Risk stratification in ACS — MCQs

A 28-year-old male presents with sharp, stabbing chest pain that worsens when lying flat and improves when sitting forward. He reports a recent viral upper respiratory infection 2 weeks ago. On examination, a friction rub is heard on auscultation. His vital signs are stable. An ECG is most likely to show which of the following findings in this patient?

Group of 100 medical students took an end of the year exam. The mean score on the exam was 70%, with a standard deviation of 25%. The professor states that a student's score must be within the 95% confidence interval of the mean to pass the exam. Which of the following is the minimum score a student can have to pass the exam?

Researchers are studying the relationship between heart disease and alcohol consumption. They review the electronic medical records of 500 patients at a local hospital during the study period and identify the presence or absence of acute coronary syndrome (ACS) and the number of alcoholic drinks consumed on the day of presentation. They find that there is a lower prevalence of acute coronary syndrome in patients who reported no alcohol consumption or 1 drink daily compared with those who reported 2 or more drinks. Which of the following is the most accurate description of this study type?

A 60-year-old woman presents to the emergency room with chest pain that started 20 minutes ago while watching television at home. The pain is substernal and squeezing in nature. She rates the pain as 6/10 and admits to having similar pain in the past with exertion. Her past medical history is significant for diabetes mellitus that is controlled with metformin. The physical examination is unremarkable. An electrocardiogram (ECG) shows ST-segment depression in the lateral leads. She is started on aspirin, nitroglycerin, metoprolol, unfractionated heparin, and insulin. She is asked not to take metformin while at the hospital. Three sets of cardiac enzymes are negative. Lab results are given below: Serum glucose 88 mg/dL Sodium 142 mEq/L Potassium 3.9 mEq/L Chloride 101 mEq/L Serum creatinine 1.2 mg/dL Blood urea nitrogen 22 mg/dL Cholesterol, total 170 mg/dL HDL-cholesterol 40 mg/dL LDL-cholesterol 80 mg/dL Triglycerides 170 mg/dL Hematocrit 38% Hemoglobin 13 g/dL Leucocyte count 7,500/mm3 Platelet count 185,000 /mm3 Activated partial thromboplastin time (aPTT) 30 seconds Prothrombin time (PT) 12 seconds Urinalysis Glucose negative Ketones negative Leucocytes negative Nitrites negative Red blood cells (RBC) negative Casts negative An echocardiogram reveals left ventricular wall motion abnormalities. With the pain subsiding, she was admitted and the medications were continued. A coronary angiography is planned in 4 days. In addition to regular blood glucose testing, which of the following should be closely monitored in this patient?

A 56-year-old man presents to the emergency room with severe substernal chest pain associated with a 2-hour history of breathlessness and sweating. An electrocardiogram shows an ST-segment elevation myocardial infarction. Cardiac enzyme levels confirm a diagnosis of acute myocardial infarction. The patient is rushed to the catheter lab for angioplasty with stenting. The patient complains of recurrent chest pain in the ICU 56 hours post-angioplasty. Which of the following enzymes facilitates the patient’s diagnosis based on his current symptoms?

A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?

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 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 25-year-old man comes to the emergency department because of a 1-week-history of progressively worsening dyspnea and intermittent chest pain that increases on inspiration. He had an upper respiratory tract infection 2 weeks ago. His pulse is 115/min and blood pressure is 100/65 mm Hg. Examination shows inspiratory crackles bilaterally. His serum troponin I is 0.21 ng/mL (N < 0.1). An x-ray of the chest shows an enlarged cardiac silhouette and prominent vascular markings in both lung fields; costophrenic angles are blunted. A rhythm strip shows inverted T waves. Which of the following additional findings is most likely in this patient's condition?

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?