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CDE Diabetes

Practice Exam: Management of Acute Coronary Syndromes (Chapter 27)

While the rates of acute myocardial infarction have decreased over the last two decades, the burden of disease remains disproportionately high for people with diabetes. The 2018 Clinical Practice Guidelines highlight a concerning paradox: despite having a higher risk of mortality and recurrent events, individuals with diabetes are often less likely to receive evidence-based therapies such as early invasive strategies and dual antiplatelet therapy.

This practice exam tests your ability to identify these treatment gaps and apply the specific protocols for glycemic management during an acute coronary event.

Key Concepts Covered in This Exam:

  • Prognostic Indicators: Understanding that diabetes and acute hyperglycemia are independent predictors of short- and long-term mortality, recurrent MI, and heart failure.

  • The “Treatment Gap”: Recognizing that patients with diabetes are statistically less likely to receive recommended interventions—including revascularization, fibrinolysis, and beta-blockers—compared to those without diabetes.

  • Acute Glycemic Control: Mastering the protocol for patients presenting with hyperglycemia (random glucose >11.0 mmol/L) and the target range of 7.0–10.0 mmol/L to improve outcomes.

  • Pharmacotherapy: Applying recommendations for the use of dual antiplatelet therapy (DAPT) and ACE inhibitors in the high-risk post-MI population.

  • Revascularization Strategies: Understanding the importance of promoting adherence to invasive strategies when indicated, rather than deferring due to diabetes status.

1. The guidelines note that despite the decrease in MI rates, the burden of MI in people with diabetes continues to rise. What is the primary reason?

2. Case: A quality improvement team is reviewing care gaps. According to the guidelines, people with diabetes are less likely to receive which treatments compared to people without diabetes?

3. Case: A 65-year-old patient with diabetes has single-vessel coronary disease not involving the LAD and a SYNTAX score of 18. What revascularization approach is acceptable?

4. What is the frequency of previously unrecognized diabetes in the ACS population according to the guidelines?

5. According to the guidelines, what percentage of people admitted with an acute coronary syndrome have known diabetes?

6. Case: A patient with diabetes and STEMI requires reperfusion. PPCI is available within 90 minutes. What is the recommendation?

7. Case: A patient with type 2 diabetes is hospitalized with ACS. Their blood glucose during the first 24 hours averages 14 mmol/L. Based on the guidelines, what is the clinical significance?

8. What is the target blood glucose range for people with ACS and hyperglycemia according to Diabetes Canada?

9. According to the guidelines, at what random blood glucose level should antihyperglycemic therapy be considered in people with acute MI?

10. According to the guidelines, what fraction of people with MI have either diabetes or prediabetes?

11. A diabetes educator is explaining why clopidogrel may be less effective in some patients with diabetes. What is the evidence-based explanation?

12. Compared to individuals without diabetes, people with diabetes have what increased risk of acute coronary syndrome?

13. What percentage reduction in acute MI rates occurred in people with diabetes between 1990 and 2010?

14. Case: A clinical team is discussing whether FPG alone is adequate for diagnosing diabetes in ACS patients. Based on the evidence, what is accurate?

15. According to the guidelines, acute coronary events occur how many years earlier in people with diabetes compared to those without?

16. Case: A healthcare team is reviewing why people with diabetes have worse outcomes after ACS. According to the guidelines, which factor contributes to adverse outcomes?

17. Case: A patient without known diabetes is admitted with ACS. Their random plasma glucose is 12.5 mmol/L. What should be initiated?

18. Case: A 58-year-old woman with diabetes presents with NSTE-ACS. She has complex multivessel coronary disease including the LAD. What revascularization modality is preferred?

19. At what A1C threshold should in-hospital capillary blood glucose monitoring be initiated in people without a history of diabetes admitted with ACS?

20. Case: A clinician asks why CABG is preferred over complex PCI in people with diabetes and complex coronary anatomy. What is the evidence-based rationale?

21. Case: A 62-year-old man with type 2 diabetes presents with NSTE-ACS and is undergoing PCI. He is clopidogrel naïve, weighs 75 kg, is 68 years old, and has no history of stroke. Which antiplatelet agent is preferred over clopidogrel?

22. For prasugrel use in people with diabetes and ACS, which patient characteristic is a contraindication according to the guidelines?

23. What is the increased short-term and long-term mortality risk in people with diabetes compared to those without diabetes after ACS?

24. Case: A patient with diabetes and NSTE-ACS with high-risk features is being managed. What strategy is recommended for revascularization?

25. According to the guidelines, what is one reason people with diabetes have a pro-thrombotic state?

26. According to the prediction model cited in the guidelines, which factors are significantly associated with 5-year mortality after AMI in people with diabetes?

27. What is the clinical significance of the finding that in-hospital mortality has a closer relationship to hyperglycemia than to diabetic status?