10-Item Quiz: ACC/AHA/SCAI Coronary Revascularization Guidelines
Question 1: Heart Team Approach
In which clinical scenario is a multidisciplinary Heart Team approach MOST strongly recommended for revascularization decisions?
A) Single-vessel LAD disease in a 55-year-old with normal LV function
B) Diabetic patient with triple-vessel disease considering revascularization options
C) STEMI patient requiring emergent primary PCI
D) Stable angina with 50% mid-RCA stenosis
Correct Answer: B
Explanation: The ACC/AHA/SCAI guidelines give a Class I recommendation for Heart Team approach when the optimal treatment strategy is unclear, with specific emphasis on patients with diabetes and multivessel disease 1. For diabetic patients with triple-vessel disease, the Heart Team must weigh CABG (which is recommended) versus PCI, making this the strongest indication 1.
Question 2: Left Main Disease Revascularization
A 62-year-old with significant left main disease and low-to-medium anatomic complexity (SYNTAX score 18) is being evaluated. Which statement is MOST accurate regarding revascularization?
A) Medical therapy alone is preferred over any revascularization
B) PCI is contraindicated regardless of anatomy
C) Surgical revascularization is indicated to improve survival; PCI is a reasonable alternative
D) The SYNTAX score alone determines the treatment choice
Correct Answer: C
Explanation: For significant left main disease, surgical revascularization is indicated (Class I) to improve survival compared to medical therapy 1. PCI is a reasonable option in selected patients with low-to-medium anatomic complexity when the disease is equally suitable for either approach 1. The 2024 ESC guidelines confirm CABG as the preferred mode given lower rates of spontaneous MI and repeat revascularization 1.
Question 3: Radial Artery Conduit Selection
During CABG planning for a patient requiring bypass of the LAD and a second vessel, which conduit choice for the second most important target vessel provides superior patency and survival?
A) Saphenous vein graft
B) Radial artery
C) Right internal thoracic artery
D) Sequential vein grafting
Correct Answer: B
Explanation: The radial artery is preferred over saphenous vein conduit for bypassing the second most important target vessel after the LAD, with benefits including superior patency, reduced adverse cardiac events, and improved survival 1. This represents a major update in the 2021 ACC/AHA/SCAI guidelines based on contemporary evidence 1.
Question 4: Radial Access for PCI
What is the PRIMARY reason radial artery access is recommended over femoral access for PCI in patients with acute coronary syndrome?
A) Faster procedure time
B) Reduced bleeding and vascular complications; mortality reduction in ACS
C) Lower cost
D) Better angiographic visualization
Correct Answer: B
Explanation: Radial artery access is recommended (Class I) to reduce bleeding and vascular complications compared with femoral approach, and patients with acute coronary syndrome specifically benefit from a reduction in mortality rate 1. The 2018 ESC/EACTS guidelines also give radial access a Class I, Level A recommendation as the standard approach 1.
Question 5: DAPT Duration After PCI for Stable Ischemic Heart Disease
A 58-year-old undergoes PCI with drug-eluting stent for stable angina. After balancing ischemia and bleeding risks, what is a reasonable DAPT strategy according to current guidelines?
A) Lifelong DAPT with aspirin and clopidogrel
B) Aspirin alone immediately after PCI
C) Transition to P2Y12 inhibitor monotherapy after 1-3 months of DAPT
D) DAPT for exactly 12 months, no exceptions
Correct Answer: C
Explanation: A short duration of DAPT after PCI in stable ischemic heart disease is reasonable to reduce bleeding risk, and select patients may safely transition to P2Y12 inhibitor monotherapy and stop aspirin after 1-3 months of DAPT 1. This contrasts with ACS patients who require 12 months of DAPT unless bleeding risk is excessive 1.
Question 6: Non-Culprit Artery Management in STEMI
A 65-year-old presents with anterior STEMI. After successful primary PCI of the LAD, a 90% stenosis is noted in the RCA. The patient is hemodynamically stable with normal renal function. What is the MOST appropriate management of the RCA lesion?
A) Medical therapy only, never intervene on non-culprit arteries
B) Immediate PCI at the time of primary PCI may be considered
C) PCI is harmful and contraindicated
D) Emergent CABG is required
Correct Answer: B
Explanation: Staged PCI of significantly stenosed non-culprit arteries in STEMI is recommended (Class I) to improve outcomes, but PCI at the time of primary PCI may be considered in stable patients with uncomplicated culprit revascularization, low-complexity non-culprit disease, and normal renal function 1. However, non-culprit PCI can be harmful in cardiogenic shock 1.
Question 7: Diabetes and Multivessel Disease
A 70-year-old diabetic patient with triple-vessel CAD (including proximal LAD involvement) and LVEF 55% is being evaluated. Which revascularization strategy is MOST appropriate?
A) PCI is preferred over CABG in all diabetic patients
B) Medical therapy alone is sufficient
C) CABG should be performed; PCI only if poor surgical candidate
D) Either PCI or CABG are equivalent choices
Correct Answer: C
Explanation: Patients with diabetes who have triple-vessel disease should undergo surgical revascularization; PCI may be considered only if they are poor candidates for surgery 1. This recommendation is based on superior long-term outcomes with CABG in diabetic patients with multivessel disease, and decisions should be optimized through Heart Team approach 1.
Question 8: Surgical Risk Assessment
Which scoring system should be calculated for ALL patients being considered for CABG to guide treatment decisions?
A) SYNTAX score
B) Society of Thoracic Surgeons (STS) score
C) GRACE score
D) TIMI risk score
Correct Answer: B
Explanation: Treatment decisions for patients undergoing surgical revascularization should include calculation of the STS score to assess surgical risk 1. In contrast, the SYNTAX score's usefulness is less clear due to interobserver variability and absence of clinical variables 1, 2. The STS score is more important than SYNTAX for CABG candidates 2.
Question 9: DAPT After PCI for NSTE-ACS
A 55-year-old with NSTE-ACS undergoes PCI with drug-eluting stent. What is the recommended duration of DAPT unless bleeding risk is excessive?
A) 1 month
B) 3 months
C) 6 months
D) 12 months
Correct Answer: D
Explanation: In patients with ACS treated with coronary stent implantation, DAPT with a P2Y12 inhibitor on top of aspirin is recommended for 12 months unless there are contraindications such as excessive bleeding risk (e.g., PRECISE-DAPT ≥25) 1. For stable CAD, 6 months is generally recommended, but ACS requires longer duration 1.
Question 10: P2Y12 Inhibitor Selection for NSTE-ACS
A 68-year-old P2Y12-naïve patient with NSTE-ACS is proceeding to PCI. Which P2Y12 inhibitor regimen is recommended as FIRST-LINE therapy?
A) Clopidogrel 600 mg load, 75 mg daily
B) Prasugrel 60 mg load, 10 mg daily
C) Ticlopidine 250 mg twice daily
D) Aspirin monotherapy
Correct Answer: B
Explanation: For P2Y12-naïve NSTE-ACS patients proceeding to PCI, prasugrel (60 mg loading dose, 10 mg daily) is recommended (Class I, Level B) 1. Ticagrelor (180 mg load, 90 mg twice daily) is also Class I regardless of pretreatment strategy 1. Clopidogrel (600 mg load, 75 mg daily) is recommended only when prasugrel or ticagrelor are unavailable or contraindicated 1.