ACS Practice Questions

Question 1

A 42-year-old man is brought to the emergency department 20 minutes after the sudden onset of severe chest pain, diaphoresis, shortness of breath, and palpitations. His symptoms occurred while he was at a party with friends. He has smoked one pack of cigarettes daily for 24 years. He uses cocaine occasionally. The last use was three hours ago. He appears pale. His pulse is 110/min, blood pressure is 178/106 mm Hg, and respirations are 24/min. His pupils are dilated and react sluggishly to light. The lungs are clear to auscultation. An ECG shows tachycardia and ST segment elevation in leads II, III, and aVF. While recording the ECG, the patient loses consciousness. A photo of the ECG at that point is shown. Which of the following is the most appropriate next step in management?

Accepted Answer

Unsynchronized cardioversion

Answer

Administer lidocaine

Answer

Administer epinephrine

Answer

Coronary angiography

Answer

Synchronized cardioversion

Question 2

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?

Accepted Answer

A 63-year-old male with a history of a transient ischemic attack

Answer

An 83-year-old female with a history of a hemorrhagic stroke 1 year ago without residual deficits

Answer

A 75-year-old male who had a drug-eluting coronary stent placed 3 days ago

Answer

A 67-year-old female who has diabetes mellitus and atrial fibrillation

Answer

A 45-year-old female with no health problems

Question 3

A 71-year-old man develops worsening chest pressure while shoveling snow in the morning. He tells his wife that he has a squeezing pain that is radiating to his jaw and left arm. His wife calls for an ambulance. On the way, he received chewable aspirin and 3 doses of sublingual nitroglycerin with little relief of pain. He has borderline diabetes and essential hypertension. He has smoked 15–20 cigarettes daily for the past 37 years. His blood pressure is 172/91 mm Hg, the heart rate is 111/min and the temperature is 36.7°C (98.0°F). On physical examination in the emergency department, he looks pale, very anxious and diaphoretic. His ECG is shown in the image. Troponin levels are elevated. Which of the following is the best next step in the management of this patient condition?

Accepted Answer

Clopidogrel, atenolol, anticoagulation and monitoring

Answer

CT scan of the chest with contrast

Answer

Echocardiography

Answer

Fibrinolysis

Answer

Oral nifedipine

Question 4

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?

Accepted Answer

Normal duration defined as less than 120 milliseconds

Answer

Elevated in patients with full thickness ischemic injury of the heart

Answer

Becomes peaked in states of hyperkalemia

Answer

Becomes prominent in states of hypokalemia

Answer

Normal duration defined as less than 200 milliseconds

Question 5

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?

Accepted Answer

Diversion of blood flow from stenotic coronary arteries

Answer

Transient atrioventricular nodal blockade

Answer

Reduced left ventricular preload

Answer

Ruptured cholesterol plaque within a coronary vessel

Answer

Increased myocardial oxygen demand

Question 6

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?

Accepted Answer

Chi-squared

Answer

Attributable risk

Answer

Analysis of variance

Answer

T-test

Answer

Pearson correlation

Question 7

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?

Accepted Answer

Metoprolol and a statin daily. Sublingual nitroglycerin as needed.

Answer

Clopidogrel and amlodipine daily. Sublingual nitroglycerin as needed.

Answer

Amlodipine and a statin daily. Sublingual nitroglycerin as needed.

Answer

Amlodipine daily. Sublingual nitroglycerin as needed.

Answer

Metoprolol and ranolazine daily. Sublingual nitroglycerin as needed.

Question 8

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?

Accepted Answer

8

Answer

5

Answer

10

Answer

6

Answer

9

Question 9

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?

Accepted Answer

Intravenous diuretics

Answer

Intravenous beta blockers

Answer

Echocardiography

Answer

Cardiac stress testing

Answer

Intravenous inotropes

Question 10

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?

Accepted Answer

Coronary CT angiogram

Answer

Nuclear exercise stress test

Answer

No further testing needed

Answer

Troponin I measurement

Answer

Dobutamine stress echocardiography

ACS

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Risk stratification in ACS

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