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Self-Assessment Questions

Cardiology

Management of Chest Pain in the Emergency Department: Review Questions

Richard Regnante, MD, and Wen-Chih Wu, MD

Dr. Regnante is a clinical fellow in cardiology, Warren Alpert Medical School of Brown University, Providence, RI. Dr. Wu is an assistant professor of medicine, Providence VA Medical Center and Warren Alpert Medical School at Brown University, Providence, RI.
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veteran Affairs.
This work is supported by the Target Research Enhancement Program, Providence VA Medical Center, providing research time for Dr. Wu; and the Brown Fellowship Program




Choose the single best answer for each question.



Figure 1. 12-Lead electrocardiogram performed in the case patient described in questions 1 and 2.
Click to Enlarge Figure


Questions 1 and 2 refer to the following case.

A 39-year-old woman with no significant past medical history presents to the emergency department (ED) with chest discomfort that started the night before presentation. The chest discomfort is 3 out of 10 in intensity, constant and sharp in quality, is located in the mid-sternal region, and does not radiate. The discomfort worsens when she takes a deep breath or lies flat and, as a result, the patient slept sitting upright in a recliner the night prior. She incidentally reports having had a recent viral illness with symptoms of a runny nose, nonproductive cough, and myalgias 2 weeks ago. Vital signs include a temperature of 99.1°F, respiratory rate of 16 breaths/min, blood pressure of 135/79 mm Hg, and pulse oximetry of 99% on room air. Physical examination is unremarkable except for an irregular heart beat. A 12-lead electrocardiogram (ECG) is obtained (Figure 1). A chest radiograph is normal.


1. In addition to treating the underlying arrhythmia, what is the next best step to improve this patient’s symptoms?
  1. Administer a nonsteroidal anti-inflammatory drug (NSAID)
  2. Administer chewable aspirin (325 mg) and activate the cardiac catheterization team
  3. Administer intravenous (IV) thrombolytic therapy
  4. Administer IV heparin bolus followed by an infusion for 48 hours
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2. Several hours after initial management, the patient’s pain is markedly improved. A repeat ECG reveals a regular heart rhythm at 60 bpm. What is the next step in this patient’s diagnostic evaluation?

  1. Admit to the coronary care unit (CCU) and immediately obtain a transthoracic echocardiogram
  2. Admit to the CCU to rule out myocardial infarction (MI) and perform stress testing in the morning
  3. Admit to the telemetry unit and obtain viral and Lyme titers and rheumatoid factor and antinuclear antibody levels
  4. Discharge home with echocardiography scheduled as an outpatient
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Questions 3 and 4 refer to the following case.

A 79-year-old man with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and tobacco abuse presents to the ED with discomfort across his left chest wall, radiating into his jaw and left arm. He notes that the pain began approximately 10 hours prior to admission and was initially mild, but it progressed in intensity and was associated with shortness of breath and diaphoresis, which prompted him to call 911. He was given an aspirin and sublingual nitroglycerin en route to the hospital. On presentation, he is still complaining of chest pain, appears ashen, and is visibly short of breath. Blood pressure is 110/88 mm Hg, respiratory rate is 22 breaths/min, and pulse oximetry is 90% on room air. Physical examination reveals jugular venous distention to the level of his jaw while sitting upright. Cardiac auscultation reveals a regular heart rhythm without murmurs and a loud S4 gallop. Lung sounds are diminished at the bases with fine crackles bilaterally about a quarter of the way up. The remainder of the examination is unremarkable. The patient is immediately placed on oxygen. After transfer from the stretcher to the examination room, the patient’s heart rate is 110 bpm with a blood pressure of 70/59 mm Hg. A 12-lead ECG is quickly obtained (Figure 2).


3. What is the next best step in this patient’s management to improve his chances of survival?

  1. Activate the coronary intervention team for emergent cardiac catheterization within 90 minutes of first medical contact
  2. Administer IV thrombolytics and IV heparin within 30 minutes of arrival
  3. Start a glycoprotein IIb/IIIa inhibitor and IV heparin, admit to the CCU, and perform cardiac catheterization within the next 24 hours
  4. Wide-open IV fluids through 2 large-bore catheters, initiate IV dobutamine at 20 µg/kg/min, and immediately obtain a transthoracic echocardiogram
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Figure 2. 12-Lead electrocardiogram performed in the case patient described in questions 3 and 4.
Click to Enlarge Figure


4. The patient’s symptoms dramatically improve after the treatment. Symptoms do not recur during hospitalization, vital signs have stabilized, and he is ready for discharge 4 days later. On discharge, what is the ideal outpatient medication regimen for this patient?
  1. Aspirin, atenolol, ezetimibe, ramipril
  2. Aspirin, carvedilol, captopril, fenofibrate, subcutaneous enoxaparin
  3. Aspirin, clopidogrel, lisinopril, metoprolol, pravastatin
  4. Cilostazol, ticlodipine, warfarin, lisinopril, atorvastatin
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Questions 5 and 6 refer to the following case.

A 46-year-old man with a long history of uncontrolled hypertension and tobacco abuse presents to the ED with acute chest pain that started 45 minutes ago. He describes the pain as sharp and 10 out of 10 in intensity and so unbearable that he had a friend drive him to the ED. The pain is substernal and radiates to his jaw, left arm, and back between his shoulder blades. He has been diaphoretic and nauseous since the pain first started but has not been short of breath. The patient is afebrile, blood pressure is 230/110 mm Hg in the right arm and 180/110 mm Hg in the left arm, respiratory rate is 18 breaths/min, and pulse oximetry is 98% on room air. On examination, he is diaphoretic and writhing in discomfort. There is no significant jugular venous distention. Cardiac auscultation reveals a grade 2/6 high-pitched early diastolic decrescendo murmur at the left sternal border that is accentuated when the patient leans forward. The remainder of the physical examination is unremarkable. A 12-lead ECG shows 5-mm ST-segment elevation in the inferior leads with reciprocal ST-segment depression in leads V2 and V3. A portable chest radiograph reveals a widened mediastinum.


5. What is the most beneficial first step in the treatment of this patient?

  1. Administer aspirin, a loading dose of clopidogrel, weight-based IV heparin, and IV metoprolol and activate the cardiac catheterization team for primary coronary angioplasty
  2. Administer aspirin, heparin, and IV thrombolytics in the ED
  3. Initiate IV labetalol infusion, titrating to a target heart rate of 60 to 80 bpm and a mean arterial pressure of 60 to 80 mm Hg, and obtain emergent cardiothoracic surgical evaluation
  4. Initiate IV nitroprusside infusion, titrating to a goal systolic blood pressure of 100 to 120 mm Hg, and obtain emergent cardiothoracic surgical evaluation
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6. What is the next step in the diagnostic work-up of this patient?

  1. Cardiac biomarkers and fasting lipid panel within 60 minutes
  2. Immediate chest computed tomography (CT) with IV contrast
  3. Immediate coronary angiogram by the cardiologist
  4. Immediate transthoracic echocardiogram by the cardiologist
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