ACS

ACS US Medical PG Question 1: A primary care physician who focuses on treating elderly patients is researching recommendations for secondary prevention. She is particularly interested in recommendations regarding aspirin, as she has several patients who ask her if they should take it. Of the following, which patient should be started on lifelong aspirin as monotherapy for secondary prevention of atherosclerotic cardiovascular disease?

• A. An 83-year-old female with a history of a hemorrhagic stroke 1 year ago without residual deficits
• B. A 75-year-old male who had a drug-eluting coronary stent placed 3 days ago
• C. A 67-year-old female who has diabetes mellitus and atrial fibrillation
• D. A 45-year-old female with no health problems
• E. A 63-year-old male with a history of a transient ischemic attack (Correct Answer)

ACS Explanation: **A 63-year-old male with a history of a transient ischemic attack** - A patient with a history of **Transient Ischemic Attack (TIA)** has a high risk of subsequent stroke and should be on **lifelong aspirin monotherapy** for secondary prevention of **atherosclerotic cardiovascular disease (ASCVD)**. - Aspirin helps prevent further thrombotic events by inhibiting platelet aggregation, making it a cornerstone for secondary prevention after TIA or ischemic stroke. *An 83-year-old female with a history of a hemorrhagic stroke 1 year ago without residual deficits* - Aspirin is generally **contraindicated** in patients with a history of **hemorrhagic stroke** due to the increased risk of recurrent bleeding. - In such cases, the risks of aspirin therapy typically **outweigh the benefits** for cardiovascular prevention. *A 75-year-old male who had a drug-eluting coronary stent placed 3 days ago* - A patient with a recently placed **drug-eluting stent (DES)** requires **dual antiplatelet therapy (DAPT)**, typically aspirin plus a P2Y12 inhibitor, for a specific duration (e.g., 6-12 months), not aspirin monotherapy. - Monotherapy with aspirin alone would be **insufficient** to prevent stent thrombosis in the immediate post-stenting period. *A 67-year-old female who has diabetes mellitus and atrial fibrillation* - This patient has two significant risk factors requiring specific management: **diabetes mellitus** for cardiovascular risk and **atrial fibrillation** for stroke risk. - For atrial fibrillation, **anticoagulation with warfarin or a direct oral anticoagulant (DOAC)** is typically indicated, which makes aspirin monotherapy either unnecessary or potentially harmful if used alone. *A 45-year-old female with no health problems* - There is no indication for **aspirin primary prevention** in this patient, especially given the increased risk of bleeding without a clear cardiovascular benefit. - Guidelines currently recommend against routine aspirin use for primary prevention in healthy individuals due to the **unfavorable risk-benefit ratio**.

ACS US Medical PG Question 2: A cardiologist is studying how a new virus that infects the heart affects the electrical conduction system of the cardiac myocytes. He decides to obtain electrocardiograms on patients with this disease in order to see how the wave patterns and durations change over time. While studying these records, he asks a medical student who is working with him to interpret the traces. Specifically, he asks her to identify the part that represents initial ventricular depolarization. Which of the following characteristics is most consistent with this feature of the electrocardiogram?

• A. Elevated in patients with full thickness ischemic injury of the heart
• B. Becomes peaked in states of hyperkalemia
• C. Becomes prominent in states of hypokalemia
• D. Normal duration defined as less than 120 milliseconds (Correct Answer)
• E. Normal duration defined as less than 200 milliseconds

ACS Explanation: ***Normal duration defined as less than 120 milliseconds*** - The question asks for the representation of **initial ventricular depolarization**, which corresponds to the **QRS complex** on an ECG. - The normal duration of the **QRS complex** is typically less than **0.12 seconds (120 milliseconds)**, reflecting efficient ventricular depolarization. *Elevated in patients with full thickness ischemic injury of the heart* - This description refers to the **ST segment elevation** seen in **ST-segment elevation myocardial infarction (STEMI)**, which represents myocardial injury, not initial ventricular depolarization. - While related to cardiac electrical activity, **ST segment elevation** is a consequence of injury and refers to repolarization abnormalities, not the QRS complex itself. *Becomes peaked in states of hyperkalemia* - **Peaked T waves** are characteristic of **hyperkalemia**, indicating altered ventricular repolarization, not ventricular depolarization. - The T wave represents ventricular repolarization, and its morphology changes significantly with potassium imbalances. *Becomes prominent in states of hypokalemia* - A **prominent U wave** is sometimes observed in **hypokalemia**, which follows the T wave and is thought to represent repolarization of Purkinje fibers. - The U wave is distinct from the QRS complex and does not represent initial ventricular depolarization. *Normal duration defined as less than 200 milliseconds* - A duration of less than 200 milliseconds (0.20 seconds) typically refers to the normal duration of the **PR interval**, which represents atrial depolarization and conduction through the AV node. - The **QRS complex** (initial ventricular depolarization) has a shorter normal duration, typically less than 120 milliseconds.

ACS US Medical PG Question 3: A 72-year-old man comes to the physician because of a 2-month history of intermittent retrosternal chest pain and tightness on exertion. He has type 2 diabetes mellitus, osteoarthritis of the right hip, and hypertension. Current medications include insulin, ibuprofen, enalapril, and hydrochlorothiazide. Vital signs are within normal limits. His troponin level is within the reference range. An ECG at rest shows a right bundle branch block and infrequent premature ventricular contractions. The patient's symptoms are reproduced during adenosine stress testing. Repeat ECG during stress testing shows new ST depression of > 1 mm in leads V2, V3, and V4. Which of the following is the most important underlying mechanism of this patient's ECG changes?

• A. Diversion of blood flow from stenotic coronary arteries (Correct Answer)
• B. Transient atrioventricular nodal blockade
• C. Reduced left ventricular preload
• D. Ruptured cholesterol plaque within a coronary vessel
• E. Increased myocardial oxygen demand

ACS Explanation: ***Diversion of blood flow from stenotic coronary arteries*** - The **adenosine stress test** induces **submaximal coronary vasodilation** in healthy vessels, diverting blood flow away from stenosed areas that are already maximally dilated, a phenomenon known as **coronary steal**. - This **relative hypoperfusion** in areas supplied by stenotic arteries leads to myocardial ischemia, manifested as **new ST depression** on the ECG due to **subendocardial oxygen supply-demand mismatch**. *Transient atrioventricular nodal blockade* - While adenosine can cause transient AV nodal blockade, leading to AV blocks, this would manifest as specific changes in **PR interval** or **QRS drop-out**, not ST segment depression indicative of ischemia. - The patient's symptoms and ECG changes point towards myocardial ischemia, not an AV conduction disturbance. *Reduced left ventricular preload* - Reduced preload can occur in certain cardiac conditions but is not the primary mechanism behind ST depression during an adenosine stress test. - ECG changes due to reduced preload are usually nonspecific, such as **sinus tachycardia** or **low voltage**, and do not typically cause new ST depression in specific leads. *Ruptured cholesterol plaque within a coronary vessel* - A ruptured plaque with subsequent **thrombus formation** would lead to **acute coronary syndrome (ACS)**, characterized by persistent chest pain, **elevated troponins**, and potentially **ST elevation** or new **pathologic Q waves** if complete occlusion occurs. - The patient's troponin level is normal, and his symptoms are intermittent and reproducible on stress testing, which is more consistent with **stable angina**. *Increased myocardial oxygen demand* - While increased myocardial oxygen demand is a component of angina pectoris, adenosine primarily causes **coronary vasodilation**, which can worsen ischemia in stenotic areas by diverting blood flow, rather than directly increasing myocardial oxygen demand itself. - **Dobutamine stress testing** would be the test that primarily increases myocardial oxygen demand.

ACS US Medical PG Question 4: A study is conducted to find an association between serum cholesterol and ischemic heart disease. Data is collected, and patients are classified into either the "high cholesterol" or "normal cholesterol" group and also into groups whether or not the patient experiences stable angina. Which type of data analysis is most appropriate for this study?

• A. Attributable risk
• B. Analysis of variance
• C. Chi-squared (Correct Answer)
• D. T-test
• E. Pearson correlation

ACS Explanation: ***Chi-squared*** - The **chi-squared test** is ideal for analyzing two **categorical variables**, such as cholesterol levels (high/normal) and the presence of stable angina (yes/no), to see if there's an association between them. - It assesses whether the observed frequencies in each category differ significantly from the expected frequencies, under the assumption of no association. *Attributable risk* - **Attributable risk** quantifies the proportion of disease in an exposed group that is directly due to the exposure. - While it might be calculated *after* establishing an association (e.g., using a chi-squared test), it's a measure of actual impact rather than a method for *finding the association* between two categorical variables. *Analysis of variance* - **Analysis of variance (ANOVA)** is used to compare the means of **three or more groups** for a continuous outcome variable. - It works when you have a categorical independent variable with multiple levels and a continuous dependent variable, which is not the case here as both variables are categorical. *T-test* - A **t-test** is used to compare the means of **two groups** for a continuous outcome variable. - It is not appropriate for analyzing the association between two categorical variables like cholesterol categories and angina presence. *Pearson correlation* - **Pearson correlation** measures the linear relationship between **two continuous variables**. - It is unsuitable for this study as both cholesterol status and angina presence are categorical variables, not continuous.

ACS US Medical PG Question 5: A 73-year-old man presents to the outpatient clinic complaining of chest pain with exertion. He states that resting for a few minutes usually resolves the chest pain. Currently, he takes 81 mg of aspirin daily. He has a blood pressure of 127/85 mm Hg and heart rate of 75/min. Physical examination reveals regular heart sounds and clear lung sounds bilateral. Which medication regimen below should be added?

• A. Metoprolol and a statin daily. Sublingual nitroglycerin as needed. (Correct Answer)
• B. Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.
• C. Amlodipine and a statin daily. Sublingual nitroglycerin as needed.
• D. Amlodipine daily. Sublingual nitroglycerin as needed.
• E. Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.

ACS Explanation: ***Metoprolol and a statin daily. Sublingual nitroglycerin as needed.*** - This patient presents with symptoms consistent with **stable angina** (**chest pain with exertion, relieved by rest**). The recommended medical therapy includes **antiplatelet agents** (aspirin, already prescribed), **beta-blockers** (metoprolol) for symptom control and improved survival post-MI, and **high-intensity statins** for lipid management and plaque stabilization. **Sublingual nitroglycerin** is crucial for acute symptom relief. - Beta-blockers like metoprolol decrease myocardial **oxygen demand** by reducing heart rate and contractility, effectively treating angina. Statins are essential for **atherosclerosis management**. *Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.* - While clopidogrel is an **antiplatelet agent**, aspirin is typically the first-line choice for stable angina unless there's an intolerance or compelling reason for dual antiplatelet therapy (e.g., recent stent placement), which is not indicated here. - Amlodipine, a **calcium channel blocker**, can be used for angina but is usually a second-line agent if beta-blockers are contraindicated or insufficient; it doesn't offer the mortality benefit seen with beta-blockers post-MI. *Amlodipine and a statin daily. Sublingual nitroglycerin as needed.* - This regimen includes a **statin** and sublingual nitroglycerin, which are appropriate. However, it uses amlodipine instead of a beta-blocker, which is generally the preferred initial therapy for angina due to its benefits in reducing myocardial oxygen demand and improving outcomes, especially in patients with a history of MI or heart failure. - Beta-blockers provide superior **mortality reduction benefits** in patients with coronary artery disease compared to calcium channel blockers. *Amlodipine daily. Sublingual nitroglycerin as needed.* - This option misses two critical components of comprehensive treatment for stable angina: a **statin** for lipid management and plaque stabilization, and a **beta-blocker** for primary symptom control and long-term cardiac protection. - Relying solely on amlodipine and sublingual nitroglycerin would leave the patient incompletely treated for their underlying **coronary artery disease**. *Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.* - This option lacks a **statin**, which is a cornerstone of therapy for stable angina to manage atherosclerosis. - While metoprolol is appropriate and ranolazine can be used as an add-on therapy for refractory angina, it's not typically a first-line agent and doesn't replace the need for a statin.

ACS US Medical PG Question 6: A 1-minute-old newborn is being examined by the pediatric nurse. The nurse auscultates the heart and determines that the heart rate is 89/min. The respirations are spontaneous and regular. The chest and abdomen are both pink while the tips of the fingers and toes are blue. When the newborn’s foot is slapped the face grimaces and he cries loud and strong. When the arms are extended by the nurse they flex back quickly. What is this patient’s Apgar score?

• A. 5
• B. 10
• C. 8 (Correct Answer)
• D. 6
• E. 9

ACS Explanation: ***8*** - The Apgar score is calculated by assigning 0, 1, or 2 points to five criteria: **Appearance**, **Pulse**, **Grimace (reflex irritability)**, **Activity (muscle tone)**, and **Respiration**. - This newborn scores 1 point for **Appearance** (pink body, blue extremities/acrocyanosis), 1 point for **Pulse** (89/min, which is below 100), 2 points for **Grimace** (cries loud and strong), 2 points for **Activity** (arms flex back quickly), and 2 points for **Respiration** (spontaneous and regular), totaling **8**. *5* - An Apgar score of 5 would indicate a more compromised state, with lower scores in multiple categories. - This newborn demonstrates strong respiratory effort, vigorous cry, and active muscle tone, all inconsistent with a score of 5. *10* - A perfect score of 10 is rare and would require the newborn to have a **pink appearance throughout** (including extremities), a heart rate over 100 bpm, strong cry, active movement, and vigorous breathing. - This newborn has two findings preventing a score of 10: **acrocyanosis** (blue extremities) and **heart rate of 89/min** (below 100). *6* - An Apgar score of 6 would imply more significant compromise, such as weak respiratory effort, minimal response to stimulation, or poor muscle tone. - This newborn's strong cry, vigorous grimace response, and quick flexion indicate better performance than a score of 6. *9* - A score of 9 would mean only one parameter scores 1 point, with all others scoring 2 points. - This newborn has **two parameters scoring 1 point**: **Appearance** (acrocyanosis) and **Pulse** (89/min, below 100), making the maximum possible score 8, not 9.

ACS US Medical PG Question 7: A 60-year-old man presents to the emergency department with progressive dyspnea for the last 3 weeks. He complains of shortness of breath while lying flat and reports nighttime awakenings due to shortness of breath for the same duration. The patient has been a smoker for the last 30 years. Past medical history is significant for myocardial infarction 7 months ago. Current medications include metoprolol, aspirin, and rosuvastatin, but the patient is noncompliant with his medications. His temperature is 37.2°C (98.9°F), the blood pressure is 150/115 mm Hg, the pulse is 110/min, and the respiratory rate is 24/min. Oxygen saturation on room air is 88%. Chest auscultation reveals bilateral crackles and an S3 gallop. On physical examination, the cardiac apex is palpated in left 6th intercostal space. Bilateral pitting edema is present, and the patient is in moderate distress. Which of the following is the best next step in the management of the patient?

• A. Intravenous beta blockers
• B. Intravenous diuretics (Correct Answer)
• C. Echocardiography
• D. Cardiac stress testing
• E. Intravenous inotropes

ACS Explanation: ***Intravenous diuretics*** - The patient presents with classic signs and symptoms of **acute decompensated heart failure**, such as progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral crackles, S3 gallop, pitting edema, and elevated blood pressure with elevated heart rate due to fluid overload. - **Intravenous loop diuretics** (e.g., furosemide) are the most appropriate initial therapy to reduce preload, alleviate pulmonary and systemic congestion, and improve oxygenation. *Intravenous beta blockers* - While beta-blockers are a cornerstone of chronic heart failure management, **starting or acutely increasing beta-blocker dosage in acute decompensated heart failure** can worsen cardiac output and lead to symptomatic hypotension or cardiogenic shock. - Beta-blockers should generally be withheld or reduced during acute exacerbations and reinstituted once the patient is stable. *Echocardiography* - While an **echocardiogram** is essential for diagnosing the underlying cause and assessing cardiac function in heart failure, it is not the *best next step* in a patient presenting with acute, severe symptoms requiring immediate stabilization. - The patient's acute respiratory distress and hypoxemia necessitate immediate medical intervention to reduce fluid overload before detailed diagnostic imaging. *Cardiac stress testing* - **Cardiac stress testing** is used to evaluate for inducible ischemia in stable patients and is not appropriate in the setting of acute decompensated heart failure. - Performing a stress test on a patient with signs of fluid overload and respiratory distress would be dangerous and could exacerbate their condition. *Intravenous inotropes* - **Intravenous inotropes** (e.g., dobutamine, milrinone) are typically reserved for patients with evidence of **cardiogenic shock** or severe heart failure with persistent hypoperfusion despite optimal fluid management and diuretic therapy. - This patient, while acutely ill, primarily exhibits signs of fluid overload without clear evidence of severe hypoperfusion compromising end-organ function.

ACS US Medical PG Question 8: A 39-year-old woman comes to the physician because of a 5-month history of episodic retrosternal chest pain. She currently feels well. The pain is unrelated to exercise and does not radiate. The episodes typically last less than 15 minutes and lead to feelings of anxiety; resting relieves the pain. She has not had dyspnea or cough. She has hyperlipidemia treated with simvastatin. She does not smoke, drink alcohol, or use illicit drugs. Her temperature is 37°C (98.6°F), pulse is 104/min, respirations are 17/min, and blood pressure is 124/76 mm Hg. Cardiopulmonary examination shows no abnormalities. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in the evaluation of coronary artery disease in this patient?

• A. Nuclear exercise stress test
• B. No further testing needed
• C. Troponin I measurement
• D. Dobutamine stress echocardiography
• E. Coronary CT angiogram (Correct Answer)

ACS Explanation: ***Coronary CT angiogram*** - This patient has symptoms (non-exertional chest pain) raising suspicion for coronary artery disease (CAD), but her pre-test probability is low due to young age, female gender, and non-anginal features, making **coronary CT angiogram** an appropriate non-invasive first-line test. - CT angiogram offers high sensitivity for detecting **coronary atherosclerosis** and can rule out CAD in patients with low-to-intermediate pretest probability. *Nuclear exercise stress test* - This test is typically reserved for patients with a **higher pre-test probability of CAD** or those with equivocal initial findings, as it involves radiation exposure and is more resource-intensive. - The patient's chest pain is **unrelated to exercise**, making an exercise-based stress test less directly relevant as a first-line diagnostic. *No further testing needed* - While the patient's symptoms are atypical, her risk factor (hyperlipidemia) and recurrent retrosternal pain warrant further evaluation to **rule out CAD**, even with a low pre-test probability. - Dismissing symptoms without further testing could miss early or atypical presentations of CAD. *Troponin I measurement* - **Troponin I** is used to diagnose **acute myocardial infarction** and indicates active myocardial necrosis; it is not for evaluating chronic, episodic chest pain in a patient who currently feels well. - Her current well-being and the episodic nature of her pain make acute cardiac injury unlikely, and a normal troponin would not rule out underlying CAD. *Dobutamine stress echocardiography* - **Dobutamine stress echocardiography** is typically used for patients who cannot perform an exercise stress test (e.g., due to mobility issues) or when an exercise ECG is non-diagnostic. - Given the patient's ability to exert herself (implied by no known mobility issues) and a non-exertional pain pattern, a CT angiogram offers superior anatomical detail for initial investigation.

ACS US Medical PG Question 9: A 67-year-old man presents to the emergency department for squeezing and substernal chest pain. He states that he was at home eating dinner when his symptoms began. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He is currently taking atorvastatin, lisinopril, insulin, metformin, metoprolol, and aspirin. Six days ago he underwent percutaneous coronary intervention. His temperature is 99.5°F (37.5°C), blood pressure is 197/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable elderly man who is sweating. An ECG is ordered. Which of the following is the best next step in management for this patient?

• A. Stress testing
• B. Angiography (Correct Answer)
• C. Cardiac troponins
• D. Creatine kinase-MB
• E. Myoglobin

ACS Explanation: ***Correct: Angiography*** - This patient presenting with **acute chest pain 6 days post-PCI** is at high risk for **stent thrombosis or acute in-stent restenosis**, which represents a life-threatening emergency. - Given the **clinical instability** (severe hypertension 197/118, tachycardia 120/min, diaphoresis) and classic ACS symptoms in the immediate post-PCI period, **urgent coronary angiography** is the best next step in management. - While ECG and troponins are important diagnostic tools, this patient requires **immediate intervention** to evaluate the recent PCI site and potentially perform emergent revascularization. - In the setting of suspected **acute stent thrombosis**, time to reperfusion is critical, and angiography allows both diagnosis and treatment. *Incorrect: Cardiac troponins* - While troponins are essential biomarkers for myocardial injury and should be obtained, they are a **diagnostic test** rather than definitive management. - Waiting for troponin results would delay definitive management in a patient with clear clinical evidence of ACS. - In this high-risk post-PCI patient with active symptoms, management should not wait for biomarker confirmation. *Incorrect: Stress testing* - Stress testing is **absolutely contraindicated** in patients with active chest pain and suspected acute MI. - It could precipitate further myocardial ischemia, arrhythmias, or cardiac arrest. - Stress testing is reserved for risk stratification in stable patients or after ACS has been ruled out. *Incorrect: Creatine kinase-MB* - CK-MB is less sensitive and specific than troponins for myocardial injury, as it can be elevated in skeletal muscle conditions. - It has a shorter elevation window and has largely been replaced by troponins in modern practice. - Like troponins, it would not change the immediate management need in this clinically unstable patient. *Incorrect: Myoglobin* - Myoglobin lacks cardiac specificity (present in both cardiac and skeletal muscle) and has poor diagnostic accuracy for MI. - Its rapid rise and fall make it unreliable, and it generates many false positives. - It has no role in guiding management decisions in suspected ACS.

ACS US Medical PG Question 10: Two days after undergoing an uncomplicated total thyroidectomy, a 63-year-old woman has acute, progressive chest pain. The pain is sharp and burning. She feels nauseated and short of breath. The patient has a history of hypertension, type 1 diabetes mellitus, medullary thyroid cancer, multiple endocrine neoplasia type 2A, anxiety, coronary artery disease, and gastroesophageal reflux disease. She smoked half a pack of cigarettes daily for 24 years but quit 18 years ago. Current medications include lisinopril, insulin glargine, insulin aspart, sertraline, aspirin, ranitidine, and levothyroxine. She appears anxious and diaphoretic. Her temperature is 37.4°C (99.3°F), pulse is 64/min, respirations are 17/min, and blood pressure is 148/77 mm Hg. The lungs are clear to auscultation. Examination shows a 3-cm linear incision over the anterior neck with 1 mm of surrounding erythema and mild serous discharge. The chest wall and abdomen are nontender. There is 5/5 strength in all extremities and decreased sensation to soft touch on the feet bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

• A. Obtain an ECG and troponin T levels (Correct Answer)
• B. Administer IV pantoprazole and schedule endoscopy
• C. Discontinue levothyroxine and obtain fT4 levels
• D. Administer IV levofloxacin and obtain chest radiograph
• E. Obtain urine and plasma metanephrine levels

ACS Explanation: **Obtain an ECG and troponin T levels** - The patient presents with acute, progressive **chest pain that is sharp and burning**, along with nausea and shortness of breath, which are classic symptoms of an acute coronary syndrome, especially given her history of **coronary artery disease**, hypertension, diabetes, and prior smoking. - An **ECG** and **troponin T levels** are crucial first steps to evaluate for myocardial ischemia or infarction in this high-risk patient. *Administer IV pantoprazole and schedule endoscopy* - While the patient has a history of gastroesophageal reflux disease (GERD) and her pain is described as "burning," the **acuteness, progression, and associated symptoms** (nausea, shortness of breath) in a patient with significant cardiac risk factors make a GI cause less likely as the primary concern. - Empiric treatment for GERD without first ruling out a life-threatening cardiac event would be inappropriate and potentially dangerous. *Discontinue levothyroxine and obtain fT4 levels* - The patient is taking levothyroxine after a thyroidectomy for medullary thyroid cancer, but there is no immediate indication of thyroid hormone imbalance (e.g., hyperthyroidism causing chest pain) that would warrant discontinuing her medication or rushing fT4 levels as the first step in an acute chest pain presentation. - Her pulse of 64/min is not suggestive of hyperthyroidism, which typically causes tachycardia. *Administer IV levofloxacin and obtain chest radiograph* - While shortness of breath can be a symptom of pneumonia, the **sharp, burning nature of the chest pain**, coupled with the absence of fever (temperature 37.4°C is mild), cough, or abnormal lung sounds (lungs clear to auscultation), makes an acute infection like pneumonia less probable as the primary diagnosis. - Antibiotics and a chest radiograph would be considered after ruling out more immediate life-threatening conditions like acute coronary syndrome. *Obtain urine and plasma metanephrine levels* - The patient has a history of multiple endocrine neoplasia type 2A (MEN2A), which includes medullary thyroid cancer and can be associated with pheochromocytoma (adrenal tumor secreting catecholamines). However, her blood pressure (148/77 mm Hg) is not acutely elevated to crisis levels, and her symptoms are more consistent with cardiac ischemia than a pheochromocytoma crisis. - While metanephrine levels would be important for long-term follow-up of MEN2A, they are not the immediate next step for acute chest pain in a patient with known coronary artery disease.

ACS Flashcard 1 of 10

Question: What EKG findings (2) are associated with unstable angina? _____

Answer: ST-segment depression and/or T-wave inversion

ACS Flashcard 2 of 10

Question: What is the most sensitive and specific cardiac biomarker used for diagnosis of myocardial infarction? _____

Answer: Troponin I

ACS Flashcard 3 of 10

Question: In regards to myocardial infarction complications, LV hypertrophy and previous MI protect against _____ rupture

Answer: ventricular free wall

ACS Flashcard 4 of 10

Question: What class of drugs may be used for reperfusion therapy for STEMI when PCI is not available? _____

Answer: Thrombolytics

ACS Flashcard 5 of 10

Question: Myocardial infarction most commonly involves the _____ artery (45%)

Answer: left anterior descending (LAD)

ACS Flashcard 6 of 10

Question: Troponin I levels return to normal _____ after an MI

Answer: 7-10 days

ACS Flashcard 7 of 10

Question: What EKG findings are associated with stable angina? _____

Answer: ST-segment depression (subendocardial ischemia)

ACS Flashcard 8 of 10

Question: What leads show ST elevations or Q waves in an anterolateral myocardial infarction? _____

Answer: V5 - V6

Extra Information:  1. Left anterior descending artery (45%): infarction of the anterior wall and anterior septum of the LV 2. Right coronary artery: infarction of the posterior wall, posterior septum, and papillary muscles** of the LV 3. Left circumflex artery: infarction of the lateral wall of the LV **papillary muscle rupture may often cause mitral regurgitation Watch associated Bootcamp video [https://app.bootcamp.com/med-school/cardiology/videos/myocardial-infarction?index=8] https://onlinemeded.org/spa/cardiology/coronary-artery-disease/acquire?ref=anki  

ACS Flashcard 9 of 10

Question: The second most common artery involved in a myocardial infarction is the _____

Answer: right coronary artery

Extra Information:  1. Left anterior descending artery (45%): infarction of the anterior wall and anterior septum of the LV 2. Right coronary artery: infarction of the posterior wall, posterior septum, and papillary muscles** of the LV 3. Left circumflex artery: infarction of the lateral wall of the LV **papillary muscle rupture may often cause mitral regurgitation Watch associated Bootcamp video [https://app.bootcamp.com/med-school/cardiology/videos/myocardial-infarction?index=4] https://onlinemeded.org/spa/cardiac?ref=anki  

ACS Flashcard 10 of 10

Question: Unstable angina is characterized by chest pain that occurs during _____

Answer: rest

Extra Information:   Watch Stable Angina, Vasospastic Angina, & Acute Coronary Syndromes (UA, NSTEMI, STEMI) [https://dashboard.sketchy.com/study/medical/courses/medical-pathophysiology/units/medical-pathophysiology-cardiac/videos/medical-pathophysiology-cardiac-ischemic-heart-disease-stable-angina-vasospastic-angina-and-acute-coronary-syndromes-ua-nstemi-stemi?utm_source=anki&utm_medium=partnership&utm_campaign=february_update&utm_content=medical]Watch associated Bootcamp video [https://app.bootcamp.com/med-school/cardiology/videos/myocardial-infarction?index=2] https://onlinemeded.org/spa/cardiology/coronary-artery-disease/acquire?ref=anki