2021 CHEST

Board Review Acute Coronary

Syndromes
– LIVE ARS

Murtuza J. Ali, MD
Professor of Medicine, Cardiology
LSU School of Medicine, New Orleans
I have no relevant financial disclosures
I will not be discussing off label use of devices/medications
Question 1
• 62M presented to emergency department with crushing substernal chest
pain, 15 minutes in duration, with associated diaphoresis and nausea.
Symptoms resolved after sublingual NTG. EKG done during the episode
showed 1mm ST depression in leads V5-V6; EKG normalized after symptoms
resolved. Which of the following is the best next step in this patient’s care?

• A. Immediate angiography
• B. Unfractionated heparin and aspirin
• C. Thrombolytic therapy
• D. CT chest – PE protocol
Q 2: 63 year-old man presents to the Emergency Department with
stuttering chest pain for 24 hours, now constant for 3 hours associated
with nausea, diaphoresis and lightheadedness. EKG is below:
Q 2: Which of the following is the most
appropriate next step after giving aspirin?

A. Get an echocardiogram
B. Get an CT chest – PE protocol
C. Give calcium channel blocker and nitrates
D. Send to cardiac cath lab
Q 2: Evolving infero-postero-lateral ST-
Elevation MI
Question 3:
A 52 year-old man presents to a rural Emergency
Department 2 hours after the onset of crushing
chest pain. His EKG shows ST elevation in the
anterior leads. In addition to tPA and aspirin which
should be done:
Q3: A 52 year-old man presents to a rural Emergency Department 2
hours after the onset of crushing chest pain. His EKG shows ST
elevation in the anterior leads. In addition to tPA and aspirin which
should be done:

A. Unfractionated Heparin and low-level stress test before discharge

B. Fondaparinux and transfer for immediate cath
C. Clopidogrel 300 mg load, + enoxaparin and transfer for cath
D. Clopidogrel 600 mg load + bivalirudin for 48 hours and low-level
stress test before discharge
E. Abciximab + unfractionated heparin and transfer for cath
Q4: 67 year-old woman with h/o DM and HTN, HLD presents to the ER
with CP that started after dinner. The pain is sharp, 4/10, not associated
with shortness of breath, diaphoresis or nausea. She has a low grade
temp, but no cough. Leaning forward makes the pain better.
Q4: 67 year-old woman with h/o DM and HTN, HL presents to the ER
with CP that started after dinner. The pain is sharp, 4/10, not associated
with shortness of breath, diaphoresis or nausea. She has a low grade
temp, but no cough. Leaning forward makes the pain better.

A. Administer fibrinolytic therapy

B. Administer calcium channel blockers
C. Send directly to the cardiac cath lab
D. Repeat EKG in 10 minutes
E. Administer aspirin and get echocardiogram
Question 5:
58 year old female presents with acute
inferolateral ST elevation. Nearest cath facility is
45 minutes away by ground transport. How
should the patient be treated?