cardiac workup at this pointHis troponin is partly due to ischemic imbalance. He fulfills the definition of MI. Perform stress testing before discharge His troponin is partly due to ischemic imbalance. He fulfills the definition of MI. Perform coronary angiography after stabilization of his infectious state and renal function3 Question 3. A 72-year-old man is admitted with melena and severe anemia (hemoglobin 6.5 g/dl). He is tachycardic but not in shock. His ECG shows diffuse 1.5 mm ST depression that has resolved after transfusion. His troponin I peaks at 3 ng/ml, with a rise and fall pattern. He does not complain of chest pain. His echo shows severe anterior hypokinesis. What is the next step?Transfuse and treat with proton pump inhibitors (PPI). No need for coronary angiography. Perform outpatient stress testingTransfuse and treat with PPI. No need for any cardiac workup unless angina occurs despite hemoglobin stabilizationTransfuse, treat with PPI, and perform gastroscopy. Perform coronary angiography once bleeding has stabilized for 1–2 weeksTransfuse, treat with PPI, and perform gastroscopy. Administer β-blockers and nitrates. Perform coronary angiography once bleeding has stabilized for 1–2 weeks
4 Question 4. A 62-year-old man has a history of heart failure with LVEF of 25%. Coronary angiography performed a year previously showed mild, non-obstructive plaques. He presents with acutely decompensated HF, volume overload, and chest tightness. His troponin I peaks at 1 ng/ml with a rise and fall pattern (his baseline troponin is 0.05 ng/ml). His ECG shows LVH with a strain pattern; no Q waves are seen. What is the next step?Diuresis and vasodilator therapy. Initiate antithrombotic therapy. Once proper diuresis is achieved, perform coronary angiographyDiuresis and vasodilator therapy. No need to repeat coronary angiography
5 Question 5. A 62-year-old man presents with progressive dyspnea and chest tightness for the last week. Exam and X-ray are diagnostic of pulmonary edema and severe HF. Echo shows LVEF 25% with global hypokinesis. Troponin I peaks at 0.5 ng/ml with a rise and fall pattern. ECG shows LVH with strain. Creatinine is 1.7 mg/dl. What is the next step?Diuresis, vasodilator therapy, and antithrombotic therapy. Once proper diuresis is achieved, perform coronary angiography during this hospitalizationDiuresis and vasodilator therapy. Once proper diuresis is achieved, perform coronary angiography during this hospitalizationDiuresis and vasodilator therapy. Once proper diuresis is achieved, perform stress testing for ischemic evaluationDiuresis and vasodilator therapy. Perform elective coronary angiography in the outpatient setting
6 Question 6. A 62-year-old man presents with progressive dyspnea and chest tightness for the last week. Exam and X-ray are diagnostic of pulmonary edema and severe HF. Echo shows LVEF 25% with global hypokinesis and inferior akinesis. Troponin I peaks at 0.5 ng/ml with a rise and fall pattern. ECG shows diffuse ST depression and inferior Q waves. Creatinine is 1.7 mg/dl. What is the next step?Diuresis, vasodilator therapy, and antithrombotic therapy. Once proper diuresis is achieved, perform coronary angiography during this hospitalizationDiuresis and vasodilator therapy. Once proper diuresis is achieved, perform coronary angiography during this hospitalizationDiuresis and vasodilator therapy. Once proper diuresis is achieved, perform stress testing for ischemic evaluationDiuresis and vasodilator therapy. Perform elective coronary angiography in the outpatient setting
7 Question 7. A 56-year-old man, with no cardiac history, presents with one severe episode of chest pain that started after pushing some furniture. The pain lasted 20 minutes and did not recur. His admission BP is 160/95 mmHg, and no murmur or rub is heard. His ECG is normal. His initial troponin I is 0.02 ng/ml, and peaks at 0.05 ng/ml (99th percentile < 0.04 ng/ml). Renal function is normal. What is the next step?Initiate antithrombotic therapy. Coronary angiography within 24 hours.Initiate antithrombotic therapy. Coronary angiography within 72 hours.Stress testing before discharge for risk stratification.
8 Question 8. A 47-year-old man, smoker, diabetic, presents to the emergency department with sharp chest pain that has been occurring intermittently at rest for the last 2 days. It does not prevent him from performing his daily activities. On exam, his BP is 145/92 mmHg, heart rate 85 bpm. He has no HF or murmur. ECG shows inferior T-wave inversion of 1 mm, and the admission hs-troponin I is undetectable (< 0.005 ng/ml). What is the next step?Perform inpatient stress testing. Home discharge followed by outpatient stress testing is not acceptablePerform inpatient stress testing. Home discharge followed by outpatient stress testing (within 72 hours) is acceptablePerform coronary angiographyDischarge home and arrange for clinic follow-up within a week. Further workup depends on progression of symptoms
9 Question 9. A 56-year-old woman has a history of RCA PCI 8 months previously. She presents with one episode of chest pain that felt similar to her prior angina. It occurred once at rest, 2 days ago, lasted 20 minutes and did not recur. ECG shows LVH with strain and inferior Q waves. Serial troponin levels are < 0.04 ng/ml. Creatinine is normal. What is the next step?Coronary angiography within 72 hoursCoronary angiography within 24 hoursStress testing 3–6 hours after presentation
10 Question 10. In comparison with men, women with ACS (multiple answers)Have a higher in-hospital mortalityAre less likely to benefit from an early invasive strategyHave fewer underlying comorbiditiesHave a higher proportion of non-obstructive CAD and less extensive CAD Have a higher bleeding riskHave a higher ischemic burden despite a lower prevalence and extent of CAD
11 Question 11. A 56-year-old woman presents with severe chest pressure that lasted 2 hours. Her ECG shows deep T-wave inversion across the precordial leads. BP was 190/105 mmHg on presentation. Troponin rises to 2.5 ng/ml. A coronary angiography is performed and only shows minimal plaques < 25%. What is the differential diagnosis at this point (multiple answers)?Stabilized plaque ruptureCoronary vasospasmTakotsubo cardiomyopathyMyopericarditisPulmonary embolismHypertensive crisis with elevated LVEDP and ischemic imbalanceDemand/supply mismatch from anemia or tachyarrhythmia
12 Question 12. For the patient in Question 11, what additional testing best helps establish a diagnosis?Cardiac MRIIVUSEcho
13 Question 13. A 62-year-old man presents with angina and a troponin of 0.12 ng/ml. ECG shows 1 mm dynamic lateral ST depression. He is started on antithrombotic therapy. Coronary angiography is performed and reveals a 40% hazy lesion in the mid RCA with TIMI grade 3 flow. It is eccentric with overhanging edges (Figure 1.9, Appendix 1). There is minimal disease otherwise. What is the next step?PCI of the hazy lesionFFR of the RCAIVUS of the RCAMedical therapy since lesion is < 50%
14 Question 14. A 66-year-old woman presents with severe chest pain that started 2 hours ago. The pain is ongoing, unrelieved with NTG, with severe distress, diaphoresis, and severe nausea. BP = 165/90, heart rate 90 bpm, O2 saturation 100% on ambient air. Exam does not reveal signs of HF. No rub is heard, and BP is equal in both arms. The abdomen is soft and non-tender. ECG is normal. Initial troponin is detectable but below MI cutoff. What is the next step?The pain is unlikely cardiac, as ECG is normal during ongoing pain. ACS likelihood is low. Obtain serial troponin levels then perform stress testingThe pain is likely cardiac by clinical features. Give morphine, metoprolol, and anticoagulation, then perform coronary angiography within 24 hoursThe pain is likely cardiac. Perform chest X-ray. Perform urgent coronary angiography
15 Question 15. A 70-year-old man who has insulin-dependent diabetes presents with chest pain and inferior ST-segment depression (dynamic). His troponin I is 0.55 ng/ml. He is currently chest pain free. He is tachycardic (sinus tachycardia 105 bpm) with BP of 110/75 mmHg. What is the appropriate therapy?Aspirin, clopidogrel load, GPI, and UFH. Perform coronary angiography within 24 hours.Aspirin and UFH. Perform coronary angiography within 72 hoursAspirin and UFH. Perform coronary angiography within 24 hoursAspirin, clopidogrel load, and UFH. Perform coronary angiography within 24 hoursAspirin, clopidogrel load, metoprolol, and UFH. Perform coronary angiography within 24 hours
16 Question 16. A 70-year-old woman presents with NSTEMI. Her coronary angiogram shows multiple moderate lesions in the LAD and RCA. The physician decides to treat her medically. What is the best long-term antiplatelet regimen?Aspirin only, as no PCI was
