1. Based on ESC guideline, what is the time recommendation to obtain 12 leads ECG in patient with suspected ACS?

• Within 5 minutes after first medical contact
• Within 10 minutes after first medical contact
• Within 15 minutes after first medical contact
• Within 20 minutes after first medical contact
• Within 30 minutes after first medical contact

2. Which of the following statements is true regarding non-ST- segment elevation (NSTE)-ACS?

• One in five patients with NSTEMI has normal ECG.
• Elevated troponin is associated with worse prognosis in NSTE-ACS.
• ST-segment deviation is associated with increased risk of long-term ischemic events.
• NSTE-ACS has higher longterm mortality rate than STEMI
• All of the above.

3. Which of the following concerning biomarkers of cardiac injury is false?

• Both troponin I and T are only found in cardiac tissue
• Troponin elevation occurs only in the context of ACS
• Cardiac troponins demostrate a graded, dose-dependent association with increasing cardiovascular risk
• Changes in cardiac troponins confer an independent and stronger impact on subsequent risk than clinical synptoms or ECG signs
• AHA guidelines recommend against the routine measurement of CK-MB for the diagnosis of MI

4. Which of the following medications are not belong to anti ischemic therapy for NSTE-ACS?

• Digoxin
• Nitroglycerin
• Beta-blockers
• Calcium channel blockers
• Isosorbide dinitrate

5. Which of the following is not considered part of routine initial anti-thrombotic therapy for NSTEMI patients, at time of presentation to the ER?

• Aspirin
• Clopidogrel
• Ticagrelor
• Abciximab (a IIb/IIIa inhibitor)
• Heparin

Male 37 y.o came with chief complain chest pain since 4 hours PTA. Chest pain felt like heavy sensation, accompanied by nausea and vomiting. Syncope (+) just after the chest pain began. SOB (+) and felt better in sitting position. Smokes 5 packs/day since he was young. His father had heart disease. Patient fully alert, BP: 115/65 mmHg, HR: 82x/mnt, slightly distended JVP, bilateral rales on one-third lower lung, other examination within normal limit. 6. What is your initial management?

• Loading acetosal 160 mg, clopidogrel 300 mg, enoxaparin 0.3 cc IV followed by subcutaneous dose, ISDN 5 mg SL, furosemide 40 mg bolus IV and and proceed the primary PCI
• Loading acetosal 160 mg, clopidogrel 300 mg, fondaparinux 2.5 mg subcutaneous dose, ISDN 5 mg SL and proceed to the primary PCI
• Loading acetosal 160 mg, clopidogrel 300 mg, enoxaparin 0.3 cc IV followed by subcutaneous dose, ISDN 5 mg SL and proceed to the fibrinolytic checklist
• Loading acetosal 80 mg, clopidogrel 160 mg, UFH bolus IV continued by IV infusion, furosemide 60 mg bolus IV proceed with conservative strategy since it is late onset

7. From the previous case, if the nearest PCI-capable hospital is 3 hours apart, what is you next plan?

• Continue conservative therapy
• Explain about fibrinolytic therapy
• Increase the dose of dual antiplatelet and anticoagulant
• Adding nitroglycerine IV to reduce pulmonary congestion
• Proceed to CABG

8. Male, 45-year-old came with chief complain chest pain since yesterday night (18 hours PTA). Felt like heavy sensation radiated to the back and left arm, accompanied by diaphoresis, nausea and vomiting. Patient first seek medical attention to private hospital next town and was advised to go to your hospital for further medical management. From the previous hospital, patient was given ISDN drip 2 mg IV, asetosal 160 mg and clopidogrel 300 mg. Patient said that the pain did not relieved after taking the medication. Patient has DM for 12 years, but with no good adherence to the medication. While we record the ECG, patient suddenly look sleepy and difficult to answer question. BP: 89/68 mmHg, HR : 145 x/mnt, RR: 28 x/mnt, Sat O2: 89% on FM 10 lpm, distended JVP, diffuse bilateral rales on both lung, cold and clammy extremity. Patient can’t lay down and prefer to be in sitting position. What is your plan for this patient?

• Patient had STEMI late onset, stabilize hemodynamic and proceed to catheterization laboratory for PCI
• Patient had STEMI late onset, conservative strategy and stabilize and monitor the patient in ICCU
• Patient had high risk profile of NSTEMI, proceed for early PCI
• Patient had NSTEMI, conservative strategy and stabilize and monitor the patient in ICCU

9. Eighty-five years old man came to the ER with crushing chest pain since 3 days ago, getting worsen 4-hours PTA, accompanied by cold sweating. Chest pain was relieved to some extent with ISDN 5mg SL. Patient felt shortness of breath and prefer to be in sitting position. History of DOE, PND or orthopnea before was denied. History of stroke (+), history of DM, HT, dyslipidemia were denied. BP : 104/69mmHg, HR : 61x regular, SaO2: 96% on 2lpm NC, JVP : PR +5cmH2O. We found rales on 2/3 basal of both lung. Laboratory result: Troponin 1.845 pg/ml and CKMB 20.58 pg/ml. What will you do next to decide your next planning to this patient?

• Do a serial ECG to evaluate whether it will have an evolution into ST elevation
• Patient had STEMI anterior, proceed to catheterization laboratory
• Conservative strategy and stabilize and monitor the patient in ICCU
• Patient had NSTEMI, and stratify the risk of this patient, proceed to catheterization laboratory

10. All statement bellow are correct for very high risk criteria of NSTEMI, except :

• Hemodynamic instability/cardiogenic shock
• Life-threatening arrhythmias
• Dynamic new or presumably new contiguous ST/T-segment changes
• Acute heart failure clearly related to NSTE-ACS