Incorrect. Target time is <10 min.

Correct. It is recommended (Class I, Level of evidence B) to establish the diagnosis and the initial short-term risk stratification on the above mentioned factors.

Incorrect. It is recommended in cases of inferior STEMI.

Correct!

Incorrect. CCTA has been investigated in many trials for the assessment of patients presenting to the ED with suspected NSTE-ACS. In RAPID-CTCA (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) trial a default approach using early non-invasive CCTA in patients with suspected NSTE-ACS did not improve clinical outcomes at 1 year and was associated with a modest increase in the duration and cost of the hospital stay.

Correct! CCTA may provide added value in patients with inconclusive cTn and ECG. CT angiography can be used to aid diagnosis and, in particular, to identify patients with non-obstructed coronary arteries who can be discharged if other relevant diseases have been excluded. CT angiography can also identify patients with obstructive coronary disease in whom revascularization may be considered.

Incorrect. In this specific situation, transthoracic echocardiography has level I, class C recommendation.

Correct! Such patients, who are found to have normal coronary arteries, non-obstructive coronary disease, or distal obstructive disease, may then not require invasive coronary angiography. Of note, the utility of CCTA may be limited in patients with tachycardia, established coronary artery disease, previous stents, or extensive coronary calcification.

Incorrect. Oxygen supplementation in patients who are not hypoxic (oxygen saturations >90%) is not associated with clinical benefits and is therefore not recommended – level III, class A recommendation.

Incorrect. Oxygen supplementation is recommended in ACS patients with hypoxaemia (oxygen saturations <90%) – level I, class C recommendation.

Incorrect. Oxygen supplementation in patients who are not hypoxic (oxygen saturations >90%) is not associated with clinical benefits and is therefore not recommended – level III, class A recommendation.

Correct! Oxygen supplementation is recommended in ACS patients with hypoxaemia (oxygen saturations <90%) – level I, class C recommendation.

Incorrect. It may increase the likelihood of ACS, but is not specific for ACS as it is also reported in other causes of non-cardiac chest pain, such as gastrointestinal disorders. In patients with a working diagnosis of STEMI, the administration of nitroglycerine can be misleading and is not recommended as a diagnostic manoeuvre.

Incorrect. Nitrate use is to be avoided in patients using phosphodiesterase-5 inhibitors such as sildenafil and similar agents, as it may cause severe hypotension and even acute myocardial infarction.

Correct! Nitrates, through the preferential dilation of coronary arteries, also improve the flow across a dynamic stenosis and relieve coronary spasm.

Correct! Due to the risk of decreasing preload in the setting of already compromised right ventricular ejection fraction, it may reduce cardiac output and precipitate hypotension or exacerbate cardiogenic shock.

Incorrect.

Incorrect.

Correct! Platelet inhibition induced by oral P2Y12 receptor antagonists may be delayed in patients with ongoing MI. Morphine may also further reduce absorption, delay the onset of action, and decrease the antiplatelet effect of oral P2Y12 receptor inhibitors in MI patients, although this effect may vary between the different P2Y12 inhibitors. Further research is ongoing in this area, but at present it should be noted that currently available clinical data have not demonstrated any increase in the risk of adverse clinical outcomes as a result of any interaction between morphine and antiplatelet agents in the setting of ACS.

Incorrect. Metoclopramide can be co-administered with opioids, as they may enhance nausea and vomiting. Evidence from small-scale trials suggests that i.v. morphine may also reduce myocardial and microvascular damage when given to patients with ongoing acute coronary artery occlusion, though co-administration with metoclopramide appears to negate this effect. Conversely, morphine has also been reported to reduce antiplatelet activity after administration of ticagrelor, though this effect was rescued by metoclopramide administration.

Incorrect. Pulmonary edema and reduced ejection fraction suggest acute heart failure. Intravenous beta-blockers are not safe in patients with signs of acute heart failure, due to their negative inotropic effect.

Correct! Early administration of intravenous metoprolol before reperfusion reduces infarct size and increases LVEF (left ventricular ejection fraction) in anterior STEMI. However as of today, the impact of early i.v. beta-blockers on clinical outcomes in patients with working diagnosis of STEMI remains unclear.

Incorrect. Not all beta-blockers appear to exert the same cardio-protective effect in the context of ongoing acute coronary occlusion, with metoprolol demonstrating the greatest protective effect in experimental studies.

Correct! Not all beta-blockers appear to exert the same cardio-protective effect in the context of ongoing acute coronary occlusion, with metoprolol demonstrating the greatest protective effect in experimental studies. Intravenous metoprolol is also the most widely tested beta-blocker in trials enrolling patients undergoing primary PCI. While the long-term clinical benefits associated with early i.v. metoprolol administration are not clear, it is safe when used in patients without signs of acute HF and has been consistently associated with a reduction in the incidence of VF and microvascular obstruction (MVO).

Incorrect. PPCI is the preferred strategy provided it can be performed in a timely manner. Due to a lack of contemporaneous data to inform a treatment delay limit at which the advantage of PCI over fibrinolysis is lost, an absolute time of 120 minutes from STEMI diagnosis to the wire crossing of the infarct-related artery (IRA) rather than a relative PCI-related delay over fibrinolysis has been chosen.

Correct! A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min (class I, level A).

Incorrect. Fibrinolysis strategy is preferred in situations when PPCI cannot be performed within 120 minutes from diagnosis. Randomized controlled trials have shown that if the delay to treatment is similar, PPCI is superior to fibrinolysis in reducing mortality, non-fatal reinfarction, and stroke. However, in some circumstances, PPCI is not an immediate option and fibrinolysis should be initiated expeditiously as part of a pharmaco-invasive strategy, provided the patient has presented within 12 h of symptom onset.

Incorrect. Early invasive strategy is not preferred in cases of STEMI. It should be considered in NSTE-ACS patients with high-risk features, like transient ST-segment elevation.

Correct! Class I, level A recommendation.

Correct! Class I, level A recommendation.

Incorrect. In case of successful fibrinolysis (i.e. ST-segment resolution >50% within 60-90 minutes), angiography and PCI of the infarct-related artery, if indicated is recommended between 2 and 24 hours later. In case of unsuccessful fibrinolysis rescue PCI in a PCI centre is indicated.

Correct! Patient presented to a non-PCI centre therefore they have to be transferred to a PCI-capable centre, if primary PCI strategy would be chosen. If fibrinolysis would be chosen, patient would need to be transferred to a PCI centre, whether the fibrinolysis was successful or unsuccessful, to undergo either early or emergency angiography respectively.

Incorrect. It would be recommended in their presence.

Correct! This is based on the data from 2,036 patients (from a total of 23,517 patients with STEMI enrolled in the Polish Registry of Acute Coronary Syndromes from June 2005 to August 2006) with STEMI presenting 12 to 24 hours from onset of symptoms, without cardiogenic shock or pulmonary edema and not reperfused by thrombolysis. Almost 45% of these patients followed the invasive approach. Compared to the conservative approach, the invasive approach demonstrated lower 12-month mortality.

Incorrect. For patients presenting after 12 h from symptom onset, a primary PCI strategy is preferred over fibrinolysis in all cases.

Correct! A small randomized controlled trial in 347 STEMI patients presenting 12–48 h after symptom onset and without persistent symptoms reported that a routine primary PCI strategy improved myocardial salvage and long-term survival compared with conservative treatment. This observation is supported by a recent analysis of data from three nationwide observational studies from the FAST-MI programme, which showed a significant lower rate of all-cause death at 1 month and after a median follow-up of 58 months with an invasive strategy in comparison to conservative treatment.

Correct! The benefits of surgical revascularization are less certain.

Incorrect. However, CABG should be considered for patients with a patent infarct-related artery (IRA) but with unsuitable anatomy for PCI, and either a large myocardial area at risk or with cardiogenic shock (CS).

Incorrect. Patients with failed fibrinolysis are indicated for rescue PCI, not CABG.

Correct!

Incorrect. Routine primary PCI should be considered (class IIa, level C) in STEMI patients. A small randomized controlled trial in 347 STEMI patients presenting 12–48 h after symptom onset and without persistent symptoms reported that a routine primary PCI strategy improved myocardial salvage and long-term survival compared with conservative treatment. This observation is supported by a recent analysis of data from three nationwide observational studies from the FAST-MI programme, which showed a significant lower rate of all-cause death at 1 month and after a median follow-up of 58 months with an invasive strategy in comparison to conservative treatment.

Incorrect. Immediate reperfusion therapy is recommended (class I, level A) in all patients with a working diagnosis of STEMI and symptoms of ischaemia of less than 12 hours in duration. If the anticipated time from diagnosis to PCI is less than 120 minutes, primary PCI strategy is recommended over fibrinolysis.

Incorrect. Patients presenting with symptoms that are less than 18 hours in duration, but still more than 12 hours, should be considered (class IIa, level C) candidates for routine primary PCI, as explained in the first answer.

Correct! Based on the data from Occluded Artery Trial (OAT), which reported no clinical benefit from routine coronary intervention with medical management in comparison to medical management alone, in stable patients with persistent occlusion of the IRA 3–28 days after myocardial infarction. A meta-analysis of trials testing whether late recanalization of an occluded IRA is beneficial also showed no benefit of reperfusion. Therefore, these patients should be managed in the same way as patients with chronic total occlusion according to the ESC Guidelines for the diagnosis and management of chronic coronary syndromes (CCS).

Correct!

Incorrect. The incidence of STEMI has decreased relative to NSTEMI in recent years. The increase in the relative incidence of NSTEMI is multifactorial (e.g. due to changes in diagnostic criteria and the emergence of high-sensitivity troponin assays).

Correct! And for high-risk groups, women less frequently receive reperfusion therapy within the recommended timeframes. One potentially relevant contributor to this observation is that women with ACS tend to present later than men.

Correct! In parallel with the increasing use of reperfusion therapy, primary percutaneous coronary intervention (PPCI), modern antithrombotic therapy, and secondary prevention therapies.

Incorrect. This is a high-risk but not very high-risk criterion. Patients with a working diagnosis of NSTE-ACS and any of the high risk criteria should be considered for an early invasive (<24 h) strategy – meaning a routine invasive angiography and PCI if needed).

Correct, haemodynamic instability is a very-high risk criterion! The presence of a cardiogenic shock is also a very high-risk criterion.

Correct! Particularly with intermittent ST-segment elevation.

Incorrect. This is a high-risk but not very high-risk criterion. Patients with a working diagnosis of NSTE-ACS and any of the high risk criteria should be considered for an early invasive (<24 h) strategy – meaning a routine invasive angiography and PCI if needed).

Correct! In several trials, a pre-specified subgroup analysis of patients with a Global Registry of Acute Coronary Events (GRACE) risk score >140 showed that they benefitted from an early invasive strategy as opposed to those with a GRACE risk score <140 (TIMACS and VERDICT trials). A significant interaction was found between timing of invasive angiography and GRACE score in terms of the risk of death: a trend toward decreased risk of all-cause mortality was seen with an early invasive strategy in patients with a GRACE score risk >140 with a higher risk of all-cause mortality in patients with a GRACE risk score ≤140.

Incorrect. This is a very high-risk criterion. In patients with a working diagnosis of NSTE-ACS and any of the very high-risk criteria it is recommended (class I, level C) to follow immediate invasive strategy – angiography as soon as possible and PCI fi indicated.

Correct!

Correct!

Incorrect.

Correct! A collaborative meta-analysis comparing an early vs. a delayed invasive strategy using a modified individual patient data approach observed no difference in mortality overall but a survival benefit in high-risk patients, including those with a GRACE risk score >140 and those with positive troponin, although tests for interaction were inconclusive. The largest meta-analysis to date (17 RCTs >10 000 patients) reported that, in all-comers with NSTE-ACS, early ICA (invasive coronary angiography) only significantly reduced the risk of recurrent ischaemia and duration of stay, with no significant reductions in all-cause mortality, MI, admission for HF, or repeat revascularization. Data from observational studies is concordant with trial data, without a strong signal of benefit with early versus delayed coronary angiography.

Incorrect.

Incorrect.

Correct! A selective invasive approach after appropriate ischaemia testing or detection of obstructive CAD (coronary artery disease) by coronary CT angiography is recommended in patients without very high- or high-risk features and a low index of suspicion for NSTE-ACS. These patients should be managed as per the ESC Guidelines for the management of CCS (chronic coronary syndromes). A selective invasive approach is also appropriate for patients with NSTEMI or UA who are not deemed good candidates for coronary angiography.

Correct! In this group of patients, early (<24 h) invasive strategy should be considered (class IIa, level A) as well.

Incorrect. These patients are recommended to undergo an inpatient invasive strategy along with a class IIa recommendation for an early invasive strategy. Immediate invasive strategy is recommended for very high-risk (i.e. mechanical complications, cardiogenic shock, acute heart failure secondary to ischaemia etc.) patients with NSTE-ACS.

Incorrect. These patients are recommended to undergo inpatient invasive strategy, not immediate. In NSTE-ACS patients immediate (meaning an emergency angiography with PCI if required) invasive strategy is recommended in the presence of very high-risk criteria like haemodynamic instability, chest pain refractory to medical treatment or life-threatening arrhythmias.

Incorrect. Advanced age is not an absolute contraindication per se, but it was identified as a significant predictor of intracranial haemorrhage. Advanced age is also associated with rupture of the LV free wall. It is also true that in the STREAM trial a slight excess of intracranial bleeding was observed in the group receiving pre-hospital fibrinolysis followed by an early PCI. However, this excess was blunted by halving the dose of Tenecteplase in patients >75 years of age.

Correct!

Incorrect. This is a relative contraindication.

Incorrect. This is a relative contraindication.

Incorrect.

Incorrect.

Incorrect.

Correct! Re-administration of streptokinase should be avoided, both because antibodies can impair its activity and due to the risk of allergic reactions.

Incorrect. Fibrin-specific agents like alteplase, reteplase or tenecteplase are preferred.

Incorrect. Fibrinolytic therapy initiation should not be delayed by waiting for the results of cardiac biomarker testing. In a meta-analysis of six randomized trials (n = 6434), pre-hospital fibrinolysis compared with in-hospital fibrinolysis reduced early mortality by 17%, particularly when administered in the first 2 h after symptom onset.

Incorrect. Fibrinolytic therapy is an important reperfusion strategy for STEMI patients presenting within 12 h of symptom onset when primary PCI cannot be performed in a timely manner; it prevents 30 early deaths per 1000 patients treated within 6 h of symptom onset. In a meta-analysis of six randomized trials (n = 6434), pre-hospital fibrinolysis compared with in-hospital fibrinolysis reduced early mortality by 17%, particularly when administered in the first 2 h after symptom onset.

Correct! Angiography is indicated in both cases; the difference is in the timing. Rescue PCI (emergency angiography and PCI of the infarct-related artery, if indicated) is recommended (class I, level A) after failed fibrinolysis or in the presence of haemodynamic or electrical instability, worsening ischaemia, or persistent chest pain. Angiography and PCI of the infarct-related artery, if indicated, is recommended between 2 and 24h after successful fibrinolysis (class I, level A).

Incorrect. This is the loading dose of prasugrel

Incorrect. This is the loading dose of ticagrelor

Incorrect.

Correct!

Incorrect. Twenty clinical criteria were identified as major or minor by consensus, supported by published evidence. Patients are considered to be at HBR if at least 1 major or 2 minor criteria are met. The definition is thus binary. It is also recognized that the coexistence of increasing numbers of risk factors for bleeding is associated with a stepwise increase in risk of bleeding, however, sufficient data are not currently available to create a point-based score that would take into account the relative weight of each HBR criterion. Bleeding risk assessment based on ARC-HBR criteria may be difficult to apply in routine clinical practice as several of the criteria are quite detailed.

Incorrect. Twenty clinical criteria were identified as major or minor by consensus, supported by published evidence. Patients are considered to be at HBR if at least 1 major or 2 minor criteria are met.

Correct! Twenty clinical criteria were identified as major or minor by consensus, supported by published evidence. Patients are considered to be at HBR if at least 1 major or 2 minor criteria are met.

Correct! Twenty clinical criteria were identified as major or minor by consensus, supported by published evidence. Patients are considered to be at HBR if at least 1 major or 2 minor criteria are met.

Incorrect. Routine pre-treatment in all STEMI patients is not recommended. In the ATLANTIC trial - which is so far the only randomized study testing the safety and efficacy of different timings of P2Y12 receptor inhibitor ticagrelor initiation - the pre-specified primary endpoint of improved ST-segment elevation resolution or TIMI (Thrombolysis In Myocardial Infarction) flow before intervention was not met. The results are also supported by real-world data from the SWEDEHEART registry of STEMI patients.

Correct! This is based on the data from the ATLANTIC trial.

Incorrect. It may be considered.

Incorrect. It may be considered.

Incorrect. This statement is true. Some other conditions that may exacerbate or precipitate ACS include anaemia, fever, hypertensive crisis, emotional stress, and metabolic or endocrine (in particular thyroid) disorders.

Correct! This statement is false. It may increase the likelihood of ACS, but is not specific for ACS as it is also reported in other causes of non-cardiac chest pain, such as gastrointestinal disorders. In patients with a working diagnosis of STEMI, the administration of nitroglycerine can be misleading and is not recommended as a diagnostic manoeuvre.

Incorrect. This statement is true. Over 80% of women and men with ACS present with chest pain or pressure.

Correct! This statement is false. Epigastric pain or indigestion occur commonly in both women and men with ACS.

Correct! Routine pre-treatment with a P2Y12 receptor inhibitor before knowing the coronary anatomy in patients anticipated to undergo an early invasive strategy (i.e. <24 h) is NOT recommended. This is based on the data from the ACCOAST and DUBIUS trials that demonstrated a lack of benefit of pre-treatment with prasugrel and ticagrelor, respectively.

Incorrect. Routine pre-treatment with a P2Y12 receptor inhibitor before knowing the coronary anatomy in patients anticipated to undergo an early invasive strategy (i.e. <24 h) is NOT recommended. This is based on the data from the ACCOAST and DUBIUS trials that demonstrated a lack of benefit of pre-treatment with prasugrel and ticagrelor, respectively.

Correct! This is also a C level recommendation.

Incorrect. Pre-treatment may be considered in patients who are NOT expected to undergo an early invasive strategy (<24 h) and do not have HBR.

Incorrect. Until evidence from ongoing prospective trials becomes available, patients with SCAD should receive the same pharmacological therapy as other ACS patients.

Incorrect. There is no evidence that administration of GP IIb/IIIa receptor inhibitors improves myocardial perfusion or outcomes in patients treated with fibrinolysis, and it may increase the risk of bleeding events.

Incorrect. Bivalirudin, not a GP IIb/IIIa inhibitor is an alternative to UFH in this clinical situation. Therapy with GP IIb/IIIa inhibitor can in fact precipitate thrombocytopenia, therefore patients who have experienced thrombocytopenia while on GP IIb/IIIa inhibitors should avoid subsequent exposure.

Correct! However, most of the trials evaluating GP IIb/IIIa inhibitors in PCI-treated ACS patients pre-date the era of routine DAPT, in particular, early initiation of DAPT including a loading dose of a potent P2Y12 receptor inhibitor. As there is no strong evidence (hence, the level C recommendation) for any additional benefit with the routine use of GP IIb/IIIa inhibitors in ACS patients scheduled for coronary angiography, it should therefore be considered only for a bailout.

Correct! In the TRITON-TIMI 38 trial comparing prasugrel with clopidogrel higher risk of bleeding events was observed in the prasugel group. In the post hoc analysis, bleeding risk was highest in patients >75 years, body weight less than 60 kg as well as patients with a history of TIA (transitory ischaemic attack) or a stroke. Because of that, prasugrel is contraindicated in patients with a history of TIA/stroke and the maintenance dose should be reduced to 5 mg daily in patients >75 years, or body weight less than 60 kg.

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Incorrect.

Incorrect.

Incorrect.

Correct! The big advantage of cangrelor use is the very rapid onset of action, parenteral route of administration, and its proven efficacy in preventing intra-procedural and post-procedural stent thrombosis in this group of patients.

Incorrect. It may be considered (class IIb recommendation). In a meta-analysis of major trials with cangrelor (CHAMPION-PCI, CHAMPION-PLATFORM, CHAMPION-PHOENIX) the benefit of cangrelor with respect to major ischaemic endpoints was counterbalanced by an increase in minor bleeding complications. In the CHAMPION-PLATFORM trial, the use of periprocedural cangrelor during PCI was not superior to placebo in reducing the primary endpoint, and in the CHAMPION-PCI trial, the ischaemic endpoints were attenuated with upfront administration of clopidogrel.

Incorrect. Large randomized controlled trials do not support the routine use of cangrelor.

Correct! Cangrelor is an intravenous antiplatelet drug.

Incorrect. However in older ACS patients, especially if high bleeding risk, clopidogrel as the P2Y12 receptor inhibitor may be considered (class IIb, level B recommendation). Clopidogrel is characterized by less effective and more variable platelet inhibition. It was compared with other P2Y12 inhibitors in many trial. In the TRITON-TIMI 38, prasugrel therapy was associated with significantly reduced rates of ischemic events compared to clopidogrel. In the PLATO trial, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rate of overall major bleeding.

Correct! It is a class IIa recommendation. ISAR-REACT 5 randomized controlled trial is the largest head-to-head comparison of 1-year DAPT with prasugrel vs. DAPT with ticagrelor in patients with ACS planned for invasive evaluation, >80% of whom underwent PCI. A treatment strategy with prasugrel vs. ticagrelor significantly reduced the composite endpoint of death, MI, or stroke, without any increase in bleeding complications, in favor of prasugrel. Limitations of this study include an open-label design and limited data on medically managed or CABG-treated patients.

Incorrect. Prasugrel should be considered (class IIa recommendation) in preference to ticagrelor in ACS patients.

Incorrect. Cangrelor may be considered (class IIb, level A recommendation) on a case-by-case basis in P2Y12 receptor inhibitor-naïve patients undergoing PCI. The big advantage of cangrelor use is the very rapid onset of action, parenteral route of administration, and its proven efficacy in preventing intra-procedural and post-procedural stent thrombosis in this group of patients. However, in large randomized trials (CHAMPION-PCI, CHAMPION-PLATFORM) the routine use of cangrelor during PCI did not show benefit compared to placebo. A meta-analysis of these trials showed that the benefit of cangrelor with respect to major ischaemic endpoints was counterbalanced by an increase in minor bleeding complications. It is also important to note that the benefit of cangrelor with respect to ischaemic endpoints was attenuated in CHAMPION PCI with upfront administration of clopidogrel.

Incorrect. Enoxaparin has class IIa recommendation. It should be considered as an alternative to UFH in patients with STEMI undergoing PPCI. The ATOLL trial reported a reduction in the primary endpoint at 30 days (incidence of death, complication of MI, procedure failure, or major bleeding) with enoxaparin in comparison to UFH in patients with STEMI undergoing primary PCI.

Incorrect. Bivalirudin has class IIa, level A recommendation. It should be considered as an alternative to UFH in patients with STEMI undergoing PPCI, and is also recommended as an alternative to UFH in patients with a history of heparin-induced thrombocytopenia. It should be noted that an additional full-dose post PCI is recommended.

Correct! Unfractionated heparin has been established as the standard of care in patients with STEMI undergoing primary PCI due to its favourable risk/benefit profile. In these patients, anticoagulation should be given during the invasive procedure. High-quality evidence with respect to the benefit of administering anticoagulation at an earlier time point in patients undergoing a primary PCI strategy is lacking.

Incorrect. Fondaparinux is not recommended in patients with STEMI undergoing PPCI (class III, level B recommendation). This is based on the data from the OASIS 6 trial, in which higher rates of coronary complications (chiefly due to guiding catheter thrombus) with fondaparinux were found in patients undergoing primary PCI.

Correct! Parenteral anticoagulation is recommended for all patients with acute coronary syndrome at the time of diagnosis, with a routine administration of weight-adjusted i.v. bolus of UFH in patients undergoing PCI.

Correct! NSTE-ACS patients who do not undergo early invasive angiography will have an extended initial treatment phase consisting of only pharmacological treatment. In these patients, fondaparinux therapy is recommended in preference to enoxaparin while awaiting invasive angiography, based on the favourable outcomes demonstrated with fondaparinux in comparison to enoxaparin in the OASIS-5 trial.

Incorrect. This is a class IIa, level B recommendation. Based on the data from the SYNERGY randomized trial, enoxaparin was found to be non superior to unfractionated heparin, but was non-inferior for the treatment of high-risk patients with non-ST-segment elevation acute coronary syndrome.

Incorrect. Fondaparinux is recommended in patients undergoing delayed angiography.

Incorrect. This is not the default duration of DAPT, but rather an alternative one, usually driven by a motivation to reduce the risk of bleeding events.

Incorrect. This is not the default duration of DAPT, but rather an alternative one, usually driven by a motivation to reduce the risk of bleeding events.

Correct! The default DAPT strategy is 12 months. It is a class I, level A recommendation to give a P2Y12 receptor inhibitor in addition to aspirin, as an initial loading dose followed by an maitenance dose for 12 months unless there is high bleeding risk.

Incorrect. There is a class IIb recommendation for this strategy, meaning that in high-bleeding risk patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered. This is based on the data from the MASTER DAPT trial which examined a strategy of abbreviated DAPT (1 month) followed by either aspirin or P2Y12 inhibitor monotherapy vs. DAPT ≥3 months (standard therapy) in a cohort of 4579 high-bleeding risk patients (49% ACS, 12% STEMI) undergoing PCI with a bioabsorbable polymer-coated stent. Net adverse clinical events and major adverse cardiac or cerebral events were comparable between the groups, whereas major or clinically relevant non major bleeding events were significantly reduced in the abbreviated therapy group.

Incorrect. Dyspnoea was found to be a side effect of ticagrelor, not of clopidogrel therapy in two large clinical trials (PLATO, PEGASUS). This side effect led to a discontinuation in some patients, but the majority of cases were mild, and in the PLATO trial, 30% of episodes resolved in 7 days.

Incorrect. Dyspnoea was found to be a side effect of ticagrelor, not of prasugrel therapy in two large clinical trials (PLATO, PEGASUS). This side effect led to a discontinuation in some patients, but the majority of cases were mild, and in the PLATO trial, 30% of episodes resolved in 7 days.

Incorrect. Dyspnoea was found to be a side effect of ticagrelor, not of cangrelor therapy in two large clinical trials (PLATO, PEGASUS). This side effect led to a discontinuation in some patients, but the majority of cases were mild, and in the PLATO trial, 30% of episodes resolved in 7 days.

Correct! Dyspnoea was found to be a side effect of ticagrelor therapy in two large clinical trials (PLATO, PEGASUS). This side effect led to a discontinuation in some patients, but the majority of cases were mild, and in the PLATO trial, 30% of episodes resolved in 7 days.

Incorrect. De-escalation means a switch from a potent P2Y12 receptor inhibitor to clopidogrel.

Correct! It is not recommended because there is a potential risk of increased ischaemic events in the first 30 days.

Incorrect. It is NOT recommended because there is a potential risk of increased ischaemic events in the first 30 days.

Incorrect. De-escalation can also be performed after clinical assessment of a patient´s bleeding and ischaemic risks.

Incorrect. Type 1 MI is characterized by atherosclerotic plaque rupture, ulceration, fissure, or erosion with resulting intraluminal thrombus in one or more coronary arteries, leading to decreased myocardial blood flow and/or distal embolization and subsequent myocardial necrosis.

Incorrect. Type 2 MI is a myocardial necrosis in which a condition other than coronary plaque instability causes an imbalance between myocardial oxygen supply and demand.

Incorrect. Type 3 is MI resulting in cardiac death with symptoms suggestive of myocardial ischaemia when biomarkers are not available or MI is detected at autopsy.

Correct!

Incorrect. Interruption of the long-term OAC and bridging with parenteral anticoagulants may lead to an increase in thrombo-embolic episodes and bleeds.

Incorrect. Radial access is recommended as the default vascular access in order to reduce bleeding risk. The radial approach for coronary angiography and PCI has been shown to be superior to the femoral one in patients with ACS. The MATRIX trial showed a significant reduction in major bleeds, as well as all-cause mortality, in patients allocated to the radial compared with the femoral approach.

Correct! As this increases the risk of bleeding.

Correct! For example enoxaparin 0.5 mg/kg i.v. or UFH 60 IU/kg

Incorrect. TAT up to 1 month should be considered (class IIa, level C recommendation) in those with high ischaemic risk or with other anatomical/procedural characteristics that are judged to outweigh the bleeding risk.

Incorrect. Up to 1 week of TAT followed by up to 12 months of DAT is recommended. It is also possible after the first 6 months from the ACS event to discontinue DAT (consisting of (N)OAC plus SAPT [single antiplatelet therapy]) and continue with only (N)OAC monotherapy for the next 6 months (class IIb recommendation). Beyond 12 months, (N)OAC monotherapy is recommended (class I recommendation).

Correct! The up to 1 week duration of TAT is based on the median treatment duration in the investigational arm of the AUGUSTUS trial. Clopidogrel is preferred as it was used in >90% of patients in the major randomized controlled trials.

Incorrect. Even though the time duration is correct, there is currently limited evidence to support the use of OAC with ticagrelor or prasugrel as DAT after ACS and/or PCI as an alternative to TAT, as ticagrelor was used in 5–12% and prasugrel in 1–2% of patients, respectively, in the four pivotal randomized controlled trials. Similarly, the use of ticagrelor or prasugrel even as a part of TAT is not recommended (class III, level C recommendation).

Incorrect. Enoxaparin is preferred over UFH because of the net clinical benefit demonstrated in clinical trials. However, when enoxaparin is unavailable UFH is recommended as a weight-adjusted i.v. bolus, followed by infusion.

Correct! Even though enoxaparin demonstrated an increased risk of major bleeding in the ASSENT 3 trial and a significant increase in non-cerebral bleeding complications in the ExTRACT-TIMI 25 trial, the net clinical benefit favoured enoxaparin over UFH.

Incorrect. Bivalirudin has not been studied with fibrin-specific agents, and there is no evidence to support direct thrombin inhibitors as an adjunct to fibrinolysis.

Incorrect. Enoxaparin is the preferred anticoagulant. However, in the large OASIS-6 trial, fondaparinux was superior to placebo or UFH in preventing death and re-infarction, especially in patients who received streptokinase. Therefore in patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an s.c. dose 24 h later should be considered (class IIa, level B recommendation).

Correct! This is based on the data from DAPT (mean duration of prolonged treatment was 18 months) and PEGASUS-TIMI 54 (mean duration of prolonged treatment was 33 months) trials, which showed a benefit of prolonged therapy with regard to ischaemic events but also an increased risk of bleeding.

Correct! This is based on the data from DAPT (mean duration of prolonged treatment was 18 months) and PEGASUS-TIMI 54 (mean duration of prolonged treatment was 33 months) trials, which showed a benefit of prolonged therapy with regard to ischaemic events but also an increased risk of bleeding.

Correct! Compared with aspirin monotherapy, P2Y12 inhibitor monotherapy is associated with a risk reduction for myocardial infarction and a comparable risk of stroke in the setting of secondary prevention. The benefit of P2Y12 inhibitor monotherapy is of debatable clinical relevance, in view of the high number needed to treat to prevent a myocardial infarction and the absence of any effect on all-cause and vascular mortality.

Correct! This is based on the data from the AFFIRE trial, which randomized 2236 AF patients treated with PCI or CABG more than 1 year earlier or with documented coronary artery disease to receive either rivaroxaban monotherapy or combination therapy with rivaroxaban plus a single antiplatelet agent. Rivaroxaban monotherapy was non-inferior to combination therapy for the primary efficacy composite endpoint of stroke, systemic embolism, MI, UA requiring revascularization, or overall death, and superior with regard to the primary safety endpoint of major bleeding. This trial and another prematurely terminated trial support the recommendation to stop antiplatelet therapy after 12 months and continue with OAC monotherapy in most patients.

Incorrect. Despite the lack of dedicated trials, patients with return of spontaneous circulation (ROSC) and persistent ST-segment elevation should, in general, undergo a primary PCI strategy (immediate invasive coronary angiography [ICA] and PCI if indicated), based on the overall clinical situation and a reasonable benefit/risk ratio. Based on registry reports, emergent ICA and PCI are associated with good outcomes in this setting, particularly in patients who are non-comatose at the initial assessment.

Correct! Despite the lack of dedicated trials, patients with return of spontaneous circulation (ROSC) and persistent ST-segment elevation should, in general, undergo a primary PCI strategy (immediate invasive coronary angiography [ICA] and PCI if indicated), based on the overall clinical situation and a reasonable benefit/risk ratio. Based on registry reports, emergent ICA and PCI are associated with good outcomes in this setting, particularly in patients who are non-comatose at the initial assessment.

Incorrect. The management of patients with ROSC without evidence of ST-segment elevation should be individualized according to haemodynamic and neurological status. In OHCA with an initial shockable rhythm and without ST-segment elevation or equivalents and without CS, routine immediate ICA is not superior to a delayed invasive strategy based on data from the COACT and TOMAHAWK trials. Smaller, underpowered trials (EMERGE, PEARL, and COUPE) have also pointed to the same conclusion.

Correct! The management of patients with ROSC without evidence of ST-segment elevation should be individualized according to haemodynamic and neurological status. In OHCA with an initial shockable rhythm and without ST segment elevation or equivalents and without cardiogenic shock, routine immediate ICA is not superior to a delayed invasive strategy based on data from the COACT and TOMAHAWK trials. Smaller, underpowered trials (EMERGE, PEARL, and COUPE) have also pointed to the same conclusion.

Incorrect. Results of clinical examinations are usually unreliable in the first days after resuscitation. In particular, the absence of pupillary light reflex at ROSC (return of spontaneous circulation) is associated with false prediction of poor outcome in about one-third of patients. Reliability of these signs increases during the first 72 h after arrest in patients not treated with controlled temperature, and it reaches a maximum at 3 days from ROSC.

Incorrect. Results of clinical examinations are usually unreliable in the first days after resuscitation. In particular, the absence of pupillary light reflex at ROSC is associated with false prediction of poor outcome in about one-third of patients. Reliability of these signs increases during the first 72 h after arrest in patients not treated with controlled temperature, and it reaches a maximum at 3 days from ROSC.

Incorrect. Results of clinical examinations are usually unreliable in the first days after resuscitation. In particular, the absence of pupillary light reflex at ROSC is associated with false prediction of poor outcome in about one-third of patients. Reliability of these signs increases during the first 72 h after arrest in patients not treated with controlled temperature, and it reaches a maximum at 3 days from ROSC.

Correct! Evaluation no earlier than 72 hours after admission is a class I, level C recommendation. Results of clinical examinations are usually unreliable in the first days after resuscitation. In particular, the absence of pupillary light reflex at ROSC is associated with false prediction of poor outcome in about one-third of patients. Reliability of these signs increases during the first 72 h after arrest in patients not treated with controlled temperature, and it reaches a maximum at 3 days from ROSC.

Incorrect. In the IABP-SHOCK II trial, IABP use was not associated with lower 30-day mortality. Therefore, in the absence of mechanical complications, the routine use of an IABP is not recommended for CS complicating acute MI.

Correct! It was not associated with lower mortality, therefore its routine use is not recommended. However, in situations where ACS-related mechanical complications are present, IABP should be considered, while awaiting surgery.

Correct! The role of mechanical circulatory devices in the acute MI setting is not well established and large-scale randomized trials are warranted. In the ECMO-CS randomized trial, immediate implementation of VA-ECMO did not result in improved clinical outcomes, however, the interpretation of this trial is challenging. There is still a lack of high-quality randomized data supporting the use of MCS in ACS patients presenting with CS, some recent observational analyses have reported that the use of intravascular LV assist devices may be associated with an increased risk of adverse events in comparison to IABP in this setting, including mortality and bleeding. Therefore, while MCS may be considered in selected patients with ACS and severe/refractory CS, caution should be exercised in this regard until further randomized data are available.

Incorrect. There is still a lack of high-quality randomized data supporting the use of MCS in ACS patients presenting with CS. Therefore, MCS may be considered in selected patients with ACS and severe/refractory CS, caution should be exercised in this regard until further randomized data are available.

Incorrect. The impact of both successful reperfusion and knowledge of the coronary anatomy (due to increasing rates of invasive coronary angiography) has resulted in progressive reductions in the length of stay after ACS, alongside significant reductions in 30-day mortality, suggesting that discharge within 72 h is not associated with late mortality.

Correct! This is a class IIa recommendation and should be considered if early rehabilitation and adequate follow-up are arranged.

Incorrect. Several prognostic models that aim to estimate the longer-term risk of all-cause mortality, or the combined risk of all cause mortality or MI, have also been developed. These models have been formulated into clinical risk scores and, among these, the GRACE risk score offers the best discriminative performance and is therefore recommended for risk assessment. A GRACE risk score-based risk assessment has been found to be superior to subjective physician assessment for the occurrence of death or MI.

Correct! Along with infarct size and intra-myocardial haemorrhage, MVO is a predictor of both long-term mortality and heart failure in STEMI survivors. In ACS patients undergoing PPCI, the index of microvascular resistance (IMR) has been correlated with the extent of MVO and infarct size, with IMR >40 being an independent predictor of all-cause death or HF.

Incorrect. A maintenance dose of 75-100 mg once daily for long-term treatment is recommended to all patients without contraindications.

Incorrect. It is true that in the COMPASS trial, in the arm with a very low dose of rivaroxaban plus aspirin an increase in the risk of major bleeding complications was observed, but no significant increase in the risk of fatal, intracranial, or critical organ bleeding was observed. However, the combination of rivaroxaban 2.5 mg b.i.d. plus aspirin resulted in a significant reduction in the risk of the combined ischaemic endpoint, overall mortality, and CV mortality alone. Based on this, it should be considered as an option for maintenance treatment beyond 12 months post-ACS in patients at high thrombotic risk and without an increased risk of major or life-threatening bleeding and may be considered in patients with moderately elevated thrombotic risk.

Correct! In the COMPASS trial, among patients with stable atherosclerotic vascular disease, those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better cardiovascular outcomes and more major bleeding events than those assigned to aspirin alone. Because of this, the combination of aspirin + rivaroxaban 2.5 mg should be considered in high ischaemic risk patients and may be considered in moderate ischaemic risk patients, both without high bleeding risk.

Incorrect. Rivaroxaban 5 mg twice daily alone did not result in better cardiovascular outcomes than aspirin alone and resulted in more major bleeding events, in the COMPASS trial.

Correct! Large randomized trials RIVAL and MATRIX have demonstrated significantly lower rates of access site-related bleeding, surgical access site repair, and blood transfusion with radial compared to femoral access.

Incorrect. Radial access is preferred. Large randomized trials RIVAL and MATRIX have demonstrated significantly lower rates of access site-related bleeding, surgical access site repair, and blood transfusion with radial compared to femoral access. However, femoral access may still be selectively chosen instead of radial access in certain patients (i.e. depending on the haemodynamic situation and other technical aspects during the index PCI procedure).

Incorrect. DES is recommended in preference to BMS. This is supported by the NORSTENT trial, as well as COMFORTABLE-AMI and EXAMINATION trials, all of which have demonstrated superiority of DES.

Correct! Large RCTs (randomized controlled trials) have failed to demonstrate a clinical benefit with routine manual thrombus aspiration in comparison to conventional primary PCI. In the sub-analysis of TOTAL trial, routine thrombus aspiration did not improve outcomes at 1 year and was also associated with an increased rate of stroke in patients with high thrombus burden. Routine use of thrombus aspiration is not recommended, but in cases of large residual thrombus burden after opening the vessel with a guide wire or a balloon, thrombus aspiration may be considered.

Incorrect. The algorithm should be used in patients who present with a suspected NSTEMI and without an indication for immediate invasive angiography.

Incorrect. The ESC 0 h/3 h algorithm is an alternative for cases where the ESC 0 h/1 h or 0 h/2 h algorithms are not available. Three recent large diagnostic studies suggested that the ESC 0 h/ 3 h algorithm appears to balance efficacy and safety less well than more rapid protocols using lower rule-out concentrations, including the ESC 0 h/1 h algorithm. The very high safety and high efficacy of applying the ESC 0 h/1 h algorithm was recently confirmed in three real-life implementation studies, including one randomized controlled trial (RCT).

Correct! Assignment to the rule-out pathway does not always equal outpatient management. However, when used in conjunction with clinical and ECG findings, the algorithms will enable the identification of appropriate candidates for early discharge and outpatient management.

Incorrect. These patients represent a heterogeneous group and have been shown to have a mortality rate that is comparable to rule-in patients. Therefore, an individual assessment based on the particular risk profile of the patient (i.e. risk scores) is of paramount importance for patients in this group. Additionally, a third measurement of cTn at 3 h (± echocardiography) is recommended as the next step in order to guide further management.

Correct! The role of intravascular imaging is well established as a tool to guide and optimize PCI. Evidence in support of intravascular ultrasound (IVUS) guidance in ACS generally derives from subgroup analyses of allcomers trials. Meta-analysis of available randomized trials confirms the superiority of IVUS guidance in the reduction of MACE, although a definitive, large-scale, multinational trial is missing. OCT (optical coherence tomography) was also studied in randomized controlled trials. In the DOCTORS study, OCT-guided PCI vs. angiography-guided PCI was compared. Higher post-PCI fractional flow reserve (FFR) with OCT guidance was observed.

Incorrect. Intravascular imaging is not a class I recommendation but a class IIa recommendation. The effect of intravascular imaging-guided revascularization on improved clinical outcomes in patients with acute coronary syndromes remains a gap in evidence as per the ESC 2023 Guidelines for the management of acute coronary syndromes.

Incorrect. It may be considered (class IIb, level C recommendation), preferably with OCT.

Correct! This is a level C recommendation (consensus of opinion of the experts and/or small studies, retrospective studies, registries).

Incorrect. In this situation, CABG is recommended. In a small observational study, patients with SCAD treated with CABG had favourable early clinical outcomes, with an event rate up to 5 years similar to that of patients treated conservatively, despite a significant (68%) rate of graft occlusion at 5 years.

Correct! In a small observational study, patients with SCAD treated with CABG had favourable early clinical outcomes, with an event rate up to 5 years similar to that of patients treated conservatively, despite a significant (68%) rate of graft occlusion at 5 years. The rate of graft occlusion over time can be explained by the fact that CABG in these patients may be technically challenging as the dissected coronary artery is more prone to anastomosis failure, and because spontaneous healing over time may restore the flow in the anastomosed vessel. For this reason, vein grafts should be considered in these patients in order to preserve arterial conduits for future use.

Incorrect. Conservative medical management, as opposed to PCI, is generally recommended for patients with SCAD. In an international case series, coronary complications following PCI occurred in >30% of patients. In a pooled analysis of three SCAD-PCI cohorts including 215 patients (94% female) drawn from Dutch, Spanish, and UK registries, and a matched cohort of conservatively managed SCAD patients (n = 221), PCI was associated with complications in ≈40% of cases (including 13% with serious complications).

Correct! PCI is recommended only for SCAD with associated symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. Useful strategies for these patients may include minimal plain balloon angioplasty to restore flow, followed by a conservative strategy, targeted stenting to seal the proximal and distal ends of the dissection, and/or extended stent lengths to prevent propagation of the haematoma.

Incorrect. Based on the CULPRIT-SHOCK trial including ACS patients (both with and without ST-segment elevation or equivalent), PCI during the index procedure should be restricted to the IRA only. In the CULPRIT-SHOCK trial, IRA-only PCI was associated with a significant reduction in all-cause death or renal replacement therapy at 30-day follow-up. At 1-year follow-up, mortality did not differ significantly between the two groups.

Correct! This is a class IIa, level C recommendation. It should be based on ischaemia, symptoms, patient comorbidities and clinical condition.

Correct! Based on the CULPRIT-SHOCK trial including ACS patients (both with and without ST-segment elevation or equivalent), PCI during the index procedure should be restricted to the IRA only. In the CULPRIT-SHOCK trial, IRA-only PCI was associated with a significant reduction in all-cause death or renal replacement therapy at 30-day follow-up. At 1-year follow-up, mortality did not differ significantly between the two groups.

Incorrect. This is recommended in haemodynamically stable STEMI patients with multivessel disease, not in patients with cardiogenic shock.

Incorrect. Complete revascularization, either during the index procedure or within 45 days is recommended. This is based on the data from the COMPLETE trial, where PCI of non-IRA was performed either during hospitalization or after discharge but always within 45 days. No treatment effect by timing of PCI interaction was observed. Given that the optimal timing of revascularization (immediate vs. staged) has still not been investigated in adequately sized randomized trials with a superiority design, no recommendation in favour of an immediate vs. a staged (i.e. either during index hospitalization or within 45 days of discharge) non-IRA PCI strategy can be formulated.

Correct! A meta-analysis of 10 randomized controlled trials (RCTs) (including 3031 patients undergoing primary PCI) assessed outcomes in patients with complete revascularization vs. IRA-only PCI according to whether the decision to carry out non-IRA preventive PCI was based on angiography alone or on angiography plus FFR (fractional flow reserve). Preventive PCI of the non-IRA was associated with a significant reduction in cardiac death and non-fatal MI only when the decision to proceed with non-IRA PCI was based solely on angiography. Similar findings were reported in another meta-analysis of seven RCTs including a total of 6597 patients undergoing primary PCI.

Incorrect. It is recommended based on angiography severity, not FFR. In a meta-analysis of 10 randomized controlled trials preventive PCI of the non-IRA was associated with a significant reduction in cardiac death and non-fatal MI only when the decision to proceed with non-IRA PCI was based solely on angiography.

Correct! Complete revascularization, either during the index procedure or within 45 days is recommended. This is based on the data from the COMPLETE trial, where PCI of non-IRA was performed either during hospitalization or after disacharge but always within 45 days. No treatment effect by timing of PCI interaction was observed. Given that the optimal timing of revascularization (immediate vs. staged) has still not been investigated in adequately sized randomized trials with a superiority design, no recommendation in favour of an immediate vs. a staged (i.e. either during index hospitalization or within 45 days of discharge) non-IRA PCI strategy can be formulated.

Incorrect. CMR is recommended. CMR can identify the underlying cause in up to 87% of patients with a working diagnosis of MINOCA and should be performed as soon as possible after presentation in these patients to maximize its diagnostic yield, ideally during the index admission.

Incorrect. CMR is recommended. CMR can identify the underlying cause in up to 87% of patients with a working diagnosis of MINOCA and should be performed as soon as possible after presentation in these patients to maximize its diagnostic yield, ideally during the index admission.

Correct! If the underlying cause of MINOCA is not established using functional coronary angiography, then non-invasive imaging (i.e. echocardiography, CMR, CT) is recommended, as clinically appropriate. CMR is one of the key diagnostic tools to determine the underlying cause of MINOCA. CMR can identify the underlying cause in up to 87% of patients with a working diagnosis of MINOCA and should be performed as soon as possible after presentation in these patients to maximize its diagnostic yield, ideally during the index admission.

Incorrect. CMR is recommended. CMR can identify the underlying cause in up to 87% of patients with a working diagnosis of MINOCA and should be performed as soon as possible after presentation in these patients to maximize its diagnostic yield, ideally during the index admission.

Correct! Myocardial bridges are a commonly overlooked cause of angina in patients without obstructive coronary artery disease and can be visualized with coronary angiography.

Incorrect. One of the features of MINOCA is the absence of stenosis ≥50% in a major epicardial artery demonstrated on coronary angiography. MINOCA is a working diagnosis in patients with symptoms suggestive of acute coronary syndrome, demonstrating troponin elevation (meeting the Universal Definition criteria), with no coronary stenosis >50% in any major epicardial vessel and no clinically overt specific cause for the acute presentation other than acute MI. It is vital for clinicians to perform further assessments and investigations to establish the underlying cause of the MINOCA, which will allow a final diagnosis to be established and patients to be managed appropriately. Failure to identify the underlying cause of MINOCA may result in inadequate or inappropriate therapy.

Correct! MINOCA can be considered as an umbrella term that encompasses a heterogeneous group of underlying causes that can include both cardiac and extra-cardiac disorders such as acute respiratory distress syndrome, end-stage renal failure, inflammation, and others. A CT scan of the brain should be considered if a cranial pathology (i.e. intracranial bleed) is suspected that might have resulted in ST elevation.

Correct! Even extra-cardiac disorders such as acute respiratory distress syndrome, end-stage renal failure, inflammation and others can be considered causes of MINOCA.

Incorrect. Echocardiography remains the first-line imaging test, but the gold standard is CMR. Contemporary CMR data report LV thrombi in up to 6.3% of all STEMI patients and in 12.2% of those with anterior STEMI, suggesting that the incidence of LV thrombi may be underestimated with echocardiography. Patients with LV thrombi that were not evident on echocardiography but were detected by CMR appear to have similar clinical outcomes to patients with LV thrombi that were evident on echocardiography. Therefore, CMR should be considered in patients with equivocal echocardiographic images or in patients considered to be at a particularly high risk of LV thrombus.

Correct! Contemporary CMR data report LV thrombi in up to 6.3% of all STEMI patients and in 12.2% of those with anterior STEMI, suggesting that the incidence of LV thrombi may be underestimated with echocardiography. Patients with LV thrombi that were not evident on echocardiography but were detected by CMR appear to have similar clinical outcomes to patients with LV thrombi that were evident on echocardiography. Therefore, CMR should be considered in patients with equivocal echocardiographic images or in patients considered to be at a particularly high risk of LV thrombus.

Incorrect. Oral anticoagulant therapy (vitamin K antagonist or NOAC) should be considered for 3–6 months in patients with confirmed LV thrombus, guided by repeated echocardiography or CMR and with consideration of bleeding risk and the need for concomitant antiplatelet therapy. However, there are a lack of prospective randomized data on the optimal anticoagulation regimen, anticoagulation duration, and the combination of oral anticoagulation with antiplatelet agents in patients with LV thrombus following MI. The choice of therapy should be tailored to the patient’s clinical status and the results of follow-up investigations.

Correct! The timing of imaging for LV thrombus may also be relevant, given that the identification of LV thrombus has been reported to increase in the first 2 weeks post-MI. While more contemporary data are required, these data suggest that a high proportion of LV thrombi may develop following hospital discharge, indicating that delayed imaging at 2 weeks in high-risk patients may be of value.

Correct! Mechanical complications may occur in the first days following MI, most commonly in patients presenting with STEMI. Sudden hypotension, the recurrence of chest pain, new cardiac murmurs suggestive of acute mitral regurgitation or a ventricular septal defect, pulmonary congestion, or jugular vein distension should raise suspicion of a mechanical complication. Immediate echocardiographic assessment is indicated when mechanical complications are suspected.

Incorrect. Mechanical complications may occur in the first days following MI, most commonly in patients presenting with STEMI. Sudden hypotension, the recurrence of chest pain, new cardiac murmurs suggestive of acute mitral regurgitation or a ventricular septal defect, pulmonary congestion, or jugular vein distension should raise suspicion of a mechanical complication. Immediate echocardiographic assessment is indicated when mechanical complications are suspected.

Incorrect. Mechanical complications may occur in the first days following MI, most commonly in patients presenting with STEMI. Sudden hypotension, the recurrence of chest pain, new cardiac murmurs suggestive of acute mitral regurgitation or a ventricular septal defect, pulmonary congestion, or jugular vein distension should raise suspicion of a mechanical complication. Immediate echocardiographic assessment is indicated when mechanical complications are suspected.

Incorrect. Mechanical complications may occur in the first days following MI, most commonly in patients presenting with STEMI. Sudden hypotension, the recurrence of chest pain, new cardiac murmurs suggestive of acute mitral regurgitation or a ventricular septal defect, pulmonary congestion, or jugular vein distension should raise suspicion of a mechanical complication. Immediate echocardiographic assessment is indicated when mechanical complications are suspected.

Incorrect. Pericarditis usually develops as an early infarct-associated pericarditis (occurring from a few hours to 4 days after acute MI, mostly transient) or a late pericarditis or post-cardiac injury (Dressler) syndrome (typically starting from 1-2 weeks to 10 weeks following an acute MI). Pericarditis beyond this time frame is not typical.

Correct! This is referred to as late pericarditis or post-cardiac injury (Dressler) syndrome (typically starting from 1-2 weeks to 10 weeks following an acute MI). This incidence of late pericarditis (<5%) is lower than the incidence of early infarct-associated pericarditis (10-20%), and it is usually associated with a larger infarct size. It does not carry independent prognostic significance.

Correct! This is referred to as early infarct-associated pericarditis. It is usually self-limited and can be treated with aspirin 500 mg every 8-12 hours typically up to 5-7 days.

Incorrect. Pericarditis after acute MI is not associated with infectious etiology. Early pericarditis develops after acute MI, with transmural necrosis causing inflammation of the adjacent pericardium. The pathophysiological mechanism in Dressler syndrome probably involves a hypersensitivity immune reaction in genetically predisposed individuals following the release of cardiac antigens during acute MI.

Incorrect. The current treatment goal for secondary prevention is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to achieve a ≥50% LDL-C reduction from baseline. This is a class I, level A recommendation.

Incorrect. The current treatment goal for secondary prevention is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to achieve a ≥50% LDL-C reduction from baseline. This is a class I, level A recommendation.

Correct! The current treatment goal for secondary prevention is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to achieve a ≥50% LDL-C reduction from baseline. This is a class I, level A recommendation.

Incorrect. The current treatment goal for secondary prevention is to lower LDL-C to <1.4 mmol/L (<55 mg/dL) and to achieve a ≥50% LDL-C reduction from baseline. This is a class I, level A recommendation.

Correct! The concentrations in healthy very young vs. ‘healthy’ very old individuals differ by up to 300%.

Correct! The differences between otherwise healthy patients with very high vs. very low estimated glomerular filtration rate [eGFR] of up to 300%.

Correct! The concentrations vary by more than 300% according to the time from the chest pain onset.

Correct! However, it appears to be a much weaker confounder of hs-cTn values compared with age or renal function. Current data on the use of sex-specific hs-cTn values in the diagnosis of MI have been controversial and failed to demonstrate a clear clinical benefit. Therefore, until automated tools (i.e. risk assessment calculators) incorporating the effect of all four clinical variables (age, eGFR, time from chest pain onset, and sex) are available, the use of uniform cut-off concentrations should remain the standard of care for the early diagnosis of MI.

Correct! It is recommended to initiate high-potency, high-dose statin therapy in all LLT-naïve patients, regardless of their LDL-C values. (Class I, level A recommendation).

Incorrect. It is recommended to initiate high-potency, high-dose statin therapy in all LLT-naïve patients, regardless of their LDL-C values. (Class I, level A recommendation). 4-6 weeks after the initiation of the therapy, the desired LDL-C value should be <1.4 mmol/L

Incorrect. Statins are the first-line therapy in all LLT-naïve patients presenting with an ACS event. It is recommended to add ezetimibe to prior high-intensity statin therapy in ACS patients with LDL-C values >1.4 mmol/L during admission. Combination of statin + ezetimibe may be considered during the index admission.

Correct! The intensity of statin therapy should be increased in patients who were receiving low- or moderate-intensity statin treatment before the ACS event. After an ACS event, lipid-lowering treatment should be initiated as early as possible, both for prognostic benefit and to increase patient adherence after discharge. It is recommended that a high-intensity statin (e.g. atorvastatin or rosuvastatin) is initiated as early as possible after hospital admission, preferably before planned PCI, and pre- scribed up to the highest tolerated dose in order to reach the LDL-C goals.

Incorrect. Re-evaluation of lipid levels is recommended after 4-6 weeks.

Incorrect. Re-evaluation of lipid levels is recommended after 4-6 weeks.

Correct! In all cases, lipid levels should be re-evaluated 4–6 weeks after each treatment or dose adjustment to determine whether treatment goals have been achieved and to check for any safety issues; the therapeutic regimen can then be adapted accordingly.

Incorrect. Re-evaluation of lipid levels is recommended after 4-6 weeks.

Correct! This is a class I recommendation.

Correct! Evolocumab and alirocumab are both PCSK9 inhibitors and therefore recommend as the next step in LLT in this situation.

Incorrect. Next step is the addition of a PCSK9 inhibitor. There is no specific recommendation for bempedoic acid as per the 2023 ESC guidelines for the management of acute coronary syndromes. Bempedoic acid is a novel, first-in-class, oral small molecule that inhibits cholesterol synthesis by inhibiting the action of ATP citrate lyase, an enzyme upstream of HMG-CoA reductase. In a phase III trial in 2230 ASCVD patients on maximally tolerated statin therapy and a mean LDL-C level of 103 mg/dL, treatment with bempedoic acid 180 mg per day lowered LDL-C by 18% vs. placebo. Interestingly, high-sensitivity C-reactive protein was also significantly lowered, and there was no effect on muscle-related symptoms. Bempedoic acid was also tested in statin-intolerant patients and in combination with ezetimibe.

Incorrect. Next step is the addition of a PCSK9 inhibitor. There is no specific recommendation for inclisiran. Inclisiran is a small interfering RNA molecule with long-lasting effects on PCSK9 synthesis and is administered subcutaneously every 6 months. Inclisiran was tested in two phase III trials in patients with ASCVD (atherosclerotic cardiovascular disease) on maximally tolerated statin therapy, with or without other LDL-C-lowering agents. A meta-analysis combining these two randomized controlled trials with a trial in patients with heterozygous familial hypercholesterolaemia, including a total of 3660 patients, demonstrated that inclisiran treatment reduced LDL-C by ∼50% over a time course of 18 months, with stable effects on LDL-C for ≥6 months after each injection. A high percentage of patients achieved LDL-C reductions ≥50% and an LDL-C threshold <50 mg/dL. No specific serious adverse events were observed. There are no outcome data available yet; a large cardiovascular outcomes trial is currently comparing inclisiran against placebo in patients with prior MI or stroke.

Incorrect. The routine use of beta-blockers for all ACS patients regardless of LVEF should be considered (class IIa, level B recommendation). The strongest evidence is for the patients with LVEF <40%, but less well established for patients with LVEF >40%. Modern observational studies and meta-analyses have yielded mixed results, with some studies suggesting a benefit of beta-blocker therapy irrespective of LVEF, and others reaching the opposite conclusion.

Correct! The clinical benefit of beta-blockers after ACS in patients with reduced LVEF is supported by evidence from contemporary trials. The CAPRICORN randomised trial showed that in patients treated long-term after an acute myocardial infarction complicated by left-ventricular systolic dysfunction, carvedilol reduced the frequency of all-cause and cardiovascular mortality, and recurrent, non-fatal myocardial infarctions.

Incorrect. The evidence for routine use of beta-blockers in patients after ACS with LVEF >40% is less well established. There are four ongoing pragmatic prospective large-scale RCTs (randomized controlled trials) in Europe randomizing ACS patients without reduced LVEF to beta-blocker or control: REBOOT-CNIC, 8468 ACS patients with LVEF >40%; REDUCE-SWEDEHEART 5000 ACS patients with LVEF ≥50%, BETAMI, 10 000 ACS patients with LVEF >40%; and DANBLOCK, 3570 ACS patients with LVEF >40%.

Incorrect.

Correct.Class I, LOA A.

Correct. Class I, LOA A.

Correct. Class IIa, LOA A.

Inocorrect. It is Class IIa, LOA A.

Incorrect. Left circumflex (LCX) artery occlusion or right ventricular MI is characterized by ST-segment elevation in V7-V9 and V3R and V4R, respectively.

Incorrect. De Winter ST-T signifies proximal left anterior descending artery occlusion. It is characterized by 1-3mm upsloping ST-segment depression at the J point in leads V1-V6 that continue into tall, positive and symmetrical T waves.

Correct! It signifies proximal LAD (left anterior descending) artery occlusion/severe stenosis. This pattern was described in the early 1980s. In a series of 1260 patients hospitalized for unstable angina (UA) between July 1980 and December 1985, 204 (16%) had this ECG pattern. After excluding patients with recent MI and missing data, 180 patients were further analyzed. All of these patients had stenosis of ≥50% in the proximal LAD and 18% had a total occlusion. The type A pattern was present in 25% of patients.

Incorrect. This sign is characterized by symmetric and deeply inverted T waves in leads V2 and V3, and occasionally in leads V1,V4,V5, and V6. Recognition of this type is equally important, as it also signifies proximal LAD occlusion/severe stenosis.

Correct!

Incorrect. It can differentiate both between acute myocardial infarction and acute myocardial injury from chronic myocardial injury (in this case troponin levels would be stable), but not acute MI from acute myocardial injury by itself. To differentiate acute myocardial infarction from acute myocardial injury there has to be evidence of ischemia (symptoms, new ischaemic ECG changes, development of pathological Q waves, imaging evidence of new loss of viable myocardium etc.).

Correct!

Correct! These causes include both cardiac (heart failure, hypertensive emergencies, myocarditis, takotsubo syndrome, and valvular heart disease) and non-cardiac conditions (critical illness, chronic kidney disease, stroke, pulmonary embolism).

Incorrect. Routine, early CCTA in patients with suspected ACS is not recommended (class III, level B).

Correct! Emergency TTE is recommended in patients with suspected ACS with cardiogenic shock or suspected mechanical complications (class I, level C).

Incorrect. Only TTE has class I, level C recommendation in this situation.

Incorrect. CMR is not recommended in cases of haemodynamic instability.