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Q A 74-year-old man presents to the Emergency Department with central, dull, aching chest pain that began 15 minutes ago. The pain was relieved with aspirin, sublingual glyceryl trinitrate, an oral antacid, and supplemental oxygen. He reports similar episodes of chest pain with exertion that resolve with rest or GTN. His vital signs are stable, and a 12-lead ECG shows no abnormalities.
What is the most appropriate next step in management?
A. Discharge the patient with outpatient follow-up B. Perform an immediate coronary angiogram C. Admit for cardiac monitoring and serial troponins D. Start high-dose proton pump inhibitor therapy E. Arrange an outpatient exercise stress test
Ans C. Admit for cardiac monitoring and serial troponins
This patient’s chest pain at rest, even though resolved, could represent unstable angina, which is a form of acute coronary syndrome (ACS). A normal ECG and pain relief do not exclude a cardiac cause. The appropriate next step is hospital admission for observation, ECG monitoring, and serial cardiac biomarkers to assess for myocardial injury.
Key features suggesting ACS:
Age >70, a strong risk factor for coronary artery disease.
Recent onset chest pain (15 minutes ago), relieved with GTN.
History of exertional chest pain relieved by rest or GTN suggests stable angina that may now be becoming unstable.
Normal ECG and vitals do not rule out ACS, especially in elderly patients.
Why the other options are incorrect:
A. Discharge with outpatient follow-up: Inappropriate. The patient is high-risk due to age and recent-onset symptoms.
B. Immediate coronary angiogram: Reserved for high-risk patients with ECG changes or positive troponins. This patient first needs risk stratification.
D. Start high-dose PPI: Not appropriate unless GI cause (like peptic ulcer) is strongly suspected and cardiac causes are ruled out.
E. Outpatient exercise stress test: Dangerous in someone with recent unstable symptoms; risk of inducing ischemia.
Which of the following is the strongest predictor of poor prognosis in a patient with chronic heart failure?
A. Elevated serum sodium B. High ejection fraction C. Low BNP level D. NYHA Class IV symptoms E. Controlled resting heart rate
Ans d
D. NYHA Class IV symptoms NYHA functional class is a powerful clinical predictor of prognosis. Class IV symptoms (dyspnea at rest) indicate severe functional impairment and are associated with significantly increased mortality.
Why others are wrong?
A. Elevated serum sodium
Incorrect
High serum sodium is not a poor prognostic marker. In fact, hyponatremia (low sodium) is associated with worse outcomes in heart failure, indicating neurohormonal activation and fluid overload.
B. High ejection fraction
Incorrect
A preserved ejection fraction (HFpEF) usually has a better prognosis compared to reduced EF (HFrEF). High EF is not considered a risk factor for mortality in the general heart failure population.
C. Low BNP level
Incorrect
Low BNP indicates less ventricular stretch and lower severity of heart failure. High BNP correlates with increased mortality and worse functional status.
E. Controlled resting heart rate
Incorrect
A controlled heart rate (e.g., <70 bpm in patients with systolic heart failure) is a good prognostic sign, especially in those on beta-blockers. In contrast, tachycardia is a negative prognostic factor.
