Acute Coronary Symptoms and Stable Angina Pectoris

Chapter 22 Acute Coronary Symptoms and Stable Angina Pectoris




Clinical Case Problem 1 A 55-Year-Old Man with Chest Pain


A 55-year-old man presents for the first time to your office for assessment of left-sided shoulder pain. The pain comes on after any strenuous activity, including walking. The pain is described as follows:



Quality: dull, aching


Quantity: 8/10 when doing any activity; otherwise he is asymptomatic


Location: mainly retrosternal


Radiation: appears to be radiating to the left shoulder area


Chronology: began approximately 8   months ago and has been getting worse ever since


Continuous/intermittent: intermittent


Aggravating factors: exercise of any kind


Relieving factors: rest


Associated manifestations: occasional nausea


Pain history: no previous pain before 8   months ago; no other significant history of pain syndromes


Quality of life: definitely affecting quality of life by limiting activity


The patient tells you that the pain seems somehow worse today. For the first time, it did not go away after he stopped walking. The patient’s blood pressure is 130/90   mm Hg; his pulse is 72 beats/minute and regular. His heart sounds are normal. There are no extra sounds and no murmurs.



Select the best answer to the following questions




1. Which of the following statements regarding this patient’s chest pain is false?


a. the patient may have suffered a myocardial infarction

b. the patient’s chest pain may be the result of angina pectoris

c. the patient’s chest pain may be the result of esophageal motor disorder

d. the administration of sublingual nitroglycerin is a sensitive test to distinguish angina pectoris from esophageal causes

e. the patient should be admitted to the coronary care unit until the origin of the pain is firmly established

2. The patient is admitted to a chest pain unit and monitored. Which of the following investigations is not indicated at this time as part of this initial inpatient evaluation?


a. an exercise tolerance test

b. coronary angiography

c. a serum thyroid-stimulating hormone (TSH) level

d. a complete blood count (CBC)

e. a fasting blood glucose concentration

His pain remits with aspirin and intravenous nitroglycerin. His cardiac troponin levels and electrocardiogram (ECG) are normal. The patient does well and has an exercise tolerance test. This test reveals a 2.5-mm ST-segment depression at 5 METs (metabolic equivalents of oxygen consumption) of activity as the patient achieved 50% of his age predicted maximum heart rate.




3. Which of the following statements regarding this test result is (are) true?


a. result indicates probable coronary artery disease (CAD)

b. coronary angiography is indicated

c. his inability to achieve maximum heart rate predicts CAD

d. a and b

e. all of the above

4. In addition to aspirin, which of the following medications is indicated as a first-line therapy for this patient?


a. diltiazem

b. atenolol

c. isosorbide dinitrate

d. prazosin

e. hydrochlorothiazide


Clinical Case Problem 2: A 67-Year-Old Man with a History of Angina Pectoris


A 67-year-old man with a history of angina pectoris is brought to the emergency department by his wife. For the past 3   days, he has been having increasing chest pain. The retrosternal chest pain has been occurring intermittently while at rest during the day, while in bed at night, and while walking (he is able to walk only very slowly because of pain). The pain has been getting progressively persistent and worse during the past 8 hours. On physical examination, his blood pressure is 120/70   mm Hg. His pulse is 96 beats/minute and regular. The rest of his examination is unchanged from previous visits to the office. His ECG shows ST-segment depression of 1.5   mm in leads V5 and V6. There is also flattening of the T waves seen across the precordial leads.



5. Which of the following statements regarding this patient is (are) true?


a. this patient has unstable angina

b. intravenous nitroglycerin and morphine may be used for pain relief

c. the patient should be started on heparin and clopidogrel

d. this patient should already be taking daily aspirin

e. all of the above


Clinical Case Problem 3: A 50-Year-Old Woman with a Sharp Retrosternal Chest Pain


A 50-year-old woman presents to the emergency department with a sharp retrosternal chest pain that awoke her. This is the fourth episode in as many nights, but she is sure that she is not having a heart attack because she saw her physician only 3   weeks ago. At that time, he gave her a “clean bill of health.” She was told that her ECG, blood pressure, and cholesterol level were completely normal. She is a nonsmoker and has no family history of CAD.


On physical examination, her blood pressure is 100/70   mm Hg. Her pulse is 96 beats/minute and regular, and the remainder of the cardiovascular and respiratory examination findings are normal.


Her ECG reveals a significant ST-segment elevation in the anterior limb leads. Within 1 hour, the ST segment has returned to normal. Cardiac troponin levels are normal.



6. Which of the following statements regarding this patient is (are) true?


a. this patient probably has Prinzmetal’s angina

b. calcium channel blockers are the treatment of choice for this type of angina

c. beta blockers are advised for this type of angina

d. a, b, and c

e. a and b

7. Which of the following statements regarding percutaneous coronary angioplasty (PTCA) and mortality from CAD is (are) true?


a. PTCA reduces overall mortality

b. PTCA improves morbidity from CAD

c. PTCA usually includes intracoronary stent placement

d. optimal lesions for angioplasty are proximal in location, noneccentric, and located at branch (bifurcation) points in the vessel

e. b and c

8. In which of the following patients would PTCA most likely be used?


a. a 55-year-old male smoker with left main stem disease

b. a diabetic patient with four-vessel disease

c. an elderly patient with a ventricular aneurysm

d. an obese patient with distal left anterior descending artery disease

e. any of the above are good indications for PTCA

9. Which of the following is least likely to be used as a combination therapy in patients with angina pectoris?


a. nitroglycerin-atenolol-nifedipine

b. nitroglycerin-enalapril-nifedipine

c. nitroglycerin-propranolol-verapamil

d. nitroglycerin-metoprolol-diltiazem

e. nitroglycerin-atenolol-nifedipine

10. Which of the following complications is (are) seen with ticlopidine?


a. thrombocytopenia

b. ventricular arrhythmias

c. atrial arrhythmias

d. syncope

e. b and d

11. Coronary artery bypass graft (CABG) surgery may be indicated as the treatment of choice for angina pectoris with which of the following patients with angina?


a. a patient with triple-vessel disease

b. a patient with one-vessel disease

c. a patient with two-vessel disease

d. CABG may be first-line therapy in any of the above

e. b or c


Clinical Case Problem 4: A 65-Year-Old Man with Angina and Hypertension


A 65-year-old man presents to your office with a history strongly suggestive of angina pectoris. He also has a long history of hypertension.


On physical examination, his blood pressure is 170/100   mm Hg. Exercise tolerance testing reveals a 2.5-mm ST-segment depression in the lateral leads. Two-dimensional M-mode echocardiography reveals apical akinesis and an estimated ejection fraction of 50%.



12. Which of the following medications would you consider the agent of first choice in the treatment of this patient?


a. hydrochlorothiazide

b. nifedipine

c. clonidine

d. atenolol

e. prazosin

13. Which of the following investigations should be performed on a patient with possible angina pectoris?


a. CBC

b. chest radiograph

c. fasting lipid profile

d. thyroid function testing

e. all of the above

14. The pathophysiologic mechanism of angina pectoris is best explained by which of the following?


a. significantly increased peripheral vascular resistance

b. a balance between oxygen supply and oxygen demand

c. an imbalance of oxygen supply and oxygen demand plus or minus coronary artery spasm

d. significant peripheral venous and arterial vasoconstriction

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Acute Coronary Symptoms and Stable Angina Pectoris

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