Non-ST-Elevation Acute Coronary Syndromes, Free CME Quiz
This week's Med-Challenger free CME quiz - Non-ST-Elevation Acute Coronary Syndromes - Special Patient Groups - the quick quiz covers different presentations of non-ST elevation acute coronary syndrome in women and men, management of non–ST elevation acute coronary syndrome in a patient after undergoing coronary artery bypass grafting, the presentation and treatment of stress "Takotsubo” cardiomyopathy, and management of non-ST elevation acute coronary syndrome in patients with diabetes mellitus.
A free Non-ST-Elevation Acute Coronary Syndromes - Special Patient Groups question included below. The full Non-ST-Elevation Acute Coronary Syndromes - Special Patient Groups CME quiz is free online for a limited time. You can earn AMA CME credit - and now you can earn ANCC contact hours as well! Play now.
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Here's this week's sample CME board review question on Non-ST-Elevation Acute Coronary Syndromes - Special Patient Groups:
A 56-year-old woman with type I diabetes mellitus presents to you with 6 hours of dull, substernal chest pain radiating to her left arm.
Her vital signs are normal.
Electrocardiography reveals 2-mm ST depression in leads II, III, and aVF.
Her blood glucose level is 260 mg/dL, and a troponin level is 1.0 ng/dL (normal < 0.6 ng/dL).
Question:
Which of the following is correct regarding the management of non–ST elevation acute coronary syndrome (NSTE-ACS) in patients with diabetes mellitus?
Answer Options:
Blood glucose level should be maintained between 81 mg/dL and 108 mg/dL
Blood glucose level should be maintained below 180 mg/dL while avoiding hypoglycemia
Glycoprotein IIb/IIIa inhibitors are contraindicated in patients with diabetes mellitus
The threshold to proceed to cardiac catheterization is the same in patients with diabetes mellitus as in those without the disease
See the Answer:
The correct answer is:
Blood glucose level should be maintained below 180 mg/dL while avoiding hypoglycemia
Educational Objective:
Manage non-ST elevation acute coronary syndrome in patients with diabetes mellitus.
Key Point:
Blood glucose should be controlled to a level below 180 mg/dL while avoiding hypoglycemia.
Explanation:
Blood glucose should be maintained at a level below 180 mg/dL while avoiding hypoglycemia. The 2014 practice guidelines for NSTE-ACS reaffirm the previous recommendation from 2012 for moderate glucose control with maintenance of blood glucose to a level below 180 mg/dL while avoiding hypoglycemia. Both hyperglycemia and hypoglycemia have been found to increase mortality in patients with diabetes mellitus and acute coronary syndrome. One trial revealed that intensive glucose control (target goal, 81-108 mg/dL) resulted in increased mortality and hypoglycemia when compared with moderate glucose control (target goal < 180 mg/dL).
The 2014 practice guidelines for NSTE-ACS also recommend that treatment decisions and medical treatment options be similar for patients with or without diabetes in the acute phase of NSTE-ACS (class I recommendation). This includes use of glycoprotein IIb/IIIa inhibitors as indicated, percutaneous coronary intervention for single-vessel disease, and coronary artery bypass graft surgery for patients with multivessel disease.
The threshold to proceed with cardiac catheterization may or may not be affected by the presence of diabetes. One of the TIMI score categories adds a point if a patient has 3 or more of the following cardiac risk factors: diabetes, hypercholesteremia, hypertension, family history of CAD, or current smoker. Diabetes by itself will not affect the TIMI score, but it adds weight to the “3 or more cardiac risk factors” point in the TIMI score.
Follow this link to an online TIMI score calculator.
References:
Amsterdam EA, Wenger NK, Brindis RG, et al; ACC/AHA Task Force Members. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [Erratum appears in Circulation. 2014;130(25):e433-e434]. Circulation. 2014;130(25):e344-e426.
Anderson JL, Adams CD, Antman EM, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(23):e663-e828.
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