QUESTIONS

A 70 year-old non-diabetic otherwise healthy

woman admitted for unstable angina has triple

vessel disease (70% LAD lesion, 70% circumflex, 70%

proximal RCA) and normal LV function. Further

workup included carotid duplex, and this test

reveals an 80% lesion in the right internal carotid

artery. There is no history of CVA or TIA

(asymptomatic carotid lesion).

Would you offer the patient:

QUESTION #1

a. Right carotid stent followed by multi vessel stenting

b. Right carotid stent followed by CABG (staged 2-3 days

later)

c. Right carotid endarterectomy followed immediately by

CABG (concomitant procedure)

d. Right carotid endarterectomy followed by CABG 2-

3 days later (staged)

e. CABG with carotid endarterectomy at a later date

RESPONSE

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

A B C D E

0 0

3

1

5

0.0% 0.0%

33.3%

11.1%

55.6%

Responses

Percentage

c. Right carotid endarterectomy followed immediately by

CABG (concomitant procedure)

d. Right carotid endarterectomy followed by CABG 2-

3 days later (staged)

e. CABG with carotid endarterectomy at a later date

A 72 year-old man is admitted for acute coronary

syndrome (NSTEMI, troponin 5), and is found to have a

tight (90%) left main. His LV function is normal. He is

pain free. He had previous PCI to Cx with bare metal

stent one year ago and is on Plavix.

Would you:

QUESTION #2

a. Perform L main PCI

b. Perform immediate CABG with no Plavix washout

c. Perform CABG after 5 days without Plavix

d. Perform CABG after a “VerifyNow” (or other platelet

inhibition test) demonstrates Plavix washout

e. Other

RESPONSE

0

1

2

3

4

5

6

7

A B C D E

1

2

4

7

07.1% 14.3%

28.6%50.0%

0.0%

Responses

Percentage

a. Perform L main PCI

b. Perform immediate CABG with no Plavix washout

c. Perform CABG after 5 days without Plavix

d. Perform CABG after a “VerifyNow” (or other platelet

inhibition test) demonstrates Plavix washout

A patient with atrial fibrillation taking dabigatran

(pradaxa) requires non-cardiac surgery.

How do you bridge this patient appropriately?

QUESTION #3

a. Stop dabigatran 5 days prior to surgery and restart 5 days later if taking PO

and recovering well. No bridge with heparin or lovenox.

b. Stop dabigatran 2 days prior to surgery and restart as soon as taking

PO and recovering well. No bridge

c. Do not stop dabigatran

d. Stop dabigatran 2 days prior to surgery, admit to hospital and start IV heparin

first day of no dabigatran, stop heparin drip at midnight prior to surgery,

restart dabigatran as soon as patient is taking PO without more heparin.)

e. Stop dabigatran 5 days prior to surgery, admit to hospital and start IV heparin

first day of no dabigatran, stop heparin drip at midnight prior to surgery,

restart heparin when surgeon says it's OK, restart dabigatran when taking PO

and stop heparin

f. Other

“Ideally would either continue the dabigatran, or need to bridge with

heparin, will depend upon the specific type of surgery”

RESPONSE

0

1

2

3

4

5

6

7

8

9

A B C D E F

2

9

0

1

0

1

15.4%

69.2%

0.0% 7.7% 0.0% 7.7%

Responses

Percentage

a. Stop dabigatran 5 days prior to surgery and restart 5 days later if

taking PO and recovering well. No bridge with heparin or lovenox.

b. Stop dabigatran 2 days prior to surgery and restart as soon as

taking PO and recovering well. No bridge

A 56 year old male presents to ER with STEMI and

systolic blood pressure of 90 mmHg, awake alert

and talking. ST elevation in lateral leads.

On the way to the cath lab, do you have ER

physician administer:

QUESTION #4

a. ASA

b. Plavix

c. Effient

d. ASA plus Plavix

e. ASA plus Effient

e. Other

RESPONSE

0

0.5

1

1.5

2

2.5

3

A B C D E F

3

0 0

1

0 0

75.0%

0.0% 0.0%

25.0%

0.0% 0.0%

Responses

Percentage

a. ASA

d. ASA plus Plavix

A 45 year old female with aortic valve endocarditis

(s. aureus), severe AI, and two-day old embolic

infarct to left cerebral hemisphere has new

expressive aphasia (neuro exam otherwise

normal).

Would you:

QUESTION #5

a. Wait four-six weeks if possible prior to AVR

b. Perform AVR during this admission after labs normalize

c. Treat medically only

d. Wait two weeks if possible prior to AVR

RESPONSE

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

A B C D

0

1

0

1

0.0%

50.0%

0.0%

50.0%Responses

Percentage

b. Perform AVR during this admission after labs normalize

d. Wait two weeks if possible prior to AVR