Acute coronary syndromes

Question 1

A 62-year-old man presents with chest pressure radiating to the left arm for 30 minutes at rest. Initial ECG shows ST depressions in leads V2–V4 and T-wave inversions. Cardiac troponin is positive. What is the most likely diagnosis?
A) Stable angina
B) NSTEMI
C) STEMI
D) Pericarditis

Answer 1

Answer: B
Rationale: ST depressions and positive troponin without ST elevation indicate NSTEMI.

Question 2

You are following up with a patient status post-percutaneous coronary intervention with stents to discuss secondary prevention. What is the appropriate antiplatelet therapy for this patient?
A. Aspirin 81 mg daily × 6 months
B. Clopidogrel 75 mg daily × 12 months
C. Aspirin 81 mg and clopidogrel 75 mg daily × 6 months
D. Aspirin 81 mg and clopidogrel 75 mg daily × 12 months

Answer 2

Correct Answer: D. Aspirin 81 mg and clopidogrel 75 mg daily × 12 months

Rationale:
For patients who have undergone percutaneous coronary intervention (PCI) with stent placement, the current guideline-recommended strategy is dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (e.g., clopidogrel) for 12 months to reduce the risk of stent thrombosis and subsequent cardiovascular events, assuming no contraindications.

Question 3

A patient presents to the emergency department with chest pain. Their past medical history includes coronary artery disease, hypertension, and hyperlipidemia. Their EKG shows ST segment elevation in two contiguous leads. What would you consider for next steps?

A. Administration of enoxaparin and a calcium channel blocker
B. Percutaneous coronary intervention, thrombolytics, ACE inhibitor, and beta blockers
C. Percutaneous coronary intervention, beta blockers, furosemide
D. ACE inhibitor and morphine

Answer 3

Correct Answer: B. Percutaneous coronary intervention, thrombolytics, ACE inhibitor, and beta blockers**

Rationale:
In the setting of ST-elevation myocardial infarction (STEMI), immediate reperfusion therapy is critical to salvage myocardium. The primary intervention is percutaneous coronary intervention (PCI) if it can be performed promptly (within 90 minutes of first medical contact). If PCI is not available within the recommended window, thrombolytic therapy is considered. In addition to reperfusion, adjunctive therapies such as beta blockers and ACE inhibitors are employed for their cardioprotective effects and to improve outcomes. This comprehensive approach makes option B the most appropriate next step.

Question 4

A patient is post-operative Day 1 status post-coronary artery bypass graft. They complain of new-onset shortness of breath at rest. Your assessment reveals muffled heart sounds, jugular venous distention, decreased pulses with inspiration. What is your suspected diagnosis?
A. Cardiac tamponade
B. Pulmonary hypertension
C. Respiratory failure
D. Fluid volume overload

Answer 4

Correct Answer: A. Cardiac tamponade

Rationale:
The patient’s post-operative presentation—new-onset shortness of breath, muffled heart sounds, jugular venous distention, and decreased pulses with inspiration (pulsus paradoxus)—is highly suggestive of cardiac tamponade. This condition is a critical emergency that can occur after cardiac surgery and requires prompt recognition and intervention to prevent further hemodynamic compromise.

Question 5

A patient presents with a history of coronary artery disease, hypertension, and obstructive sleep apnea with exertional dyspnea, fatigue, chest pain, and edema. On exam, they have an S3 gallop and sinus tachycardia with right axis deviation. What medications will you recommend?

A. Nitrate and beta blocker
B. ACE inhibitor and calcium channel blocker
C. Calcium channel blocker and phosphodiesterase inhibitor
D. Nitrate and phosphodiesterase inhibitor

Answer 5

Correct Answer: A. Nitrate and beta blocker

Rationale:
This patient presents with signs and symptoms consistent with heart failure secondary to coronary artery disease and hypertension, as evidenced by exertional dyspnea, fatigue, chest pain, edema, and the presence of an S3 gallop. Beta blockers are a cornerstone in the management of heart failure because they reduce myocardial oxygen demand, improve left ventricular function, and have been shown to decrease mortality. Nitrates help reduce preload, alleviate chest pain, and improve coronary blood flow, making them useful in patients with concomitant coronary artery disease. The other medication combinations do not address the key pathophysiologic issues in this scenario and may not provide the mortality benefit seen with beta blockers in heart failure management.

Question 6

A patient presents with chest pain over 4 days and is status post an upper respiratory tract infection. They are leaning forward and are dyspneic at rest. Their vitals are stable and their EKG is normal. What diagnostic test will you recommend?
A. Chest x-ray
B. Serial troponins
C. Coronary angiogram
D. Echocardiogram

Answer 6

Correct Answer: D. Echocardiogram

Rationale:
The patient’s history and presentation—chest pain for several days following an upper respiratory tract infection, a leaning forward posture, and dyspnea—are highly suggestive of pericarditis, possibly with a pericardial effusion. While the EKG is normal, an echocardiogram is the most sensitive diagnostic test to assess for pericardial inflammation and effusion. It provides direct visualization of the pericardium, helping to confirm the diagnosis and guide further management.

Question 7

The advanced practice registered nurse (APRN) is performing an initial assessment on a 32-year-old patient who is 22 weeks pregnant. She presents to the emergency department experiencing fatigue, headache, and visual changes. The patient’s neurologic exam is grossly nonfocal despite her reported symptoms. Her blood glucose level is 140. Her vital signs are as follows: T 36.8, BP 165/90, HR 100, RR 20. A urine dipstick reveals proteinuria. Based on this information, which of the following interventions will the APRN recommend?
A. Aggressive reduction in blood pressure
B. Administration of subcutaneous insulin
C. Aggressive fluid resuscitation
D. Normalization of blood pressure over 24–48 hours

Answer 7

Correct Answer: D. Normalization of blood pressure over 24–48 hours

Rationale:
This patient’s presentation is consistent with preeclampsia, evidenced by hypertension (165/90 mm Hg), proteinuria, and neurological symptoms such as headache and visual changes. In preeclampsia, it is important to reduce blood pressure in a controlled manner over 24–48 hours to avoid abrupt decreases that could compromise placental perfusion. Aggressive blood pressure reduction, subcutaneous insulin administration, or aggressive fluid resuscitation are not indicated in this scenario.

Question 8

A 70-year-old diabetic woman complains of epigastric pain and malaise. ECG shows nonspecific changes; troponin is elevated. Which of the following is most indicative of ACS in diabetic patients?
A) Silent ischemia with minimal “typical” chest pain
B) Extremely high WBC count
C) Loud pericardial friction rub
D) Frequent hyperglycemic episodes

Answer 8

Answer: A
Rationale: Diabetics often present with atypical or minimal chest pain, “silent ischemia,” yet can have significant myocardial injury.

Question 9

A 55-year-old man has intermittent chest pain at rest for the past week, now more frequent. ECG is normal, troponins negative. Which of the following best describes his condition?
A) Stable angina
B) Unstable angina
C) NSTEMI
D) STEMI

Answer 9

Answer: B
Rationale: Unstable angina: new/worsening rest angina, negative biomarkers, normal or transient ECG changes.

Question 10

Which of the following best explains why tachycardia can precipitate myocardial ischemia in a patient with known coronary artery disease?
A) It reduces preload
B) It shortens diastole, reducing coronary perfusion
C) It elevates systolic blood pressure
D) It improves collateral coronary flow

Answer 10

Answer: B
Rationale: Coronary perfusion occurs primarily during diastole; tachycardia shortens diastole, reducing supply.

Question 11

A patient has chest pain radiating to the jaw. Which finding is most suggestive of ACS vs. a noncardiac cause?
A) Pain improves with antacids
B) Pain reproducible by palpation
C) Pain accompanied by diaphoresis and a sense of doom
D) Pain lasting <10 seconds, intermittently

Answer 11

Answer: C
Rationale: ACS often presents with diaphoresis, anxiety, “impending doom,” lasting many minutes.

Question 12

A 68-year-old with 10/10 crushing chest pain. ECG: ST elevation in leads V2–V4. He denies prior chest pain history. Which coronary artery is most likely involved?
A) Right coronary artery
B) Left anterior descending (LAD)
C) Left circumflex (LCx)
D) Ramus intermedius

Answer 12

Answer: B
Rationale: ST elevations in V2–V4 typically localize to the LAD territory (anterior wall).

Question 13

A 59-year-old man with chronic stable angina now has more frequent episodes at rest. Troponins are normal, ST segments temporarily drop during pain. This scenario suggests:
A) STEMI
B) Unstable angina
C) NSTEMI
D) Pericarditis

Answer 13

Answer: B
Rationale: Worsening or new rest angina, normal troponins, and transient ST depressions → Unstable angina.

Question 14

Which risk factor is most strongly linked to development of atherosclerotic coronary artery disease?
A) Family history of pericarditis
B) Cigarette smoking
C) Frequent sinusitis
D) Left bundle branch block

Answer 14

Answer: B
Rationale: Smoking is a major modifiable risk factor for coronary artery disease.

Question 15

A 70-year-old experiences sudden collapse at home. EMS arrives to find pulseless electrical activity (PEA). Bystanders mention chest pain prior to collapse. Which potential cause is most likely?
A) Rupture of papillary muscle
B) Torsades de pointes
C) Sudden cardiac death secondary to acute coronary syndrome
D) Status epilepticus

Answer 15

Answer: C
Rationale: Sudden cardiac death is often due to acute coronary thrombosis or lethal arrhythmia from ACS.

Question 16

Which diagnostic test is most definitive for identifying coronary artery anatomic lesions in ACS?
A) Troponin I
B) Resting ECG
C) Coronary angiography (cardiac catheterization)
D) Stress echocardiography

Answer 16

Answer: C
Rationale: Coronary angiography is the gold standard for visualizing coronary artery lesions.

Question 17

A 64-year-old with possible ACS arrives in the ED. Which initial medication has been shown to significantly reduce mortality in acute MI?
A) Sublingual nitroglycerin
B) Chewable aspirin
C) IV morphine
D) High-flow oxygen for all patients

Answer 17

Answer: B
Rationale: Chewable aspirin promptly reduces platelet aggregation, lowers mortality in acute MI.

Question 18

A patient is having an NSTEMI. Troponin is positive, ECG shows ST depressions in V5–V6. Which immediate therapy is most appropriate?
A) Urgent PCI within 30 minutes
B) Intravenous fibrinolytics
C) Dual antiplatelet therapy + anticoagulation (e.g. heparin)
D) Wait for troponins to normalize

Answer 18

Answer: C
Rationale: NSTEMI management includes antiplatelets (aspirin + P2Y12 inhibitor) and anticoagulants; urgent PCI is not always immediate but can be scheduled early.

Question 19

Which of the following is part of the MONA-B acronym for initial ACS management?
A) Magnesium
B) Oxygen for all, regardless of saturation
C) Aspirin loading dose
D) Amiodarone infusion

Answer 19

Answer: C
Rationale: MONA-B typically references Morphine, Oxygen, Nitrates, Aspirin, Beta-blocker; Aspirin is critical.

Question 20

A patient with suspicious chest pain gets sublingual nitroglycerin. The chest pain quickly improves. This response indicates:
A) Definitive proof of ACS
B) Likely coronary vasospasm or esophageal spasm relief
C) Negative troponin is guaranteed
D) Unstable angina is ruled out.

Answer 20

Answer: B
Rationale: Relief with nitroglycerin does not confirm ACS, as it can also relieve esophageal spasm or vasospasm

Question 21

A 58-year-old with acute MI is given IV beta-blocker. Which patient factor is a contraindication to early IV beta-blockade?
A) Tachycardia of 110 bpm
B) Mild wheezing history
C) BP 85/50 mmHg, signs of poor perfusion
D) LVEF of 55%

Answer 21

Answer: C
Rationale: Hypotension or signs of shock are contraindications to acute IV beta-blocker.

Question 22

A 50-year-old smoker with typical crushing chest pain for 30 minutes arrives. ECG: ST elevations in leads II, III, aVF. The team plans immediate reperfusion. Which artery is most likely occluded?
A) Left anterior descending
B) Left circumflex
C) Right coronary artery
D) Ramus intermedius

Answer 22

Answer: C
Rationale: ST elevations in II, III, aVF localize to the inferior wall → commonly Right coronary artery.

Question 23

In STEMI, the recommended door-to-balloon time for percutaneous coronary intervention (PCI) is:
A) Under 30 minutes
B) Under 90 minutes
C) Under 12 hours
D) No specific time requirement

Answer 23

Answer: B
Rationale: Guidelines aim for PCI within 90 minutes of arrival for best outcomes.

Question 24

A patient with a STEMI in a remote hospital cannot be transferred for PCI within 2 hours. Which reperfusion approach is recommended if no contraindications?
A) Intravenous fibrinolysis (thrombolytics)
B) High-dose nitrates
C) Immediate coronary artery bypass graft (CABG)
D) Beta-blockers alone

Answer 24

Answer: A
Rationale: If PCI is delayed (>120 mins), fibrinolysis is indicated if no contraindications and symptom onset <12 hrs.

Question 25

A 70-year-old with STEMI and severe ongoing chest pain receives morphine. This helps by: A) Boosting heart rate B) Decreasing anxiety and preload C) Increasing coronary spasm D) Elevating blood pressure significantly

Answer 25

Answer: B Rationale: Morphine reduces pain, anxiety, sympathetic drive, and thus lowers preload.

Question 26

Which therapy in acute NSTEMI most reduces the risk of stent thrombosis if PCI is performed? A) Intravenous morphine B) Dual antiplatelet therapy (DAPT) C) High-dose magnesium D) IV amiodarone

Answer 26

Answer: B Rationale: DAPT (aspirin + P2Y12 inhibitor) is crucial to prevent stent thrombosis.

Question 27

A patient with STEMI has a blood pressure of 80/50. Which medication, commonly used for chest pain, might exacerbate hypotension? A) Aspirin B) Nitroglycerin C) Clopidogrel D) Heparin

Answer 27

Answer: B Rationale: Nitrates can drop BP further via vasodilation.

Question 28

Troponin I is elevated in which scenario? A) Stable angina that resolves after 1 minute B) Unstable angina with no necrosis C) NSTEMI with myocardial necrosis D) Costochondritis

Answer 28

Answer: C Rationale: Elevated troponin indicates myocardial necrosis, as in NSTEMI or STEMI.

Question 29

An inferior STEMI (leads II, III, aVF) is diagnosed. The patient develops hypotension after initial nitrates. You suspect right ventricular involvement. Which management step is most helpful? A) More nitroglycerin IV B) Fluid challenge to improve RV preload C) Immediate beta-blocker bolus D) Urgent fibrinolysis only

Answer 29

Answer: B Rationale: RV infarction requires adequate preload; IV fluids can help maintain BP.

Question 30

A 75-year-old has chest pain with ST depressions in V1–V2 and tall R waves. This might indicate a posterior MI. Which coronary artery is often implicated? A) Left anterior descending B) Posterior descending branch of the RCA C) Left circumflex marginal branch D) Diagonal branch of LAD

Answer 30

Answer: B Rationale: Posterior MI is often due to PDA (Posterior Descending Artery), typically arising from the RCA in most individuals.

Question 31

A patient with NSTEMI is given IV heparin. Which lab test is followed to ensure therapeutic anticoagulation? A) PT/INR B) aPTT C) ACT (activated clotting time) D) Platelet function assay.

Answer 31

Answer: B Rationale: Unfractionated heparin effect is monitored by aPTT

Question 32

A 60-year-old with ongoing chest pain has ST depressions in multiple leads, troponin positive, but no ST elevations. The plan is early invasive strategy. This typically means: A) Urgent PCI within 90 minutes B) PCI or angiography within 24–48 hours C) Thrombolytics immediately D) High-dose nitrates as the only approach

Answer 32

Answer: B Rationale: Early invasive approach in NSTEMI usually means angiography within 24–48 hours (not emergent like STEMI).

Question 33

A patient receives ticagrelor plus aspirin after a drug-eluting stent for NSTEMI. This dual antiplatelet therapy is typically maintained for: A) 1 month B) 3 months C) At least 6–12 months D) Indefinitely

Answer 33

Answer: C Rationale: After stent (especially drug-eluting), DAPT is recommended for 6–12 months (often 12 months ideally).

Question 34

Which sign/symptom is most concerning for extension of myocardial infarction or reinfarction? A) Chest discomfort relieved by food B) Recurrent ST elevations or new Q waves C) Muffled heart sounds with pericardial friction rub D) Sinus bradycardia at 50 bpm

Answer 34

Answer: B Rationale: New ST elevations or Q waves can indicate ongoing/extended infarction.

Question 35

In ACS, which finding suggests left ventricular failure or cardiogenic shock? A) BP 110/70 mmHg, HR 100 B) Bibasilar crackles, S3 gallop, hypotension C) Loud S2 at the pulmonic area D) Mid-systolic click Answer: B Rationale: S3, crackles, hypotension → classic for LV failure or cardiogenic shock post-MI.

Question 35

Which mechanical complication can occur days after an MI and present with acute severe mitral regurgitation? A) Papillary muscle rupture B) Dressler’s syndrome C) Ventricular aneurysm D) Coronary artery spasm

Answer 35

Answer: A Rationale: Papillary muscle rupture leads to acute severe MR → emergent condition.

Question 36

A patient with STEMI is hypotensive (BP 85/50) and shows cool extremities, confusion. This indicates cardiogenic shock. Which emergent therapy, in addition to reperfusion, might stabilize hemodynamics? A) High-dose beta-blockers B) IV vasopressors/inotropes (e.g., norepinephrine, dobutamine) C) Large fluid boluses D) Sublingual nitroglycerin

Answer 36

Answer: B Rationale: Cardiogenic shock requires inotropes or vasopressors to maintain perfusion alongside emergent PCI if feasible.

Question 37

Fibrinolytic therapy is indicated in STEMI patients if: A) PCI can be performed within 60 minutes B) The patient is in advanced heart failure C) Time from symptom onset <12 hours and no major contraindications D) There's trivial ST depression.

Answer 37

Answer: C Rationale: Fibrinolysis is indicated if PCI is unavailable timely, symptom onset <12 hours, and no contraindications

Question 38

A patient is on dual antiplatelet therapy after a NSTEMI. He complains of bleeding gums and easy bruising. Which step is most appropriate? A) Stop aspirin and continue P2Y12 inhibitor alone B) Evaluate for excessive anticoagulation or other causes, but generally continue DAPT C) Reduce P2Y12 inhibitor dose in half D) Switch to warfarin

Answer 38

Answer: B Rationale: Mild bleeding can occur; typically continue dual antiplatelets if the bleed is not significant, and investigate other causes or correct modifiable factors.

Question 39

An intra-aortic balloon pump (IABP) may help in cardiogenic shock by: A) Directly lysing coronary clots B) Increasing coronary perfusion during diastole C) Completely replacing the function of the left ventricle D) Preventing atrial fibrillation.

Answer 39

Answer: B Rationale: The IABP inflates in diastole, improving coronary perfusion and reducing afterload in systole

Question 40

Dressler’s syndrome is a pericarditis that can occur weeks after an MI. Symptoms typically include: A) New ST elevations in every lead, pericardial chest pain B) Massive ST depression in leads II, III, aVF C) Loud S3 D) Pleuritic chest pain relieved by lying flat.

Answer 40

Answer: A Rationale: Dressler’s syndrome involves post-MI pericarditis, with diffuse ST elevations, pericardial friction rub, chest pain better upright

Question 41

A 58-year-old with acute MI suddenly develops a harsh holosystolic murmur best heard at apex, hypotension, and pulmonary edema. This suggests: A) Papillary muscle rupture causing acute MR B) Aortic dissection C) Ventricular septal defect D) Ventricular aneurysm

Answer 41

Answer: A Rationale: A new holosystolic murmur at apex + acute pulmonary edema = acute mitral regurgitation from papillary muscle rupture.

Question 42

Which factor most reduces the risk of ventricular remodeling post-MI? A) High-dose nitrates alone B) Early use of beta-blockers, ACE inhibitors C) Discontinuing statins D) Prolonged bed rest

Answer 42

Answer: B Rationale: Beta-blockers + ACE inhibitors mitigate maladaptive remodeling post-MI.

Question 43

You suspect a right ventricular MI in an inferior STEMI patient. Administration of nitrates worsened the BP drastically. Management includes: A) Rapid IV fluid bolus to improve RV preload B) Immediate fibrinolysis C) Give more nitrates to reduce afterload D) Start IV beta-blocker

Answer 43

Answer: A Rationale: RV infarction often needs fluids to maintain preload & BP; nitrates can worsen hypotension.

Question 44

An older adult has NSTEMI. Post-PCI, they are started on high-intensity statin therapy. The main reason is: A) Statins reduce risk of stent thrombosis B) Statins lower LDL and reduce recurrent cardiac events C) Statins cause coronary vasodilation acutely D) Statins prevent bradycardia

Answer 44

Answer: B Rationale: High-intensity statins post-ACS reduce LDL, stabilizing plaque & reducing further events.

Question 45

Which lab marker remains elevated longest after an MI? A) Myoglobin B) Troponin T or I C) CK-MB D) LDH

Answer 45

Answer: B Rationale: Cardiac troponins can remain elevated for up to 1–2 weeks post-infarction.

Question 46

41. A 66-year-old has a STEMI and undergoes successful PCI. Which medication combination is standard upon discharge to reduce mortality and reinfarction risk? A) Beta-blocker, ACE inhibitor, statin, dual antiplatelet therapy B) IV nitrates, morphine, prophylactic antibiotics C) Warfarin plus low-dose aspirin only D) GPIIb/IIIa inhibitor indefinite

Answer 46

Answer: A Rationale: Post-MI standard includes beta-blocker, ACEI, statin, and dual antiplatelet (aspirin + P2Y12 inhibitor).

Question 47

A 55-year-old with NSTEMI has urgent angiography revealing 3-vessel coronary disease and reduced EF. The team suggests CABG instead of PCI. Which scenario often favors CABG? A) Single vessel RCA lesion B) Left main or multi-vessel disease with LV dysfunction C) Minor diagonal branch lesion only D) Low surgical risk but single small lesion

Answer 47

Answer: B Rationale: Left main or extensive multi-vessel disease + low EF often benefits from CABG for better long-term outcomes.

Question 48

A patient has persistent chest pain and recurrent ST changes 48 hours after NSTEMI with medical therapy. Troponins remain elevated. This suggests: A) Early post-infarct pericarditis (Dressler’s) B) Possible re-infarction or ongoing ischemia C) Normal course of troponin washout D) Mechanical complication is ruled out

Answer 48

Answer: B Rationale: Persistent or recurrent ST changes and elevated troponins may indicate ongoing ischemia or re-infarction.

Question 49

In STEMI, which intervention is critical within recommended time windows to prevent extensive myocardial damage? A. Immediate surgical bypass for all B. Percutaneous coronary intervention (PCI) within 90 minutes C. Delayed angiography after 24 hours D. High-dose diuretic therapy

Answer 49

Correct Answer: B. Percutaneous coronary intervention (PCI) within 90 minutes Rationale: In STEMI, the primary goal is rapid reperfusion to minimize myocardial injury. Guidelines recommend that PCI should be performed within 90 minutes of first medical contact (door-to-balloon time) to restore blood flow, limit infarct size, and improve outcomes. Immediate surgical bypass is not routinely performed for all STEMI cases, delayed angiography would miss the optimal window for myocardial salvage, and high-dose diuretic therapy does not address coronary occlusion.

Question 50

In unstable angina or NSTEMI, which management error can worsen patient outcomes? A. Dual antiplatelet therapy B. Early invasive strategy when indicated C. Delayed initiation of anticoagulation D. Beta-blocker administration

Answer 50

C. Delayed initiation of anticoagulation Rationale: In unstable angina or NSTEMI, timely initiation of anticoagulation is critical to prevent further thrombus formation and to stabilize the plaque. Dual antiplatelet therapy, an early invasive strategy when indicated, and beta-blocker administration are all beneficial measures that improve outcomes in these patients. Delaying anticoagulation, however, can allow ongoing clot formation and worsen the patient's condition.

Question 51

Which medication combination is commonly started for ACS initial therapy? A. Aspirin, P2Y12 inhibitor (e.g., clopidogrel), nitrates, beta blockers B. Oral antibiotics and diuretics C. High-dose NSAIDs D. Inhaled bronchodilators

Answer 51

Correct Answer: A. Aspirin, P2Y12 inhibitor (e.g., clopidogrel), nitrates, beta blockers Rationale: In the initial management of Acute Coronary Syndrome (ACS), the standard therapy includes antiplatelet agents like aspirin combined with a P2Y12 inhibitor, nitrates to alleviate chest pain, and beta blockers to reduce myocardial oxygen demand. This combination is aimed at stabilizing the patient and preventing further thrombus formation. The other options do not address the core pathophysiological processes in ACS.

Question 52

41. Which condition is encompassed by the term “acute coronary syndrome” (ACS)? A. Stable angina only B. Unstable angina, NSTEMI, and STEMI C. Atrial fibrillation D. Heart failure.

Answer 52

o Answer: B o Rationale: ACS includes unstable angina, NSTEMI, and STEMI, all representing acute myocardial ischemia

Question 53

42. In the context of ACS, which finding “will kill your patient” if not treated emergently? A. A small Q wave on EKG B. ST-segment elevation indicating transmural infarction C. Mild troponin elevation D. Asymptomatic chest discomfort

Answer 53

o Answer: B o Rationale: ST-segment elevation indicates a transmural MI that requires immediate reperfusion therapy to prevent death.

Question 54

43. Which medication is “common” in the initial management of ACS? A. Beta blockers, nitrates, aspirin, and heparin B. Oral antibiotics C. High-dose calcium supplements D. Only ACE inhibitors

Answer 54

o Answer: A o Rationale: Standard ACS management includes beta blockers, nitrates, aspirin, and heparin to limit infarct size and prevent further thrombus formation.

Question 55

44. What is the role of fibrinolytic therapy in ACS? A. To reduce heart rate B. To dissolve coronary thrombi in STEMI when primary PCI is unavailable C. To provide long-term anticoagulation D. To improve diastolic function

Answer 55

o Answer: B o Rationale: Fibrinolytic agents are used in STEMI to dissolve clots when primary percutaneous coronary intervention (PCI) is not immediately available.

Question 56

45. In a patient with ACS, which complication “will harm your patient” if not recognized? A. Atrial fibrillation B. Cardiogenic shock due to pump failure C. Sinus tachycardia D. Benign ectopic beats

Answer 56

o Answer: B o Rationale: Cardiogenic shock is a life-threatening complication of ACS that requires prompt recognition and management.

Question 57

Which factor is most important to address for secondary prevention post-ACS? A) Strict bed rest for 2 weeks B) Smoking cessation C) Caffeine elimination D) Eliminating all dietary fats

Answer 57

Answer: B Rationale: Smoking is a major modifiable risk factor; cessation greatly reduces recurrent ACS risk.

Question 58

A patient with prior NSTEMI returns with unstable angina. He is already on aspirin. Which additional antiplatelet might be preferred to add for dual therapy? A) Dipyridamole B) Clopidogrel or ticagrelor C) Warfarin D) Low molecular weight heparin

Answer 58

Answer: B Rationale: Clopidogrel or ticagrelor + aspirin is standard dual antiplatelet therapy (DAPT).

Question 59

In acute coronary syndrome, which presentation is most concerning for immediate mechanical complication? A) Mid-systolic murmur best heard at right second intercostal B) New holosystolic murmur at apex + acute pulmonary edema C) Sinus bradycardia at 50 bpm D) Stable small pericardial effusion

Answer 59

Answer: B Rationale: Sudden new holosystolic murmur at apex = suspect papillary muscle rupture.

Question 60

A 68-year-old with a STEMI in leads V2–V4 is found to have persistent chest pain despite PCI, with new ST re-elevations. This might be: A) Prinzmetal angina B) Coronary artery dissection C) Stent thrombosis or re-occlusion D) Esophageal reflux

Answer 60

Answer: C Rationale: Recurrent ST elevation after PCI can indicate acute stent thrombosis or re-occlusion.

Question 61

A 75-year-old with an LV ejection fraction of 30% post-infarct is at higher risk for: A) Ventricular arrhythmias and remodeling B) Improved exercise tolerance C) Reduced chance of heart failure D) No significant complications.

Answer 61

Answer: A Rationale: Reduced EF raises risk of arrhythmias, remodeling, and future heart failure

Question 62

A patient with an anterior STEMI is treated with fibrinolytics. 2 hours later, chest pain drastically improves, ST segments return near baseline. This indicates: A) Failure of fibrinolysis B) Successful reperfusion C) Papillary muscle rupture D) Need for emergent CABG

Answer 62

Answer: B Rationale: Decreased pain, ST resolution → suggests successful lysis and reperfusion.

Question 63

Which is a typical discharge recommendation post-ACS? A) Strict bed rest for 4 weeks B) High-intensity statin, dual antiplatelet therapy, beta-blocker, and ACE inhibitor (if no contraindications) C) Discontinue all medications once asymptomatic D) Intravenous heparin for 6 months

Answer 63

Answer: B Rationale: Standard post-ACS regimen includes high-intensity statin, DAPT, beta-blocker, ACEI for those without contraindications.

Question 64

ACS

Answer 64

spans unstable angina, NSTEMI, and STEMI—distinguished by ECG changes and troponin.

Question 65

includes MONA-B (Morphine, Oxygen if hypoxic, Nitrates, Aspirin, Beta-blocker), plus antithrombotics.

Answer 65

Initial management of ACS

Question 66

requires urgent reperfusion (PCI <90 min door-to-balloon) or fibrinolysis if PCI delayed.

Answer 66

STEMI

Question 67

uses dual antiplatelet therapy + anticoagulation, with early invasive strategy if high-risk.

Answer 67

NSTEMI

Question 68

arrhythmias, cardiogenic shock, mechanical rupture (papillary muscle, septum), remodeling. Meds like beta-blockers, ACE inhibitors, statins reduce recurrence and remodeling.

Answer 68

Complications: of ACS

Question 69

A 58-year-old man with crushing substernal chest pain arrives with ST elevations in leads V1–V4 and hypotension. Bedside echo reveals right ventricular (RV) involvement. Which immediate management step would most help maintain his blood pressure? A) High-dose nitroglycerin B) IV fluid bolus to augment RV preload C) Intravenous beta-blocker D) Sublingual morphine

Answer 69

Answer: B Rationale: RV involvement (especially in inferior/anterior MI) often needs IV fluid to maintain preload and BP; nitrates can worsen hypotension

Question 70

A patient presents 3 days after an anterior STEMI with a new holosystolic murmur at the left sternal border and acute decompensation. Which mechanical complication is most likely? A) Ventricular septal rupture B) Papillary muscle rupture C) Acute mitral valve prolapse D) Pericardial effusion

Answer 70

Answer: A Rationale: Ventricular septal rupture post-anterior MI often presents with a new holosystolic murmur best heard at the left sternal border and cardiogenic shock.

Question 71

A 65-year-old man has chest pain typical of ACS. ECG: ST depressions in leads II, III, aVF with elevated troponin. He denies prior CAD. Which coronary artery is most suspect? A) Left anterior descending (LAD) B) Right coronary artery (RCA) C) Left circumflex (LCx) D) Posterior descending artery

Answer 71

Answer: C Rationale: ST depressions in inferior leads can sometimes reflect lateral or posterior involvement. LCx often causes lateral or “true posterior” changes, though the specific localizations can be variable. (Alternatively, some might interpret ST depressions in II, III, aVF as reciprocal to a high lateral STEMI, but LCx is frequently implicated in lateral/inferior-lateral patterns for ACS with troponin elevation.)

Question 72

A patient with NSTEMI is found to have minimal troponin elevation but ongoing rest angina. Which risk stratification tool is commonly used to decide invasive vs. conservative management? A) HAS-BLED score B) TIMI risk score C) CHA₂DS₂-VASc score D) Wells criteria

Answer 72

Answer: B Rationale: TIMI risk score guides early invasive vs. conservative approach in NSTEMI/unstable angina.

Question 73

Which finding in the setting of an acute STEMI is most worrisome for impending cardiogenic shock? A) Stable BP of 120/70, mild chest discomfort B) Cool extremities, altered mental status, and hypotension C) Mild tachycardia at 110 bpm, normal oxygen saturation D) Sinus bradycardia at 58 bpm with stable BP

Answer 73

Answer: B Rationale: Cardiogenic shock → hypotension, poor perfusion signs (cool extremities, confusion).

Question 74

A 70-year-old with a history of stable angina now presents with chest pain at rest for 2 hours, not relieved by nitroglycerin. Troponins are negative initially. The best next step? A) Discharge with outpatient stress test B) Repeat troponin in a few hours, keep on telemetry C) Immediate fibrinolysis D) High-dose IV beta-blocker bolus

Answer 74

Answer: B Rationale: Unstable presentation but negative initial troponin → must repeat troponins and monitor (telemetry). Early discharge would be inappropriate without serial biomarker data.

Question 75

A 58-year-old with STEMI undergoes primary PCI. Post-procedure, which medication combination is most crucial to prevent stent thrombosis and future events? A) Aspirin alone B) Aspirin + P2Y12 inhibitor (clopidogrel/ticagrelor) C) Subcutaneous LMWH indefinitely D) High-dose beta-blocker only

Answer 75

Answer: B Rationale: After coronary stent in ACS, dual antiplatelet therapy reduces stent thrombosis and recurrent MI.

Question 75

A 61-year-old is 3 days post-MI. He suddenly develops a friction rub and chest pain worse on inspiration, improved when leaning forward. ECG shows diffuse ST elevations. This is most consistent with: A) Ventricular septal defect B) Post-infarct (Dressler’s) pericarditis C) Aortic dissection D) Pulmonary embolism

Answer 75

Answer: B Rationale: Dressler’s syndrome or acute pericarditis post-MI → rub, positional chest pain, diffuse ST changes.

Question 76

Which long-term management element most reduces all-cause mortality after STEMI? A) Proton pump inhibitor for 12 months B) Beta-blockers and high-intensity statins C) Antibiotics prophylaxis D) IV heparin for 3 weeks

Answer 76

Answer: B Rationale: Beta-blockers reduce arrhythmic death, statins stabilize plaque and reduce events → proven mortality benefits.

Question 77

A patient with NSTEMI is planned for early coronary angiography. He’s on aspirin and clopidogrel. Which additional anticoagulant is typically used until the angiography is performed? A) IV tissue plasminogen activator B) Subcutaneous low molecular weight heparin or IV unfractionated heparin C) Oral rivaroxaban D) IV amiodarone infusion

Answer 77

Answer: B Rationale: In NSTEMI, adding anticoagulation (LMWH or UFH) is standard until definitive intervention.

Question 78

changes, troponins, provide anti-ischemic therapies (nitrates, beta-blockers), and antithrombotics (aspirin + P2Y12 ± anticoagulation).

Answer 78

For Suspected ACS → Monitor ECG

Question 79

→ Urgent reperfusion (PCI <90 min or fibrinolysis if PCI delayed).

Answer 79

Interventions for STEMI

Question 80

if high risk NSTEMI

Answer 80

Early invasive strategy

Question 81

→ medical management for NSTEMI

Answer 81

includes DAPT + anticoagulant

Question 82

cardiogenic shock, mechanical ruptures, arrhythmias, postinfarction pericarditis.

Answer 82

Post-MI complications

Question 83

Beta-blockers, ACE inhibitors, high-intensity statins, and dual antiplatelet therapy (for stents).

Answer 83

Long-term NSTMI Intervention

Question 84

A patient presents with retrosternal chest pain. Their blood pressure in their right upper extremity is 230/110 and the left upper extremity is 210/110. Which medication do you order for this patient? A. Labetalol 20 mg IV push B. Metoprolol 5 mg IV push C. Nicardipine gtt at 5 mg/hr D. Diltiazem gtt at 5 mg/hr

Answer 84

Correct Answer: A. Labetalol 20 mg IV push Rationale: In a hypertensive emergency with chest pain, particularly when there's a concern for aortic dissection, the first-line therapy is rapid blood pressure control using an IV beta-blocker. Labetalol is ideal because it offers combined alpha and beta blockade, which reduces both blood pressure and the force of cardiac contractions, thereby decreasing shear stress on the aortic wall. Options such as metoprolol, nicardipine, or diltiazem are either less effective in this acute setting or are typically reserved as adjunctive agents after beta blockade is established.

Question 85

You are caring for a patient who becomes diaphoretic and dyspneic. Their heart rate is 120, and they are complaining of chest pain. You note signs of hypoxia. What interventions do you recommend? A. Warfarin, O2 support, and chest CT angiogram B. Heparin gtt, O2 support, and chest CT angiogram C. Aspirin, EKG, and O2 support D. Dabigatran, chest CT angiogram, and transfer to the ICU

Answer 85

**Correct Answer: B. Heparin gtt, O₂ support, and chest CT angiogram** *Rationale:* The patient's presentation—diaphoresis, dyspnea, tachycardia, chest pain, and hypoxia—raises concern for an acute pulmonary embolism (PE), which is a life-threatening condition. The recommended approach in suspected PE includes providing supplemental oxygen support and promptly obtaining a chest CT angiogram to confirm the diagnosis. Meanwhile, starting an IV heparin infusion (heparin gtt) is essential for immediate anticoagulation. Options involving warfarin or dabigatran are not suitable for the acute setting because they either require time to achieve therapeutic levels or are not the first-line agents in emergent management. Although aspirin and an EKG (option C) are standard in the evaluation of acute coronary syndrome, the inclusion of a chest CT angiogram in option B aligns better with the suspicion for PE in this clinical scenario.

Question 86

A patient presents to the emergency department with chest pain. Their past medical history includes coronary artery disease, hypertension, and hyperlipidemia. Their EKG shows ST segment elevation in two contiguous leads. What would you consider for next steps? A. Administration of enoxaparin and a calcium channel blocker B. Percutaneous coronary intervention, thrombolytics, ACE inhibitor, and beta blockers C. Percutaneous coronary intervention, beta blockers, furosemide D. ACE inhibitor and morphine

Answer 86

**Correct Answer: B. Percutaneous coronary intervention, thrombolytics, ACE inhibitor, and beta blockers** *Rationale:* In a patient presenting with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is the priority. Percutaneous coronary intervention (PCI) is the preferred method if it can be performed within the recommended time window (ideally within 90 minutes of first medical contact). If PCI is not available promptly, thrombolytic therapy is indicated. Adjunctive therapies, such as ACE inhibitors and beta blockers, are also used to reduce myocardial workload, improve remodeling, and enhance survival. This comprehensive management strategy addresses both immediate reperfusion and subsequent cardioprotective measures.

Question 87

A patient presents with a history of coronary artery disease, hypertension, and obstructive sleep apnea with exertional dyspnea, fatigue, chest pain, and edema. On exam, they have an S3 gallop and sinus tachycardia with right axis deviation. What medications will you recommend? A. Nitrate and beta blocker B. ACE inhibitor and calcium channel blocker C. Calcium channel blocker and phosphodiesterase inhibitor D. Nitrate and phosphodiesterase inhibitor

Answer 87

**Correct Answer: A. Nitrate and beta blocker** *Rationale:* This patient presents with signs of heart failure—exertional dyspnea, fatigue, chest pain, edema, and an S3 gallop—which, in the context of coronary artery disease and hypertension, suggest underlying ischemic cardiomyopathy. Beta blockers are essential in managing heart failure because they reduce myocardial oxygen demand, improve left ventricular function, and have a mortality benefit. Nitrates help alleviate chest pain and reduce preload, which can further improve symptoms in patients with coronary artery disease and heart failure. The other medication combinations do not adequately target the pathophysiologic mechanisms at play in this scenario.

Question 88

A patient presents with chest pain over 4 days and is status post an upper respiratory tract infection. They are leaning forward and are dyspneic at rest. Their vitals are stable and their EKG is normal. What diagnostic test will you recommend? A. Chest x-ray B. Serial troponins C. Coronary angiogram D. Echocardiogram

Answer 88

**Correct Answer: D. Echocardiogram** *Rationale:* The patient's presentation—chest pain lasting several days following an upper respiratory infection, a leaning forward position, and dyspnea at rest—is highly suggestive of pericarditis, potentially with an associated pericardial effusion. Although the EKG is normal, an echocardiogram is the most sensitive diagnostic test to assess the pericardium, allowing for visualization of inflammation or fluid accumulation. This makes it the most appropriate next step in evaluation.

Question 89

A patient presents with retrosternal chest pain. Their blood pressure in their right upper extremity is 230/110 and the left upper extremity is 210/110. Which medication do you order for this patient? A. Labetalol 20 mg IV push B. Metoprolol 5 mg IV push C. Nicardipine gtt at 5 mg/hr D. Diltiazem gtt at 5 mg/hr

Answer 89

**Correct Answer: A. Labetalol 20 mg IV push** *Rationale:* In the context of a hypertensive emergency with chest pain—suggestive of aortic dissection—the priority is to rapidly lower blood pressure and decrease the force of left ventricular ejection (dP/dt). Labetalol, with its combined alpha- and beta-blocking properties, is ideal for this purpose, as it lowers both blood pressure and heart rate while reducing shear stress on the aortic wall. Options like metoprolol lack alpha-blockade and may not provide the necessary blood pressure reduction in this acute setting.