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A. new onset of chest pain and discomfort at rest or worsening of symptoms with activities that previously did not provoke symptoms B. predictable onset of chest pain or discomfort, usually with physical exertion C. results from full-thickness (transmural) necrosis of the myocardium and total occlusion of coronary artery D. results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus and/or atheromatous material

. Correct: D. retrosternal diffuse pain for 30 minutes accompanied by diaphoresis In a younger patient presenting with acute MI, a classic presentation would be expected. This would include chest pain lasting several minutes that is described as pressure, tightness, heaviness, or aching and can be accompanied by dyspnea, nausea/vomiting, or diaphoresis (D). Incorrect: Chest tightness that occurs with exercise, such as stair climbing, is more likely due to stable or unstable angina (A). Meanwhile, chest pressure that lasts 20 minutes and occurs at rest is likely to be due to unstable angina (C). Severe, localized chest pain that lasts 3 hours is not a typical presentation of MI, but other causes should be investigated, possibly related to the GI system (B).

Stable angina

. predictable onset of chest pain or discomfort, usually with physical exertion

Which of the following is an absolute contraindication to the use of thrombolytic therapy? A. history of hemorrhagic stroke B. BP of 160/100 mm Hg or greater at presentation C. current use of warfarin D. active peptic ulcer disease

A. history of hemorrhagic stroke For patients with ACS due to coronary artery occlusion, treatment options can include fibrinolysis, stenting, or revascularization procedures (e.g., percutaneous coronary intervention). When fibrinolytic therapy is selected, it is important to recognize contraindications to ensure patient safety. A history of intracranial hemorrhage is an absolute contraindication for this treatment (A). Incorrect: Relative contraindications include the use of oral anticoagulant therapy, such as warfarin (C), and active peptic ulcer disease (D). Significant HTN of greater than 180/110 mm Hg is also a relative contraindication (B).

For a patient with a history of MI and who demonstrates intolerance to aspirin, an acceptable alternative antiplatelet medication is: A. ibuprofen. B. clopidogrel. C. warfarin. D. rivaroxaban.

B. clopidogrel. The P2Y12 inhibitors can be used as an alternative to aspirin in the situation of aspirin intolerance. Members of this class include clopidogrel (B), ticagrelor, and prasugrel. Incorrect: Warfarin (C) and rivaroxaban (D) are oral anticoagulant therapies and not antiplatelet medications. Ibuprofen and other NSAIDs provide only a transient antiplatelet effect and are not considered an acceptable alternative to aspirin (A).

Causes of unstable angina include all of the following except: A. left ventricular hypertrophy. B. vasoconstriction. C. nonocclusive thrombus. D. inflammation or infection.

Correct: A. left ventricular hypertrophy. Unstable angina is predominantly caused by CHD or another condition that can diminish the flow of blood in the coronary arteries to adequately supply the heart with oxygen. Left ventricular hypertrophy is often caused by long-standing, poorly controlled HTN but would not impact blood flow to the heart (A). Incorrect: Vasoconstriction (B) or a nonocclusive thrombus (C) present in the coronary artery can lead to diminished blood flow to the heart and result in unstable angina. Inflammation and infection, such as acute endocarditis, can also trigger unstable angina, particularly with the development of embolisms from vegetative growth (D).

The initial manifestation of CHD in men is most commonly: A. unstable angina. B. MI. C. intracranial hemorrhage. D. stable angina.

Correct: B. MI. The most common initial manifestation of CHD in men is MI (B). Incorrect: In women, the most common initial manifestation of CHD is angina (A, D), which often leads to MI. In men, MI is more common than intracranial hemorrhage (C) or angina as the initial manifestation of CHD.

39. The cardiac finding most commonly associated with unstable angina is: A. physiological split S2. B. S4. C. opening snap. D. summation gallop.

Correct: B. S4. The fourth heart sound, also known as S4 or atrial gallop, is frequently heard with myocardial ischemia and poorly controlled angina pectoris (B). The sound occurs just before S1 and can be a sign of poor myocardial relaxation and diastolic dysfunction that can cause diminished cardiac output. Incorrect: A physiological split S2 occurs when closure of the aortic valve and closure of the pulmonary valve are not aligned (A) and is usually a benign finding. An opening snap can occur early in diastole and is caused by thickened valve leaflets, which produce a snapping sound when they open, as observed with mitral stenosis (C). A summation gallop is more likely associated with tachycardia and not angina pectoris (D).

. Routine use of the treadmill exercise tolerance test is most appropriate for: A. a healthy 34-year-old woman. B. a 56-year-old man following two-vessel stenting to establish activity tolerance. C. an 84-year-old man with stable angina who uses a walker. D. a 52-year-old woman with dyslipidemia and no history of ACS.

Correct: B. a 56-year-old man following two-vessel stenting to establish activity tolerance. For patients with a history of ACS and who underwent a reperfusion intervention, routine use of the treadmill exercise test should be performed to assess restoration or change in functional capacity as well as the efficacy of the current medication regimen (B). Routine testing can also be useful in stratifying patient risk for future ACS events. Incorrect: Routine use of the treadmill exercise test is not warranted in healthy individuals (A) as well as individuals with dyslipidemia and no history of ACS (D). Due to safety concerns, the treadmill exercise test should be avoided in elderly individuals who have difficulty walking without assistance (C).

You see a 54-year-old man who reports acute angina episodes with significant exertion. He is currently taking a beta blocker and clopidogrel. You consider the use of which of the following at the start of anginal symptoms? A. an oral dose of a calcium channel blocker B. a dose of nitroglycerin via oral spray C. an extra dose of the beta blocker D. a sustained-effect nitroglycerin patch

Correct: B. a dose of nitroglycerin via oral spray At the first signs of an anginal episode, nitroglycerin is recommended due to its powerful vasodilation effects. A rapid-acting formulation is preferred, either as an oral spray or quick-dissolving tablet. Incorrect: Immediate administration of rapid-acting nitroglycerin is the preferred treatment at the start of an anginal episode rather than a sustained-effect patch (D). An extra dose of a beta blocker (C) or a dose of a calcium channel blocker (A) will not have an immediate impact to alleviate anginal symptoms and can be associated with adverse effects depending on patient factors.

The ECG of a 72-year-old woman with a history of MI is shown. Geiter HB Jr. E-Z ECG Rhythm Interpretation. Philadelphia, PA: F.A. Davis; 2007. Transmural injury in this patient is best demonstrated by the presence of: A. U waves. B. pathological Q waves. C. low QRS voltage. D. ST-segment depression.

Correct: B. pathologic Q waves. This ECG demonstrates a broadening of the QRS complex that is consistent with a pathological Q wave (B). The pathological Q waves are an indication of cardiac tissue damage from a prior MI. Incorrect: A U wave is not evident in this ECG, which would come after the T wave and possibly represent repolarization of the Purkinje fibers (A). There is no indication of low QRS voltage as evident by the peak of the QRS complex (C). There is no ST-segment depression or elevation indicated in this example (D).

Beta-adrenergic antagonists are used in ACS therapy because of their ability to: A. reverse obstruction-fixed vessel lesions. B. reduce myocardial oxygen demand. C. enhance myocardial vessel tone. D. stabilize arterial volume.

Correct: B. reduce myocardial oxygen demand. Beta-adrenergic antagonists, or beta blockers, are typically used first-line during ACS due to their ability to reduce myocardial workload and oxygen demand by lowering heart rate, lowering stroke volume, and blunting catecholamine response (B). Incorrect: Beta blockers are not able to reverse vessel lesions (A), enhance myocardial vessel tone (C), or stabilize arterial volume (D).

Thrombolytic therapy is indicated in patients with chest pain and ECG changes such as: A. 1-mm ST-segment depression in leads VI and V3. B. physiological Q waves in leads aVF, V5, and V6. C. 3-mm ST-segment elevation in leads VI to V4. D. T-wave inversion in leads aVL and aVR.

Correct: C. 3-mm ST-segment elevation in leads VI to V4. Clinically significant ST-segment elevation largely determines the use of reperfusion therapy with thrombolytic therapy. Among the answer choices, the patient with an ST-segment elevation of 3 mm will be the best candidate for thrombolytic therapy (C), though the presence of absolute and relative contraindications must be considered.

Which of the following changes on the 12-lead ECG do you expect to find in a patient with ACS? A. flattened T wave B. R wave larger than 25 mm C. ST-segment deviation (greater than 0.05 mV) D. fixed Q wave

Correct: C. ST-segment deviation (greater than 0.05 mV) The characteristic finding on ECG for ACS is a new or presumably new transient ST-segment deviation or a T-wave inversion along with symptoms (C). Incorrect: T-wave flattening (A) or inversion in leads with dominant R waves (B) usually indicates a low likelihood of ACS. A finding of fixed Q waves typically indicates an intermediate likelihood of ACS (D).

The ECG of a 57-year-old man who presents in the ED complaining of chest pain and shortness of breath lasting over 20 minutes is shown. Jones SA. ECG Notes: Interpretation and Management Guide. 3rd ed. Philadelphia, PA: F.A. Davis; 2016. This most likely demonstrates: A. a normal ECG reading. B. NSTEMI. C. STEMI. D. AF.

Correct: C. STEMI. The ECG shows a clear elevation in the ST segment following the QRS complex. This is a characteristic finding in individuals who have experienced a STEMI (C). Incorrect: A normal ST segment will not have an elevation or depression, of which a clear elevation is demonstrated in this example (A). An NSTEMI will not produce ST-segment elevation by its definition (B). AF is characterized by a very rapid atrial rate (up to 400 to 600 beats per minute) so that the action potential is very low, resulting in an absence of P waves, which are evident in this example (D).

Which of the following changes on the 12-lead ECG would you expect to find in a patient with myocardial ischemia? A. 2-mm ST-segment elevation B. S wave larger than 10 mm C. T-wave inversion D. deep Q waves

Correct: C. T-wave inversion Myocardial ischemia occurs with inadequate blood flow to the heart leading to oxygen deficiency. The reduced blood flow could be the result of a complete or partial blockage of a coronary artery. The classic ECG finding of myocardial ischemia is a T-wave inversion (C). Incorrect: ST elevation indicates cardiac injury and is transiently found during STEMI (A). Q waves indicate necrosis of myocardial tissue and persist following MI (D). S waves in excess of 1 mV (10 mm) can be considered a normal finding, depending on the lead (B).

Nitrates are used in ACS therapy because of their ability to: A. reverse fixed vessel obstruction. B. reduce myocardial oxygen demand. C. cause vasodilation. D. stabilize cardiac rhythm.

Correct: C. cause vasodilation. Nitrates primarily work by causing vasodilation and improving blood flow (C). Nitroglycerin can be administered as soon as possible either via sublingual spray or tablet followed by parenteral administration. Incorrect: Beta blockers are used to reduce myocardial oxygen demand (B). Nitrates are not involved in reversing fixed vessel obstruction (A) or stabilizing cardiac rhythm (D), such as with an antiarrhythmic drug (e.g., amiodarone, flecainide).

Which of the following is most consistent with a person presenting with unstable angina? A. a 5-minute episode of chest tightness brought on by stair climbing and relieved by rest B. a severe, searing pain that penetrates the chest and lasts about 30 seconds C. chest pressure lasting 20 minutes that occurs at rest D. "heartburn" relieved by position change

Correct: C. chest pressure lasting 20 minutes that occurs at rest Unstable angina presents with chest pain that is typically described as pressure, tightness, heaviness, or aching sensation. The pain can occur at rest or with exercise or stress and can last several minutes (C). Incorrect: Chest tightness that results from exercise and is relieved by stress best describes stable angina rather than unstable angina (A). Chest pain associated with unstable angina is described as pressure, tightness, or heaviness rather than severe or searing pain, and the pain will last for several minutes in duration rather than only 30 seconds (B). A feeling of "heartburn" that is relieved by a positional change would more likely be GI in nature and not unstable angina (D).

In assessing a 62-year-old woman with or at risk for ACS, the NP considers that the patient will likely present: A. in a manner similar to that of a man with equivalent disease. B. at the same age as a man with similar health problems. C. more commonly with angina and less commonly with acute MI. D. with confusion and cognitive impairment.

Correct: C. more commonly with angina and less commonly with acute MI. The most common initial presentation of ACS in women is angina, while the most common initial manifestation in men is MI (C). Incorrect: Women usually have disease onset at an older age compared to men and will present differently (B). However, women younger than 60 years will often present in a similar manner as men (A). Atypical presentation of ACS can occur in both men and women 80 years and older and can include symptoms of confusion and cognitive impairment (D).

An abnormality of which of the following is the most sensitive marker for myocardial damage? A. aspartate aminotransferase B. creatine phosphokinase (CPK) C. troponin I (cTnI) D. lactate dehydrogenase

Correct: C. troponin I (cTnI) The presence of several biomarkers can be used to detect myocardial tissue damage and provide an early indication for MI. Troponin subtypes cTnI and cThT are released in the presence of myocardial damage. Both biomarkers increase rapidly during the first 12 hours after MI. However, cTnI is more cardiac specific and is sensitive to small-volume cardiac damage (C). Incorrect: Aspartate aminotransferase is a liver enzyme used to detect for liver damage, such as due to hepatitis or cirrhosis (A). CPK is released in the presence of muscle damage and is not specific to myocardial damage (B). Creatine kinase myocardial band (CK-MB) is more specific to cardiac damage. However, its utility in detecting MI is being replaced with other more sensitive and specific tests, such as troponin subtypes. Lactate dehydrogenase is used to detect tissue and organ damage but is not specific for myocardial damage (D).

Which of the following changes on the 12-lead ECG would you expect to find in a patient with history of acute transmural MI 6 months ago? A. 2-mm ST-segment elevation B. R wave larger than 25 mm C. T-wave inversion D. deep Q waves

Correct: D. deep Q waves Long-term ECG findings in a person who experienced a past acute transmural MI will include the presence of deep Q waves, which are indicative of preexisting structural or ischemic heart disease (D). Incorrect: An acute transmural MI, or STEMI, is characterized by ST deviation on ECG. However, this deviation is transient and will resolve when symptoms abate (A). A T-wave inversion is also an early indication of STEMI but will likely resolve soon after the episode (C). R waves are not a typical indication for acute transmural MI (B).

All of the following should be prescribed as part of therapy in ACS except: A. aspirin. B. metoprolol. C. lisinopril. D. nisoldipine.

Correct: D. nisoldipine. Nisoldipine is an NHP calcium channel blocker that can provide potent vasodilation. These agents can be a useful option when the patient is intolerant of beta blockers, which is considered a first-line treatment option during ACS (D). Incorrect: During ACS, a beta blocker (e.g., metoprolol) should be given if there are no contraindications in order to decrease myocardial workload and oxygen demand (B). An ACEI (e.g., lisinopril) is also recommended in the absence of contraindications (C). Aspirin is recommended at the first sign of ACS due to its antiplatelet effect (A).

Which of the following is least likely to be reported in ACS? A. newly noted pulmonary crackles B. transient mitral regurgitation murmur C. hypotension D. pain reproduced with palpation For answers and rationales, see end of chapter.

Correct: D. pain reproduced with palpation Patient signs and symptoms can provide an early indication if they are experiencing an actual ACS event or some other condition. The presence of chest discomfort or pain that is reproduced by palpation would suggest a low likelihood of an ACS event (D). Incorrect: Signs and symptoms associated with a high likelihood of an ACS event include hypotension (C), pulmonary edema, new rales or crackles (A), and a transient MR murmur (B). Heart Failure

]Which of the following is most consistent with a 50-year-old man presenting with acute MI? A. a 2-minute episode of chest tightness brought on by stair climbing B. a severe, localized pain that penetrates the chest and lasts about 3 hours C. chest pressure lasting 20 minutes that occurs at rest D. retrosternal diffuse pain for 30 minutes accompanied by diaphoresis

Correct: D. retrosternal diffuse pain for 30 minutes accompanied by diaphoresis In a younger patient presenting with acute MI, a classic presentation would be expected. This would include chest pain lasting several minutes that is described as pressure, tightness, heaviness, or aching and can be accompanied by dyspnea, nausea/vomiting, or diaphoresis (D). Incorrect: Chest tightness that occurs with exercise, such as stair climbing, is more likely due to stable or unstable angina (A). Meanwhile, chest pressure that lasts 20 minutes and occurs at rest is likely to be due to unstable angina (C). Severe, localized chest pain that lasts 3 hours is not a typical presentation of MI, but other causes should be investigated, possibly related to the GI system (B).

38. Rank the following signs and symptoms in the order of most common to least common in a 60-year-old woman in the time preceding an ACS event. A. dyspnea B. indigestion C. sleep disturbance D. unusual fatigue

Correct: D. unusual fatigue; C. sleep disturbance; A. dyspnea; B. indigestion A study of 515 women with ACS identified new or different symptoms preceding their ACS episode. The most common symptom was unusual fatigue (70%), followed by sleep disturbance (48%), shortness of breath (42%), and indigestion (39%).

NSTEMI

D. results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus and/or atheromatous material

Unstable angina

new onset of chest pain and discomfort at rest or worsening of symptoms with activities that previously did not provoke symptoms

STEMI

results from full-thickness (transmural) necrosis of the myocardium and total occlusion of coronary artery Stable angina is characterized by symptoms that occur in a predictable manner, usually with exertion and relieved with rest (45). Unstable angina is associated with the appearance of symptoms either at rest or with activities that previously did not provoke symptoms

According to the recommendations of the ACC/AHA, the recommended first-line lipid-lowering therapy for a patient with elevated ASCVD risk is: A. niacin. B. statin. C. fish oil. D. fibrate.

statin. The latest recommendations for ACC/AHA recommend statin therapy as the preferential first-line treatment for dyslipidemia (B). The use of moderate- or high-intensity statin therapy should be determined based on current low-density lipoprotein (LDL) cholesterol level and patient factors. Incorrect: Statin therapy is the preferred first-line agent to reduce LDL levels. If intensification is needed beyond optimized statin dosing, ezetimibe or a PCSK9 inhibitor can be added to statin therapy. Dietary supplements of fish oil are not recommended to reduce LDL (C). Fibrates (D) and niacin (A) are not recommended due to lack of evidence demonstrating cardiovascular benefits with use of these agents.