of the following represent guideline-indicated therapy? a) Heparin b) Low molecular weight heparin c) Both A and B d) Neither A and B 6) Low molecular weight heparin is prepared through fractionation of the parent compound, heparin. 7) In the ESSENCE and TIMI IIB trials, enoxaparin reduced the composite end points of death, MI, or recurrent angina/need for urgent revascularization compare to heparin. 8) In the SYNERGY trial, which of the following patients experienced increased risk of bleeding? a) Elderly patients b) Patients with renal insufficency c) Patients experiencing switching between unfractionated heparin and enoxaparin 4. According to the ACUITY Timing trial results, which of the following patients received the most benefit in ischemic endpoint reduction with upstream GP IIb/IIIa inhibition? a) CABG patients b) Medical management patients c) PCI patients 81
CRUSADE Quality Improvement Initiative: Better Care for Patients with Unstable Angina and non- ST-segment Elevation Myocardial Infarction 9) The CRUSADE initiative includes the following types of patients: a) Only those with ST-segment elevation myocardial infarction. b) All chest pain patients admitted to the hospital c) Only chest pain patients admitted when a myocardial infarction d) Patients with a Non-ST-segment elevation myocardial infarction and ST-segment depression, as well as cardiac biomarker positivity. 10) The CRUSADE initiative has the following objectives: a) To determine compliance with AHA/ACC guidelines for the management of these patients in the acute setting and time of discharge b) To educate physicians about the AHA/ACC guidelines for NSTEMI ACS c) To provide quality improvement tools 11) The CRUSADE initiative has been used to evaluate the following subjects except: a) Disparities in care based on gender b) Direct comparison of pharmacologic agents in a prospective, randomized fashion c) Cardiac biomarker discrepancies d) Disparities in care based on race ST-segment Elevation Myocardial Infarction (STEMI): Decreasing the Time to Treatment in the ED 12) For patients presenting to the emergency department with STEMI, the ideal maximum door-to-needle time for infusion of fibrinolytic therapy is 30 minutes while the maximum door-to-balloon inflation time for percutaneous coronary intervention (PCI) is 90 minutes. 13) Myocardial muscle salvage for patients with STEMI, based on trials of fibrinolytic therapy, occurs up to the following time after symptom onset: a) 4 hours d) 16 hours b) 8 hours e) 20 hours c) 12 hours 14) Based on National Registry of Myocardial Infarction data for patients undergoing PCI for STEMI from 1994 through 1998, the advantage for mechanical intervention decreases substantially how many minutes after presentation to the ED: a) 30 minutes c) 90 minutes b) 60 minutes d) 120 minutes 15) For patients being transferred from one hospital to another hospital for PCI, what percentage of patients typically receive a door-to-balloon time of 90 minutes or less at the receiving hospital? a) 5% d) 20% b) 10% e) 30% c) 15% 16) In the D2B program instituted by the American College of Cardiology in November 2006, emergency physicians are responsible for activating the cardiac catheterization team to decrease the doorto-balloon time for patients presenting with STEMI. Novel Anti-thrombotic Therapies for Acute Coronary Syndrome: Direct Thrombin Inhibitors 17) New landmark studies in patients with acute coronary syndromes have focused on which of the following in the primary outcome: a) Death b) Acute myocardial infarction c) Urgent revascularization d) Bleeding complications e) All of the above including both efficacy and safety parameters f) 1, 2, 3 as the efficacy parameters 82
18) Bivalirudin monotherapy was associated with reduction in ischemic endpoints 19) Use of glycoprotein IIb/IIIa receptor antagonists was associated with an increase in bleeding endpoints, whether it was used with heparin or bivalirudin 20) Bivalirudin monotherapy (without concurrent glycoprotein 2b/3a receptor antagonists) was associated with reduction in bleeding endpoints, as well as an improvement in net clinical benefit. Management of ST-segment Elevation Myocardial Infarction in the ED: State-of-the-Art Anti-platelet and Anti-thrombotic Therapy 21) Which of the following anti-platelet drugs is NOT presently recommended by the ACC/ AHA Guidelines for the emergency department management of STEMI? a) Clopidogrel b) Glycoprotein IIb/IIIa inhibitors c) Aspirin d) None of the above 22) Based on the CLARITY trial, what are the effects of adding clopidogrel 300 mg to aspirin and fibrinolytic therapy in the ED treatment of STEMI? a) Increase in intracranial hemorrhage b) Reduction in death, MI, and occluded artery at angiogram c) Increase in PCI-related mortality d) Reduction in bleeding complications. 23) According to the ASSENT-4 Trial, the routine utilization of fibrinolytic therapy prior to immediate primary PCI results in: a) Increased intracerebral complications b) Increased mortality c) Worse ischemic outcomes 24) According to the TITAN TIMI-34 trial, utilization of GPI s for facilitated primary PCI results in: a) Increase angiographic reperfusion at angiogram b) Increased tissue perfusion at angiogram c) No significant increase in bleeding Acute Decompensated Heart Failure: Novel Approaches to Classification and treatment 25) When used for ADHF, IV nitroglycerin provides the following: a) Reduces mortality b) Improves symptoms of congestion c) Neither d) Both 26) All patients with ADHF should receive IV vasoldilators and IV diuretics: 27) Most patients with acute flash pulmonary edema have: a) Diastolic dysfuction b) Systolic dysfuction c) Severe hypertension d) Hypotension e) a and c f) b and d 28) The majority of ADHF patients require admission to the ICU: Lactate - A Marker for Sepsis and Trauma 29) Lactate is a product of anaerobic metabolism. 30) Seizures can cause a transient elevation in serum lactate. 83
31) Stable or increasing serum lactate levels are associated with improved mortality in septic patients. 32) Lactate is cleared by the liver, kidney, brain, and red blood cells. Point-of-Care Testing for Cardiac Biomarkers in the ED: Blueprint for Implementation 33) Factors which have increased the growth of pointof-care (POC) testing for cardiac biomarkers in the United States include all of the following except: a) Large volume of patients presenting to emergency departments each year causing overcrowding. b) Guidelines for non-st-segment elevation acute coronary syndrome published in 2002. c) The low cost of the POC test compared to the central laboratory assay. d) Decreased complexity of performing the POC test compared to using an assay performed on a central laboratory analyzer. 34) Cardiac biomarkers which are commonly used for POC testing in the emergency department include all of the following except: a) Myosin heavy chain b) Myoglobin c) CK-MB d) Troponin e) BNP (brain natriuretic peptide) 35) POC testing for cardiac biomarkers in the emergency department can be used for risk stratification and to identify patients with ACS for treatment with antithrombotic and anti-platelet agents 36) From the laboratory perspective, usual turn-around time (TAT) for cardiac biomarker testing includes pre-analytical time which occurs in the emergency department and the actual analysis of the specimen and reporting of the results back to the emergency physician. 37) Stakeholders for the implementation of a POC testing program in an emergency department should include: a) Laboratorians b) Clinicians c) Hospital administrators Advances in Acute Stroke Care 38) CT perfusion is designed to show areas of: a) ischemia b) infarction c) both d) neither 39) MRA and CTA are both capable of documenting proximal cerebral vessel occlusion. 40) Intra-arterial mechanical embolectomy devices have been shown to: a) Improve rate of recanalization b) Improve mortality c) Improve long-term outcomes 41) Recombinant Factor VIIa has been shown to: a) Decrease hemorrhage volume b) Improve mortality c) Improve long-term outcomes 84
ACEP 2006 Scientific Assembly EMCREG Symposia Continuing Medical Education Post-Test Answer Form and Evaluation After you have read the monograph, carefully record your answers by circling the appropriate letter for each question and complete the evaluation questionnaire. Mail the answer sheet to: Office of Continuing Medical Education University of Cincinnati College of Medicine PO Box 670567 Cincinnati OH 45267-0567 CME expiration date February 1, 2008. 1. a b c d 2. a b c d 3. a b c d 4. a b c d 5. a b c d 6. a b 7. a b 8. a b c d 9. a b c d 10. a b c d 11. a b c d 22. a b c d 23. a b c d 24. a b c d 25. a b c d 26. a b 27. a b c d e f 28. a b 29. a b 30. a b 31. a b 32. a b EVALUATION QUESTIONNAIRE On a scale of 1 to 5, with 1 being highly satisfied and 5 being highly dissatisfied, please rate this program with respect to: Highly satisfied Highly dissatisfied Overall quality of material: 1 2 3 4 5 Content of monograph: 1 2 3 4 5 Other similar CME programs: 1 2 3 4 5 How well course objectives were met: 1 2 3 4 5 What topics would be of interest to you for future CME programs? Was there commercial or promotional bias in this monograph? YES NO If YES, please explain: How long did it take for you to complete this monograph? 12. a b 13. a b c d e 14. a b c d 15. a b c d e 16. a b 17. a b c d e f 18. a b 19. a b 20. a b 21. a b c d 33. a b c d 34. a b c d e 35. a b 36. a b 37. a b c d 38. a b c d 39. a b 40. a b c 41. a b c d Name (Please print clearly): Degree: Specialty: Academic Affiliation (if applicable): Address: City: State: Zip Code: Telephone Number: ( ) 85