Section 1

Cardiovascular Medicine
Questions
The pain sometimes occurs at rest and is worsened with lateral
movement of the trunk. It does not worsen with exertion. He has no
other symptoms and no other medical problems. He does not use
drugs and takes no medications.

Item 1 [Basic]
A 42-year-old woman is evaluated in the emergency department. She
has a 2-day history of nonexertional chest pain. The pain is sharp,
substernal, and worse when lying down or with deep breaths. She
denies shortness of breath. Her symptoms were preceded by a recent
upper respiratory tract infection.

On physical examination, temperature is 37.0C (98.6F), blood

pressure is 132/70 mm Hg, pulse rate is 90/min, and respiration rate
is 14/min. There is reproducible point tenderness along the left sternum. The remainder of the examination, including the cardiovascular examination, is normal.

On physical examination, temperature is 37.9C (100.3F), blood

pressure is 165/90 mm Hg, pulse rate is 102/min, respiration rate is
18/min, and oxygen saturation is 96% on ambient air. The cardiopulmonary examination is normal as is the remainder of the
physical examination.

Which of the following is the most likely diagnosis?

(A)
(B)
(C)
(D)

An electrocardiogram is shown. Echocardiogram shows a small pericardial effusion.

Which of the following is the most appropriate initial therapy?
(A)
(B)
(C)
(D)

Clopidogrel
Heparin
Ibuprofen
Prednisone

Acute pericarditis
Aortic dissection
Costochondritis
Unstable angina

Item 3 [Basic]
A 24-year-old man is evaluated for a 6-month history of episodic
substernal chest pain. Episodes occur four to five times per week and
are accompanied by palpitations and sweating. They resolve spontaneously after approximately 30 minutes. His symptoms are unrelieved with antacids, can occur at rest or with exertion, and are nonpositional. There are no specific precipitating factors. Lipid levels
were obtained last year and were normal. The patient is a nonsmoker. He has no personal or family history of coronary artery disease,
diabetes mellitus, hyperlipidemia, or hypertension. He is not taking
any medications.

Item 2 [Basic]
A 38-year-old man is evaluated in the emergency department. He
has a 2-week history of nonpleuritic, sharp, anterior chest pain. Each
episode of pain lasts 3 to 10 hours. He describes the pain as being
located mostly to the left of the sternum, although at times it radiates across the entire chest but not to his shoulders, arms, or back.

Item 1

2 Cardiovascular Medicine

On physical examination, vital signs are normal. He has no cardiac

murmurs and no abdominal pain. Complete blood count, serum thyroid-stimulating hormone level, and electrocardiogram are all normal.
Which of the following is the most appropriate management of this
patient?
(A)
(B)
(C)
(D)

Cardiac event monitor

Cardiac stress test
Empiric trial of proton pump inhibitor
Treatment with a selective serotonin reuptake inhibitor

Item 4 [Basic]
A 70-year-old man is evaluated for sharp left-sided pleuritic chest
pain and shortness of breath that began suddenly 24 hours ago. The
pain has been persistent over the last 24 hours and does not worsen
or improve with exertion or position. The patients history is significant for a 50-pack-year smoking history and severe chronic obstructive pulmonary disease, although he is currently a nonsmoker.
Medications are ipratropium and albuterol.
On physical examination, temperature is normal, blood pressure is
128/80 mm Hg, pulse rate is 88/min, and respiration rate is 18/min.
Oxygen saturation on ambient air is 89%. The trachea is midline.
Lung examination shows hyperresonance, decreased chest wall
expansion, and decreased breath sounds on the left. Cardiac examination shows distant heart sounds but no extra heart sounds.
Which of the following is the most appropriate diagnostic test to
perform next?
(A)
(B)
(C)
(D)

Chest CT
Chest radiography
Echocardiography
Electrocardiography

Item 5 [Basic]
A 50-year-old woman is evaluated for a 1-year history of recurrent
left-sided chest pain. The pain is poorly localized and nonexertional and occurs in 1-minute episodes. There is no dyspnea, nausea, or
diaphoresis associated with these episodes. The patient has not had
dysphagia, heartburn, weight change, or other gastrointestinal
symptoms. She has no other medical problems and does not smoke
cigarettes.
On physical examination, vital signs are normal. The patients chest
pain is not reproducible by palpation. The cardiac examination is
unremarkable, as is the remainder of the physical examination.
Results of a lipid panel, a fasting plasma glucose test, and a chest
radiograph are normal. An echocardiogram shows a normal ejection
fraction, with no wall motion abnormalities. Results of an exercise
stress test are normal.
Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)

Ambulatory pH study
Endoscopy
Treatment with a nonsteroidal anti-inflammatory drug
Trial of a proton pump inhibitor

Questions

Item 6 [Basic]
A 65-year-old man is evaluated because of chronic angina. He has a
10-year history of symptomatic coronary artery disease. The diagnosis was confirmed with an exercise stress test. Results of the test
showed no high-risk features. His estimated left ventricular ejection
fraction by echocardiography at that time was 56%. He occasionally
has chest pain after walking four blocks. The pain is relieved by taking one sublingual nitroglycerin or by resting. His exercise capacity
has not diminished, and the frequency, character, and duration of
the pain have not changed. He denies shortness of breath, orthopnea,
or paroxysmal nocturnal dyspnea. Current medications include simvastatin, aspirin, metoprolol, and sublingual nitroglycerin.
On examination, blood pressure is 122/82 mm Hg, pulse rate is
68/min, respiratory rate is 16/min, and body mass index is 27. There
is no jugular venous distention, and there are no murmurs, gallops,
rubs, or pulmonary crackles or peripheral edema.
Which of the following is the most appropriate management?
(A)
(B)
(C)
(D)

Cardiac catheterization
Current medical management
Echocardiogram
Exercise stress test

Item 7 [Basic]
A 60-year-old man is evaluated because of a 3-month history of
intermittent chest pain. He has occasional substernal chest pressure
when he exercises at the gym and occasionally after he eats a spicy
meal. The pressure is not consistently relieved with rest and is occasionally relieved with antacid. He has no associated symptoms of
shortness of breath, dizziness, or diaphoresis. His medical history
includes hypertension and hyperlipidemia. Medications are lisinopril and pravastatin.
On physical examination, blood pressure is 128/80 mm hg, pulse rate
is 84/min, and respiration rate is 16/min. Findings on cardiovascular examination are normal.
The electrocardiogram is shown.
Which of the following is the most appropriate diagnostic test to
evaluate the patients chest pain?
(A)
(B)
(C)
(D)

Cardiac catheterization
Dobutamine echocardiography
Exercise echocardiography
Exercise electrocardiography

Item 8 [Basic]
A 55-year-old woman is evaluated for symptoms of sharp, localized,
left-sided chest pain for the last 3 weeks. The pain is unrelated to exertion and is associated with mild dyspnea and fatigue. Typically it lasts
for 5 to 10 minutes and abates spontaneously. The pain is not pleuritic,
positional, or related to eating. She has hypertension and hypercholesterolemia. Her father had a myocardial infarction at 54 years of age.
Daily medications are hydrochlorothiazide, simvastatin, and aspirin.
On physical examination, blood pressure is 135/78 mm Hg, pulse rate
is 78/min, and respiration rate is 14/min. Cardiac auscultation shows
S4 but is otherwise normal, as is the remainder of her physical examination.

Questions

Cardiovascular Medicine 3

Item 7

Electrocardiogram shows sinus rhythm, with a heart rate of 75/min

and no ST-segment or T-wave abnormalities.
Which of the following is the most appropriate diagnostic study?
(A)
(B)
(C)
(D)

Coronary angiography
Exercise echocardiography
Exercise electrocardiography
Pharmacologic stress test

Item 9 [Advanced]
A 68-year-old man is evaluated for exertional chest pain of 3 months
duration. He describes the chest pain as midsternal pressure without radiation that occurs with walking one to two blocks and resolves
with rest or sublingual nitroglycerin. No symptoms have occurred at
rest. His medical history is significant for myocardial infarction 3
years ago, hypertension, and hyperlipidemia. Medications are
aspirin, metoprolol, simvastatin, isosorbide dinitrate, and sublingual
nitroglycerin as needed for chest pain.

Which of the following is the most appropriate management?

(A)
(B)
(C)
(D)

Add diltiazem
Add ranolazine
Increase the metoprolol dosage
Refer the patient for coronary angiography

Item 10 [Advanced]
A 62-year-old man with coronary artery disease is evaluated for
angina. He was diagnosed 4 years ago, and since that time, his symptoms have been well controlled with metoprolol and isosorbide
mononitrate. He had exertional angina 8 months ago. His dosages of
metoprolol and isosorbide were increased and long-acting diltiazem
was added, with improved control of his symptoms. He has had
increasing symptoms over the last 2 months and now requires daily
sublingual nitroglycerin for relief of angina during exercise. He has
not had any episodes of angina at rest. His medical history is significant for hyperlipidemia treated with atorvastatin.
On physical examination, the patient is afebrile, blood pressure is
110/60 mm Hg, pulse rate is 55/min, and respiration rate is 12/min.
Results of cardiopulmonary examination are unremarkable, as are
the remainder of the findings of the physical examination.

On physical examination, temperature is normal, blood pressure is

150/85 mm Hg, pulse rate is 80/min, and respiration rate is 12/min.
The lungs are clear. Cardiac examination shows normal S1 and S2
with no extra heart sounds or murmurs. The remainder of the examination is unremarkable.

Electrocardiogram shows no acute ischemic changes.

Electrocardiogram shows normal sinus rhythm, no left ventricular

hypertrophy, no ST- or T-wave changes, and no Q waves.

Which of the following should be the next step in this patients

management?
(A)
(B)
(C)
(D)

Coronary angiography
Exercise treadmill testing
Increase -blocker dosage
Increase nitrate dosage

4 Cardiovascular Medicine

Questions

Item 11 [Basic]

Item 13 [Basic]

A 68-year-old man is evaluated in the emergency department

because of a 2-day history of intermittent chest pain. The pain is substernal, is not related to activity, and lasts less than 15 minutes. His
medical history includes hypertension, hyperlipidemia, and type 2
diabetes. His medications include aspirin, metoprolol, lisinopril,
simvastatin, and metformin. In the emergency department he
received a dose of liquid antacid, and his chest pain partially resolved.

A 52-year-old woman was evaluated in the emergency department

because of acute onset of dyspnea while shoveling snow this morning. The dyspnea resolved within 2 minutes of rest but recurred an
hour later while she was watching television. Over the previous 10
days she has had several similar episodes of dyspnea with mild exertion, such as walking upstairs, and also at rest. She has no chest pain,
palpitations, or orthopnea. She has a 15-year history of type 2 diabetes, hyperlipidemia, and hypertension treated with aspirin, metformin, chlorthalidone, ramipril, and rosuvastatin.

On physical examination, he is afebrile, blood pressure is 130/80 mm

Hg, pulse rate is 70/min, respiration rate is 18/min, and oxygen saturation is 98% on ambient air. Results of cardiopulmonary examination are normal.
The electrocardiogram shows minor T-wave abnormalities. Troponin
T measurement is less than 0.01 ng/mL (0.01 g/L).
Which of the following is the most appropriate management of this
patients chest pain?

On physical examination, temperature was 37C (98.6F), blood

pressure was 110/70 mm Hg, pulse rate was 80/min, respiratory rate
was 18/min, and oxygen saturation was 96% on ambient air. There
was no jugular distention, normal cardiac sounds were present without extra sounds or murmurs, and the lungs were clear to auscultation.
The initial electrocardiogram showed ST-segment changes. The first
troponin I level was 0 ng/mL (0 g/L).

(A) Admission to the telemetry unit with serial electrocardiograms and troponin measurements
(B) Coronary angiography
(C) Discharge to home
(D) Esophageal pH probe
(E) Pharmacologic stress test with nuclear imaging

An hour after admission to the emergency department, she had an

episode of acute dyspnea. A repeat electrocardiogram at this time is
shown. Repeat troponin level is 0.8 ng/mL (0.8 g/L).

Item 12 [Advanced]

(A)
(B)
(C)
(D)

A 58-year-old woman is evaluated in the emergency department for

chest pain, diaphoresis, and shortness of breath of 4 hours duration.
Three years ago she was diagnosed with a nonST-elevation myocardial infarction and was treated medically. Additional medical history includes type 2 diabetes and hypertension. Her current medications are aspirin, lisinopril, atorvastatin, and glargine insulin.
On physical examination, she is afebrile, blood pressure is 125/60
mm Hg, pulse rate is 48/min, respiratory rate is 18/min, and oxygen
saturation is 98% on ambient air. Cardiac examination shows no
jugular venous distention, and the lungs are clear. An S4 is present.
Electrocardiogram shows ST-segment elevation and T-wave inversions in leads II, III, and aVF. The initial troponin T measurement is
elevated.
The nearest hospital capable of percutaneous coronary intervention
is more than 2 hours away. The patient has no contraindication to
thrombolytic therapy.
Which of the following is the most appropriate initial management
for this patient?
(A) Aspirin, heparin, clopidogrel, intravenous nitroglycerin, and
thrombolytic therapy
(B) Aspirin, heparin, intravenous nitroglycerin, metoprolol, and
thrombolytic therapy
(C) Heparin, clopidogrel, pravastatin, and intravenous nitroglycerin
(D) Immediate transfer for percutaneous coronary intervention

What of the following is the most appropriate next diagnostic test?

Cardiac catheterization
Echocardiogram
Exercise stress test
Repeat of troponin I level

Item 14 [Advanced]
A 78-year-old man is evaluated in the emergency department
because of chest pain. He describes left substernal discomfort that
began approximately 8 hours ago. He reports no similar episodes of
chest pain. Medical history is significant for hypertension and a 30pack-year history of ongoing tobacco use. His only medication is
amlodipine.
On physical examination, the patient is afebrile, blood pressure is
130/80 mm Hg, pulse rate is 72/min, and respiration rate is 12/min.
There is no jugular venous distention, the lung fields are clear, and
cardiac examination shows a normal S1 and S2 without murmurs. No
peripheral edema is present.
The initial troponin I level is 26 ng/mL (26 g/L). Laboratory findings
are otherwise normal.
Electrocardiogram shows sinus rhythm of 70/min and 2-mm ST-segment elevation in leads II, III, and aVF.
Which of the following is the most appropriate treatment
approach?
(A)
(B)
(C)
(D)

Coronary artery bypass surgery

Intracoronary thrombolytic therapy
Medical therapy
Primary percutaneous coronary intervention

Questions

Cardiovascular Medicine 5

Item 13

Item 15 [Advanced]
A 70-year-old woman is hospitalized for an ST-elevation myocardial
infarction involving the anterior wall. Her symptoms initially began
3 days before admission. The pain resolved spontaneously before she
reached the hospital.
Two hours after presentation to the emergency department, she has
acute onset of dyspnea and hypotension and requires emergent intubation. A portable chest radiograph shows cardiomegaly and pulmonary edema. Vasopressor therapy is initiated to support her blood
pressure.
On physical examination, blood pressure is 90/60 mm Hg, pulse rate
is 120/min, and respiration rate is 12/min. She has a grade 4/6 harsh
holosystolic murmur at the right and left sternal borders associated
with a palpable thrill. No S3 or S4 is heard. Crackles are heard bilaterally at the lung bases.
Which of the following is the most likely diagnosis?
(A)
(B)
(C)
(D)

Aortic dissection
Free wall rupture
Right ventricular infarction
Ventricular septal defect

Item 16 [Basic]
A 64-year-old man is evaluated in the emergency department
because of chest pain. He describes the chest pain as nonradiating
pressure in the midchest that began at rest 1 hour ago and is not associated with any symptoms. Medical history is remarkable for hypertension, type 2 diabetes mellitus, hyperlipidemia, and a 20-pack-year
history of smoking. Medications are hydrochlorothiazide, metformin, and simvastatin.

On physical examination, he is afebrile, blood pressure is 140/80 mm

Hg, pulse rate is 78/min, and respiration rate is 16/min. There is no
jugular venous distention, the lungs are clear, and the findings on
heart examination are normal.
Electrocardiogram shows a normal sinus rhythm and T-wave inversions in leads V2 through V6 without Q waves.
Initial cardiac biomarkers are within normal limits.
He is given aspirin, clopidogrel, low-molecular-weight heparin, and
a nitrate, with resolution of his chest pain.
Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)

Add metoprolol
Add nifedipine
Coronary angiography
Thrombolysis

Item 17 [Basic]
A 54-year-old man is evaluated in the emergency department for an
acute coronary syndrome that began 30 minutes ago. His medical
history is significant for hypertension and type 2 diabetes mellitus.
Medications are lisinopril and glipizide.
On physical examination, he is afebrile, blood pressure is 160/90 mm
Hg, pulse rate is 80/min, and respiration rate is 12/min. Cardiovascular examination shows a normal S1 and S2 without an S3 and
no murmurs. Lung fields are clear.

Section 1

Cardiovascular Medicine
Answers and Critiques
Item 1

Answer: C

Item 2

Answer: C

Educational Objective: Treat pericarditis with an NSAID.

Educational Objective: Diagnose costochondritis.

The most appropriate initial therapy is ibuprofen. Acute pericarditis

is the most likely diagnosis. Viral infection is the most common
known cause of acute pericarditis. Diagnosis is most often made by
confirming two of three classic findings: chest pain, often with a
pleuritic component; friction rub; and diffuse ST-segment elevation
on electrocardiography (ECG). This patient has chest pain and diffuse ST-segment elevation on ECG. A pericardial friction rub is virtually pathognomonic of acute pericarditis. It is best auscultated at
the left lower sternal border during suspended respiration while the
patient is leaning forward. The classic rub has three components and
can be squeaky, scratchy, or swooshing. It is often transient. Although
a pericardial friction rub is a highly specific sign of acute pericarditis, it is not very sensitive and its absence does not rule out the diagnosis. In acute pericarditis, epicardial inflammation causes upwardly concave ST-segment elevation in all leads except aVR. PR-segment
depression in the limb leads (particularly lead II) or precordial leads
and elevation in lead aVR may accompany ST-segment elevation. PRsegment shifts are highly specific but not sensitive findings for acute
pericarditis. Echocardiography can detect very small pericardial
effusions that may help with the diagnosis of pericarditis. More
importantly, echocardiography can detect cardiac tamponade and
heart failure that may complicate acute pericarditis.

This patient most likely has costochondritis. The cause of chest pain
can be determined in most cases after a careful history and physical
examination. Musculoskeletal chest pain has an insidious onset and
may last for hours to weeks. It is most recognizable when it is sharp
and localized to a specific area of the chest; however, it can also be
poorly localized. The pain may be worsened by turning, deep breathing, or arm movement. Chest pain may or may not be reproducible
by chest palpation (pain reproduced by palpation does not exclude
ischemic heart disease), and the results of cardiovascular examination are often normal. Importantly, the patients findings are not consistent with an alternative cause of chest pain. Treatment is typically rest and use of anti-inflammatory drugs.
The chest pain associated with acute pericarditis is typically pleuritic and is worsened when the patient lies down. A two- or three-component friction rub is often present. This patient does not have any
risk factors for pericarditis. Specifically, he has no history of recent
viral infection, myocardial infarction, trauma, malignancy, medication use, connective tissue disease, or uremia. Therefore, pericarditis is highly unlikely.
Aortic dissection is generally described as a tearing or ripping pain
with radiation to the back. It is more commonly seen in patients with
a history of hypertension. This patients description of chest pain,
the results of physical examination, and the absence of risk factors
are inconsistent with aortic dissection.

Appropriate initial therapy for acute pericarditis is either aspirin or

an a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen. Chest pain resulting from acute pericarditis usually resolves
within 24 hours of treatment with anti-inflammatory medications.
Nonrandomized and nonblinded studies support the use of
colchicine as an alternative first-line agent or an adjunctive treatment for acute pericarditis.

This patient has no risk factors for cardiac disease. His history is
inconsistent with descriptors that increase the probability of
ischemic chest pain, including unstable angina. Specifically, there is
no radiation to the arms, exertional component, relief with rest,
diaphoresis, nausea, vomiting, or description of pressure.
Considering the patients age and description of his chest pain, the
probability of unstable angina or an acute coronary syndrome is low.

In the absence of a specific indication for their use, a glucocorticoid,

such as prednisone, should only be used in refractory cases of acute
pericarditis or in patients with contraindications to aspirin, NSAIDs,
and colchicine. Glucocorticoids increase the risk of recurrent pericarditis.

KEY POINT

Musculoskeletal chest pain has an insidious onset and may last for hours to
weeks. It is most recognizable when it is sharp and localized to a specific area
of the chest. The pain may be worsened by turning, deep breathing, or arm
movement.

The nature of the chest pain and the findings of PR-segment depression on ECG and a small effusion on echocardiography are most consistent with acute pericarditis and make acute coronary syndrome
or pulmonary embolism unlikely. Therefore, heparin and clopidogrel are not indicated.

Bibliography
Stochkendahl MJ, Christensen HW. Chest pain in focal musculoskeletal disorders.
Med Clin North Am. 2010;94:259-73. [PMID: 20380955]

KEY POINT

Appropriate initial therapy for acute pericarditis is either aspirin or an NSAID,

such as ibuprofen.
Bibliography
Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;351:2195202. [PMID: 15548780]

20

Answers and Critiques

Item 3

Answer: D

Educational Objective: Manage panic disorder.

The most appropriate management of this patient is to prescribe a selective serotonin reuptake inhibitor. Panic disorder is a syndrome characterized by sudden panic attacks with acute onset of somatic symptoms
that may include chest pain, palpitations, sweating, nausea, dizziness,
dyspnea, and numbness. These symptoms usually last from 5 to 60 minutes. Approximately 50% of patients with panic disorder also have associated agoraphobia, with fears of being in crowds or in places from
which escape would be difficult. Diagnosis is based on clinical descriptors and setting, but care should be taken to consider underlying medical disorders, such as cardiac disease, thyroid disease, or pheochromocytoma, particularly in patients who are at increased risk for one of
these disorders. However, extensive testing is not necessary in most
patients with a characteristic presentation and normal findings on
physical examination and basic laboratory studies. Treatment options
for panic disorder include medication and psychotherapy. Cognitive
behavioral therapy (CBT) has been shown to be the most effective psychotherapeutic intervention in controlled trials. Selective serotonin
reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors
have been shown to be effective. Panic disorder that is severe or refractory appears to be most amenable to a combination of CBT and pharmacotherapy compared with either treatment alone.
This patient has classic symptoms of panic disorder and no cardiac
risk factors. It would be inappropriate to order further cardiac testing in the setting of a normal electrocardiogram and classic symptoms. This patients symptoms are also atypical for gastroesophageal
reflux disease, and so empiric proton pump inhibitor therapy would
be inappropriate.
KEY POINT

Panic disorder is characterized by sudden panic attacks with acute onset of

somatic symptoms that may include chest pain, palpitations, sweating, nausea,
dizziness, dyspnea, and numbness.
Bibliography
McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam
Physician. 2013;87:177-82. [PMID: 23418761]

Item 4

Answer: B

Educational Objective: Evaluate a patient with pleuritic

chest pain.
This patient should undergo chest radiography. He has severe chronic obstructive pulmonary disease (COPD) and findings that are consistent with spontaneous secondary pneumothorax. These findings
include sudden, sharp, nonradiating pleuritic chest pain and shortness of breath with hyperresonance, decreased breath sounds, and
decreased chest wall expansion on the side of the pneumothorax in
a patient with underlying lung disease. Pneumothorax should be
considered in any patient who has sudden onset of pleuritic chest
pain and dyspnea. The diagnostic test of choice if pneumothorax is
suspected is an upright chest radiograph. Findings on chest radiograph include separation of the parietal and visceral pleura by a collection of gas and the absence of vessels in this space. This patient is
at increased risk for pneumothorax because of his COPD.
Pneumothorax occurring in patients without known lung disease or
a clear precipitating cause is termed primary spontaneous pneumothorax (PSP). PSP tends to occur more often in men, smokers,
and those with a family history of PSP. The clinical presentation is
similar in both primary or secondary pneumothorax.

Cardiovascular Medicine 21

Chest computed tomography (CT) also can be used to diagnose pneumothorax. Chest CT may be more sensitive than a chest radiograph
in delineating smaller collections of gas in the pleural space and providing more information about the pulmonary parenchyma and
pleura. However, plain film radiography remains the initial test of
choice for most patients, and chest CT should be reserved for cases
when the chest radiograph does not provide information to guide
further treatment or evaluation.
The patients history and physical examination are classic for pneumothorax, and his pain descriptors do not strongly suggest ischemia
or other primary cardiovascular disease. Electrocardiogram and
echocardiogram, which are the tests of choice to evaluate ischemic
heart disease, valvular heart disease, or cardiomyopathy, would not
be the first diagnostic tests of choice for suspected pneumothorax.
KEY POINT

Pneumothorax should be considered in any patient who has sudden onset of

pleuritic chest pain and dyspnea. The diagnostic test of choice if pneumothorax
is suspected is an upright chest radiograph.
Bibliography
Noppen M. Spontaneous pneumothorax: epidemiology, pathophysiology and cause.
Eur Respir Rev. 2010;19:217-9. [PMID: 20956196]

Item 5

Answer: D

Educational Objective: Manage noncardiac chest pain.

This patient should receive twice-daily proton pump inhibitor (PPI)
therapy for 8 to 10 weeks. Pain associated with gastroesophageal
reflux can mimic ischemic chest pain. A cardiac cause should be
carefully assessed and excluded in all patients with chest pain. This
patient has nonanginal chest pain, no additional risk factors, and
normal findings on exercise stress testing. Therefore, the likelihood
of a cardiac cause of chest pain is low. Randomized controlled trials
have shown that a therapeutic trial of twice-daily PPI treatment is
effective in 50% to 60% of patients with noncardiac chest pain, indicating that gastroesophageal reflux disease is the underlying cause.
If the PPI trial is unsuccessful, further evaluation with endoscopy (to
detect erosive esophagitis or achalasia), manometry (to detect esophageal motility disorders such as diffuse esophageal spasm), and ambulatory pH recording (to detect refractory reflux) would be reasonable.
Musculoskeletal chest pain has an insidious onset and may last for
hours to weeks. It is most recognizable when it is sharp and localized
to a specific area of the chest; however, it can also be poorly localized.
The pain may be worsened by turning, deep breathing, or arm movement. Chest pain may or may not be reproducible by chest palpation
(pain reproduced by palpation does not exclude ischemic heart disease), and findings on cardiovascular examination are often normal.
This patient does not have the typical features of musculoskeletal
chest pain. Therefore, treatment with an nonsteroidal anti-inflammatory drug is not the most appropriate first step in management.
KEY POINT

After cardiac causes have been excluded by comprehensive cardiac examination, an 8- to 10-week trial of proton pump inhibitor therapy is reasonable
before further testing in patients with noncardiac chest pain who do not have
concerning symptoms.
Bibliography
Fass R, Achem SR. Noncardiac chest pain: diagnostic evaluation. Dis Esophagus.
2012;25:89-101. [PMID: 21777340]

22 Cardiovascular Medicine

Item 6

Answer: B

Educational Objective: Manage chronic stable angina.

Continuing the current management is the most appropriate action.
Several large trials have compared revascularization with optimal
medical therapy. These studies found that revascularization combined with aggressive medical therapy was not superior to aggressive medical therapy alone in reducing death or myocardial infarction. Based on these studies, current guidelines recommend
reserving coronary angiography and revascularization for patients
who continue to have symptoms despite optimal medical therapy,
patients who are unable to tolerate the side effects of medications,
and those who have high-risk findings on noninvasive testing. This
patients pattern of angina is stable, he is tolerating his medications,
and his original stress test showed no high-risk features. Therefore,
a more aggressive intervention such as coronary angiography is not
indicated as there would not be an expected improved outcome.
Routine follow-up electrocardiography, exercise stress testing (or
other noninvasive imaging studies), and echocardiography are not
indicated in patients with chronic stable angina. Although careful
and frequent follow-up is indicated, disease assessment is conducted with a detailed history and physical examination. The history
should focus on changes in physical activity and the frequency,
severity, or pattern of chest pain. Reasonable laboratory monitoring
includes periodic measurement of lipids and blood glucose levels.
Follow-up electrocardiography should be considered when there are
medication changes that could affect cardiac conduction; there is a
change in the severity, frequency, or pattern of angina; symptoms
that suggest dysthymia occur; or syncope develops. There are no
indications for an electrocardiogram, an exercise stress test, or
echocardiography.
KEY POINT

Routine follow-up electrocardiography, exercise stress testing (or other noninvasive imaging studies), and echocardiography are not indicated in patients
with chronic stable angina.

ity of CAD. For patients with a high pretest probability of CAD, stress
testing is not useful to diagnose CAD and empiric medical therapy
should be initiated. In this setting, a normal stress test result would
likely be a false-negative finding and an abnormal stress test result
would only confirm a high pretest probability of CAD.
Exercise ECG testing is the standard stress test for the diagnosis of
CAD in patients with normal baseline ECG findings. If abnormalities
that limit ST-segment analysis are present (left bundle branch block,
left ventricular hypertrophy, paced rhythm, Wolff-Parkinson-White
pattern), the results may be difficult to interpret. In patients with
abnormalities on resting ECG that impair the ability to interpret STsegment changes, imaging increases diagnostic accuracy and ability
to determine the site and extent of ischemia. Exercise is preferred to
pharmacologic stressors because it provides a gauge of functional
capacity and a contextual understanding of symptoms as well as a
record of the hemodynamic response to exercise. For patients who
cannot exercise because of physical limitations or physical deconditioning, pharmacologic stressors can be used. These agents, recommended if the patient cannot achieve at least 5 metabolic equivalents, increase myocardial contractility and oxygen demand
(dobutamine) or induce regional hypoperfusion through coronary
vasodilation (adenosine, dipyridamole, and regadenoson).
This patient has atypical chest pain (substernal pressure caused by
exercise but not relieved with rest) and normal findings on ECG. The
most appropriate diagnostic test to evaluate the patients chest pain
is exercise electrocardiography. Because he is a candidate for the preferred type of stress test, alternative methods, including imaging
with echocardiography or pharmacologic stress testing with dobutamine, are not indicated.
Cardiac catheterization would not be an appropriate intervention
given the patients intermediate risk for cardiovascular disease. It
might be appropriate if he had a high pretest probability of coronary
artery disease or he had specific findings of coronary occlusion on
stress testing.
KEY POINT

Bibliography
Qaseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease:
summary of a clinical practice guideline from the American College of
Physicians/American College of Cardiology Foundation/American Heart
Association/American Association for Thoracic Surgery/Preventive Cardiovascular
Nurses Association/Society of Thoracic Surgeons. Ann Intern Med. 2012;157:735-43.
[PMID: 23165665]

Item 7

Answers and Critiques

Answer: D

Educational Objective: Diagnose chronic angina with

an exercise stress test.
The most appropriate test to evaluate the patients chest pain is exercise electrocardiography.
A variety of noninvasive stress tests are available to determine
whether a patient with cardiovascular symptoms has coronary
artery disease (CAD). The decision to perform a specific test is based
on the pretest probability of CAD, the patients ability to exercise,
findings on resting electrocardiography (ECG), and comorbid conditions, such as reactive airways disease, that may influence the
choice of a pharmacologic stress agent. Stress testing is most useful
in patients with an intermediate pretest probability of CAD. For
patients with a low pretest probability of CAD, stress testing is not
useful because an abnormal test result is likely a false-positive finding and a normal test result only confirms the low pretest probabil-

Exercise electrocardiography is the standard stress test used to diagnose coronary artery disease in patients who have normal findings on baseline electrocardiogram and are able to exercise.
Bibliography
Qaseem A, Fihn SD, Dallas P, et al. Clinical Guidelines Committee of the American
College of Physicians. Management of stable ischemic heart disease: summary of a
clinical practice guideline from the American College of Physicians/American College
of Cardiology Foundation/American Heart Association/American Association for
Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic
Surgeons. Ann Intern Med. 2012;157:735-43. [PMID: 23165665]

Item 8

Answer: C

Educational Objective: Evaluate a woman with atypical chest pain.

This patient should undergo exercise electrocardiography (ECG). She
has several risk factors for coronary artery disease (CAD), including
hypertension, hypercholesterolemia, and a family history of premature CAD. Her symptoms are not typical of angina (her chest discomfort is localized, sharp, and not reproducible with exertion), and
the resting ECG is normal. Because this patient has multiple risk factors and atypical symptoms, the pretest probability that CAD is the
cause of her symptoms is intermediate. The results of exercise ECG
testing, whether normal or abnormal, will significantly affect the

Answers and Critiques

posttest probability of CAD. Exercise testing is recommended as the

initial test in patients with an intermediate pretest probability of CAD
based on age, sex, and symptoms, including patients with right bundle branch block or ST-segment depression of less than 1 mm at baseline. In addition, the results of the exercise ECG test will provide
prognostic information about the risk of death and myocardial
infarction on the basis of exercise duration, angina, and the magnitude of ST-segment depression.
Coronary angiography is not appropriate for this patient because the
pretest probability of CAD is intermediate, which is too low to warrant immediate coronary angiography as the initial diagnostic test.

Cardiovascular Medicine 23

Ranolazine should be considered only in patients who remain symptomatic despite optimal dosages of -blockers, calcium channel
blockers, and nitrates. Ranolazine decreases angina symptoms but is
significantly more expensive and less effective than the usual
antianginal medications.
Coronary angiography may be indicated in a patient who is receiving maximal medical therapy with continued symptoms of angina
that affect quality of life. Referral for coronary angiography is not
indicated for this patient because he is not currently receiving optimal medical therapy.
KEY POINT

Although exercise ECG testing has been found to have lower specificity and a higher false-positive rate in women than in men, the routine use of exercise testing with echocardiography to assess left ventricular regional wall motion or perfusion imaging is not
recommended for either women or men in the absence of baseline
ECG abnormalities. Although echocardiography increases the sensitivity of the ECG results, the use of stress echocardiography as the
initial test has not been found to reduce cardiovascular events compared with exercise ECG testing alone.
Pharmacologic stress testing is not indicated because this patient is
physically able to exercise. Pharmacologic agents include dobutamine (which increases heart rate and myocardial contractility) and
vasodilators (which cause relative increases in coronary blood flow
in myocardial regions that are not supplied by stenotic vessels).
Exercise is preferred over pharmacologic treatment because of the
additional diagnostic and prognostic information provided by exercise testing.
KEY POINT

Although exercise electrocardiography is associated with a higher false-positive

rate in women, it is the recommended modality for noninvasive diagnostic
testing in women who are able to exercise and have interpretable electrocardiograms.
Bibliography
Shaw LJ, Bugiardini R, Merz CN. Women and ischemic heart disease: evolving knowledge. J Am Coll Cardiol. 2009;54:1561-75. [PMID: 19833255]

Item 9

Answer: C

Educational Objective: Treat continuing angina in a

patient with chronic stable coronary artery disease.
In this patient with coronary artery disease and continuing angina,
the medical therapy should be optimized by increasing the dosage
of -blocker. Physical examination is notable for blood pressure and
heart rate that would allow further up-titration of the -blocker
dosage. Complete -blockade typically results in a resting pulse rate
of approximately 55 to 60/min. Therefore, the pulse rate of 80/min
suggests that the dosage of metoprolol should be increased. -blockers are particularly effective antianginal medications because they
decrease heart rate, myocardial contractility, and systemic blood
pressure, thereby lowering myocardial oxygen demand.
Calcium channel blockers are first-line antianginal therapy in
patients with contraindications to -blockers. In patients with continuing angina despite optimal dosages of -blocker and nitrates, a
calcium channel blocker may be added. A calcium channel blocker
such as diltiazem is not indicated in this patient because his dosage
of metoprolol is not yet optimal.

In the treatment of chronic stable angina, the -blocker dose is adjusted to

achieve a resting pulse rate of approximately 55 to 60/min.
Bibliography
Boden WE, ORourke RA, Teo KK, et al. Optimal medical therapy with or without
PCI for stable coronary disease. N Engl J Med. 2007;356:1503-16. [PMID: 17387127]

Item 10

Answer: A

Educational Objective: Evaluate chronic stable angina.

Coronary angiography is the most appropriate option in this patient
who has had continued symptoms of angina despite optimal medical therapy. Although it has been shown that a routine strategy of
coronary angiography and revascularization provides no benefit
compared with optimal medical therapy in patients with chronic stable angina, coronary angiography may be of benefit in patients who
are highly symptomatic despite optimal medical therapy, such as this
patient. Coronary angiography allows direct evaluation of the coronary anatomy, with possible percutaneous coronary intervention or
surgical revascularization if indicated. Coronary revascularization
has been shown to be beneficial in patients with chronic stable angina and the following conditions: angina pectoris that is refractory to
medical therapy; a large area of ischemic myocardium and high-risk
criteria on stress testing; high-risk coronary anatomy, including left
main coronary artery stenosis or three-vessel disease; and significant coronary artery disease with reduced left ventricular systolic
function. In appropriately selected patients, revascularization, with
either percutaneous coronary intervention or coronary artery bypass
grafting surgery, has been shown to reduce angina, increase longevity, and improve left ventricular performance.
Exercise treadmill stress testing would not be useful in the management of this patient because it would only confirm the known diagnosis of coronary artery disease. Results of an exercise stress test
would not influence therapeutic decisions.
Although -blockers and nitrates are effective antianginal medications, the patient is receiving near-maximal doses of both drugs, as
indicated by his pulse rate, which shows effective -blockade, and
his blood pressure, which likely would not tolerate an increase in the
dosage of either medication.
KEY POINT

Coronary angiography is indicated in patients with chronic stable angina who

have lifestyle-limiting angina despite optimal medical therapy.
Bibliography
Qaseem A, Fihn SD, Dallas P, et al. Management of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American
College of Cardiology Foundation/American Heart Association/American Association
for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic
Surgeons. Ann Intern Med.2012;157:735-43. [PMID: 23165665]

24 Cardiovascular Medicine

Item 11

Answer: A

Answers and Critiques

Item 12

Answer: A

Educational Objective: Manage chest pain in the emergency department.

Educational Objective: Treat an ST-elevation myocardial infarction with thrombolytic therapy.

The most appropriate management of this patients chest pain is

admission to the telemetry unit and ongoing assessment with serial electrocardiograms and troponin measurements. Based on this
patients age and the substernal nature of his chest pain, there is at
least an intermediate likelihood of an acute coronary syndrome. The
decision to hospitalize a patient with chest pain is challenging. The
goal is to identify patients with life-threatening disease who require
immediate attention while minimizing unnecessary evaluation and
treatment in others. A rapid clinical determination of the likelihood
of an acute coronary syndrome is the essential first task and should
guide the admission decision. In addition, the physician should consider the likelihood of short-term adverse outcomes, including death
and nonfatal myocardial infarction, in patients with acute coronary
syndrome. When acute coronary syndrome is suspected, the patient
should be admitted for evaluation and management. Low-risk
patients can be further stratified with stress testing.

The most appropriate initial management of this patient consists of

aspirin, heparin, intravenous nitroglycerin, and thrombolytic therapy. This patient has evidence of an ST-elevation myocardial infarction (STEMI) with acute ST-segment changes present in the inferior
leads and an elevated troponin T level. The treatment of choice for
STEMI is reperfusion therapy. Reperfusion for patients with STEMI
can be achieved with thrombolytic therapy or primary percutaneous
coronary intervention (PCI). Many patients with STEMI in the United
States present to nonPCI-capable hospitals; as a result, thrombolytic
therapy and transfer for primary PCI are the available treatment
options. The time to achieve balloon inflation is a major determinant
of the benefits of PCI versus thrombolytic therapy. If PCI must be
delayed, then thrombolytic therapy should be considered.
Observational data from community hospitals within the United
States have found that fewer than 5% of patients achieve the guideline-suggested door-to-balloon time of less than 90 minutes. A projected 2-hour delay to a PCI facility makes thrombolytic therapy the
best option for this patient.

At this point, the patient does not have an indication for coronary
angiography and acute intervention. If further chest pain develops
in association with ST-segment or T-wave changes on electrocardiography or elevated cardiac enzyme levels and the patient is considered high risk according to his TIMI (Thrombolysis in Myocardial
Infarction) score, cardiac angiography would be reasonable.
The most common gastrointestinal cause of chest pain is gastroesophageal reflux disease (GERD). Although the pain associated with
GERD is often described as burning, it can mimic angina and may be
relieved by nitroglycerin. It generally is worsened with bending over
or recumbency and is relieved with antacids, histamine-2 blockers, or
proton pump inhibitors. Because acute coronary syndrome is a lifethreatening condition, this diagnosis must be addressed first. In addition, the preferred initial diagnostic test for GERD is a therapeutic trial
of a proton pump inhibitor, not esophageal pH monitoring.
Cardiac stress testing can be highly valuable in identifying significant coronary insufficiency, and it would be the test of choice to diagnose stable angina. However, in the acute setting, stress testing is
contraindicated in a patient with possible acute coronary syndrome.
Once the patient is stabilized and acute coronary syndrome is
excluded, stress testing can be used to further stratify risk in a lowor intermediate-risk patient. In this patient, the preferred cardiac
stress test is an exercise stress test, not a pharmacologic stress test
with nuclear imaging.
KEY POINT

The decision to hospitalize a patient with chest pain is based on the identification of potentially life-threatening disease that requires immediate assessment
and stabilization.
Bibliography
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA Focused Update of the
Guideline for the Management of Patients with Unstable Angina/Non-ST-Elevation
Myocardial Infarction (updating the 2007 Guideline and replacing the 2011 Focused
Update): A Report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;60:645-81.
PMID: 22809746

-Blockers reduce mortality and should be given to all patients with

acute coronary syndrome except those with heart failure, systolic
blood pressure of less than 90 mm Hg, bradycardia (<50/min), or
second-degree atrioventricular block. Because this patients heart
rate is 48/min, metoprolol should not be administered. Treatment
with heparin, clopidogrel, pravastatin, and intravenous nitroglycerin
without thrombolytic therapy does not address the need for immediate myocardial reperfusion and is not adequate treatment for this
patient.
KEY POINT

The time to achieve balloon inflation within 90 minutes is a major determinant of

the benefits of percutaneous coronary intervention versus thrombolytic therapy.
Bibliography
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA Focused Update of the
Guideline for the Management of Patients with Unstable Angina/Non-St-Elevation
Myocardial Infarction (updating the 2007 Guideline and replacing the 2011 Focused
Update): A Report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;14;60:645-81.
PMID: 22809746

Item 13

Answer: A

Educational Objective: Manage nonST-elevation

myocardial infarction.
The most appropriate next test is cardiac catheterization. Although
chest pain is the most common presenting symptom for an acute
coronary syndrome, women and patients with diabetes are more
likely to have atypical angina symptoms, such as fatigue, dyspnea,
and nausea. Acute coronary syndromes include unstable angina,
nonST-elevation myocardial infarction (NSTEMI), and ST-elevation
myocardial infarction (STEMI). Patients with ischemic chest pain and
STEMI benefit from reperfusion therapy, either thrombolytic therapy or primary angioplasty. Patients with NSTEMI or unstable angina are a heterogeneous group and require risk stratification (determination of their risk of death or nonfatal myocardial infection) to
direct therapy. Although patients with unstable angina may have
similar electrocardiographic findings to those with NSTEMI, they can
be differentiated by the lack of elevation in serum cardiac biomark-