Coronary artery disease: Clinical

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Coronary artery disease: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 60-year-old man is brought to the emergency department because of crushing substernal chest pain for the past 45 minutes. The patient received 325 mg of aspirin in the ambulance. Medical history includes diabetes mellitus type 2 and asthma, for which the patient takes albuterol as needed. Other medications include carvedilol and sildenafil. The patient’s temperature is 36.8°C (98°F), pulse is 99/min, respirations are 18/min, and blood pressure is 160/90 mm Hg. The patient appears diaphoretic. An ECG is obtained and shown below:  

Reproduced from: Wikimedia Commons  

Which of the following is the most appropriate next step in management?  


Coronary artery disease can lead to myocardial ischemia which is when the myocardium isn’t getting a sufficient blood supply; so there isn’t enough oxygen to meet the heart’s demands.

And coronary artery disease is characterized by a type of chest pain called angina pectoris, which can be due to either vasospastic disease and atherosclerotic disease.

Vasospastic disease, also called Prinzmetal angina, is when for unclear reasons there’s transient vasoconstriction of a coronary artery, leading to transient ischemia.

These attacks generally occur at rest, during the night or early morning, and occur in clusters.

Atherosclerotic disease is when a coronary artery narrows due to build up of atherosclerotic plaque, and it can be further divided into stable angina, unstable angina, and myocardial infarction.

Unstable angina and myocardial infarction are collectively called acute coronary syndrome.

Patients with stable angina don’t feel pain at rest, but they do feel chest pain during intense physical exercise, because that’s when the myocardium has increased oxygen demand, which leads to transient or demand ischemia.

The chest pain stops when the exercise stops, so these patients often just rest rather than going to the emergency department or ED.

Now, angina is considered unstable if it presents at rest, or if it becomes more frequent, lasts longer, or occurs with less exertion than previous episodes of angina.


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