{"id":3010,"date":"2021-01-20T18:44:00","date_gmt":"2021-01-20T18:44:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=3010"},"modified":"2025-11-04T11:20:41","modified_gmt":"2025-11-04T19:20:41","slug":"usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension","title":{"rendered":"USMLE\u00ae Step 1 Question of the Day: Acute Chest Pain with Diabetes and Hypertension"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\" >The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\/#Major_Takeaway\" >Major Takeaway<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\/#References\" >References<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong>A 60-year-old man<\/strong> is brought to the emergency department due to <strong>acute onset of chest pain<\/strong>. Medical history is significant for <strong>smoking 1 pack per day for the past 30 years<\/strong>, <strong>diabetes mellitus type 2<\/strong>, and <strong>hypertension<\/strong>. An <strong>ECG shows ST-segment elevation on V1-V4 leads<\/strong>. <strong>Cardiac catheterization<\/strong> is performed and shows <strong>80% occlusion of the left anterior descending artery.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>The first step in the pathogenesis of this patient\u2019s condition most likely involves which of the following cell types?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Macrophages&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Smooth muscle cells&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Platelets&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Endothelial cells<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Monocytes<\/strong>&nbsp;<\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-rich is-provider-embed-handler wp-block-embed-embed-handler wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Everybody loves Osmosis.org\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/kizbJZ9cdLg?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><u><em><strong>\u2192 Reinforce your understanding <\/strong>with more <strong>self-assessment items on Osmosis.<\/strong><\/em><\/u><\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_1_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s USMLE\u00ae Step 1 Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Endothelial cells<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This patient is likely having an <strong>acute myocardial infarction<\/strong> complicated by <strong>atherosclerosis<\/strong>. Before we go into the full answer explanation, let&#8217;s review the incorrect answers.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Macrophages&nbsp;<\/strong>&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0<\/strong>Macrophages participate in the <strong>pathogenesis of atherosclerosis<\/strong> but do <strong>not initiate it<\/strong>. \u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Smooth muscle cells<\/strong>&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0<\/strong>Smooth muscle cells participate in the <strong>pathogenesis of atherosclerosis<\/strong> but do <strong>not initiate it<\/strong>. \u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Platelets&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong>\u00a0Platelets participate in the <strong>pathogenesis of atherosclerosis<\/strong> but do <strong>not initiate it<\/strong>. \u00a0<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Monocytes&nbsp;<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:\u00a0<\/strong>Monocytes participate in the <strong>pathogenesis of atherosclerosis<\/strong> but do <strong>not initiate it<\/strong>. \u00a0\u00a0<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/ad-general.png\" alt=\"\" class=\"wp-image-4425\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/ad-general.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/ad-general.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">This patient&#8217;s presentation and <strong>ECG findings<\/strong> are consistent with <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Myocardial_infarction\" target=\"_blank\" rel=\"noreferrer noopener\">acute myocardial infarction<\/a><\/strong>, which, given the patient\u2019s risk factors, is most likely due to <strong>atherosclerosis of the coronary arteries.<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Atherosclerosis ~high yield~\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/4e5exFO68Ls?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.osmosis.org\/learn\/High_Yield:_Atherosclerosis\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Atherosclerosis<\/strong><\/a>\u00a0is a <strong>pathologic process<\/strong> that affects arteries throughout the body, including the <strong>aorta, coronary, cerebral, and peripheral arteries.<\/strong> Atherosclerosis is the <strong>hardening of any artery<\/strong> (but usually medium-large arteries), which is caused by the buildup of <strong>plaques (atheromas).<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Atherosclerosis can begin as early as childhood with the development of <strong>fatty streaks<\/strong> and advances with aging. The current hypothesis of the pathogenesis is the <strong>response-to-injury model<\/strong>, which is as follows:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Endothelial cell injury<\/strong> due to <strong>hypertension, smoking, hyperlipidemia, homocysteine, or diabetes<\/strong> is the <strong>first step in pathogenesis.<\/strong> Injury to endothelial cells results in <strong>endothelial dysfunction, increased membrane permeability, leukocyte adhesion, and thrombosis.<\/strong><\/li>\n\n\n\n<li><strong>Lipoproteins<\/strong>, mainly <strong>oxidized LDL and cholesterol crystals<\/strong>, aggregate in the <strong>blood vessel wall.<\/strong><\/li>\n\n\n\n<li><strong>Platelets (choice C)<\/strong> adhere to exposed collagen and are activated.<\/li>\n\n\n\n<li><strong>Monocytes (choice E)<\/strong> adhere to the endothelium, migrate into the intima, and differentiate into <strong>macrophages.<\/strong> <strong>Macrophages (choice A)<\/strong> engulf LDL, becoming <strong>foam cells<\/strong> (macrophages ingest LDL and become laden with lipids, giving them a foamy appearance). The macrophages with engulfed lipids eventually undergo apoptosis (<strong>fatty streak<\/strong>) and release <strong>toxic oxidized LDL<\/strong> and <strong>inflammatory cytokines.<\/strong><\/li>\n\n\n\n<li>At the same time, <strong>growth factors and inflammatory cytokines<\/strong> released from the <strong>activated platelets, macrophages, and endothelial cells<\/strong> recruit <strong>smooth muscle cells (choice B).<\/strong><\/li>\n\n\n\n<li>The growing smooth muscle secretes <strong>collagen, proteoglycans, and elastin fibrous cells<\/strong>, which all help form a wall around the fatty streak. The <strong>lipid core center surrounded by a fibrous cap<\/strong> is termed a <strong>\u201cfibrous plaque.\u201d<\/strong><\/li>\n\n\n\n<li>When the <strong>formed fibrous plaques rupture<\/strong> due to <strong>shearing forces of blood flow<\/strong>, <strong>thrombogenic material (e.g., collagen)<\/strong> is exposed, allowing <strong>platelets to adhere<\/strong> to it. This buildup of platelets eventually <strong>occludes the artery<\/strong> and results in <strong>myocardial infarction<\/strong>, as seen in this patient.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" height=\"1024\" width=\"479\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-response-to-injury-model.png?w=479\" alt=\"1. Chronic endothelial injury\nLayers shown: endothelium, intima, media, adventitia\n\n2. Endothelial dysfunction, monocyte adhesion, and migration\nInvolvement of platelets and monocytes\n\n3. Macrophage activation, smooth muscle recruitment, accumulation of lipids in vessel wall\nFormation of fatty streaks and lymphocyte involvement\n\n4. Macrophages and smooth muscle cells engulf lipids\n\n5. Smooth muscle proliferation, collagen and other extracellular matrix deposition, extracellular lipids\nFormation of fibrofatty atheroma, collagen, and lipid debris\" class=\"wp-image-3012\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-response-to-injury-model.png 748w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-response-to-injury-model.png?resize=140,300 140w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-response-to-injury-model.png?resize=479,1024 479w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2024\/09\/the-response-to-injury-model.png?resize=718,1536 718w\" sizes=\"auto, (max-width: 479px) 100vw, 479px\" \/><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Atherosclerosis<\/strong> is a <strong>pathologic process<\/strong> that mainly affects <strong>medium to large arteries.<\/strong> The <strong>pathogenesis<\/strong> begins with an <strong>endothelial injury<\/strong>, followed by <strong>chronic inflammation<\/strong> and the formation of <strong>fibrous plaques<\/strong> that obstruct the lumen.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Kumar, V., Abbas, A. K., Aster, J. C., Perkins, J. A., &amp; Robbins, S. L. (2018).&nbsp;<em>Robbins Basic Pathology<\/em>&nbsp;(10th ed.). Philadelphia, PA: Elsevier.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/Blog_Display_Ads_GENERAL3_2023.png\" alt=\"\" class=\"wp-image-4426\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/Blog_Display_Ads_GENERAL3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/01\/Blog_Display_Ads_GENERAL3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><figcaption class=\"wp-element-caption\"><em>The United States Medical Licensing Examination (USMLE\u00ae) is a joint program of the Federation of State Medical Boards (FSMB\u00ae) and the National Board of Medical Examiners (NBME\u00ae). Osmosis is not affiliated with NBME nor FSMB.<\/em><\/figcaption><\/figure>\n\n\n\n<p class=\"has-text-align-left wp-block-paragraph\"><em>Want more <strong>USMLE\u00ae Step 1<\/strong> practice questions? Try <strong>Osmosis from Elsevier<\/strong> today! Access your\u00a0<a href=\"https:\/\/www.osmosis.org\/plans\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>\u00a0and find out why millions of current and future clinicians and caregivers love learning with us.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 60-year-old with chest pain and ECG changes shows LAD artery occlusion. Learn why endothelial cell injury is the first step in atherosclerosis causing myocardial infarction.<\/p>\n","protected":false},"author":202,"featured_media":3011,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,1369,44],"tags":[2197,2198,2199,2204,736,417,2038,2200,2205,739,2201,2206,2202,2203,664],"class_list":["post-3010","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-1-questions","category-step-1","tag-acute-myocardial-infarction","tag-atherosclerosis","tag-cardiac-catheterization","tag-cardiac-pathology","tag-cardiovascular-disease","tag-coronary-artery-disease","tag-diabetes-mellitus","tag-endothelial-cells","tag-foam-cells","tag-hypertension","tag-macrophages","tag-myocardial-ischemia","tag-plaque-rupture","tag-stemi","tag-usmle-step-1"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>USMLE\u00ae Step 1 Question of the Day: Acute Chest Pain with Diabetes and Hypertension - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-1-question-acute-chest-pain-with-diabetes-and-hypertension\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"USMLE\u00ae Step 1 Question of the Day: Acute Chest Pain with Diabetes and Hypertension - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A 60-year-old with chest pain and ECG changes shows LAD artery occlusion. 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