ECC Risk Assessment & Management 2 — Questions and Answers
Question 1: A 58-year-old male presents with diaphoresis, nausea, and jaw pain but denies chest pain. What is the most appropriate initial risk stratification step?
- Discharge with follow-up
- Obtain a 12-lead ECG immediately (Correct answer)
- Administer antacids and observe
- Order a chest X-ray only
Correct answer: Obtain a 12-lead ECG immediately
Atypical ACS presentations (jaw pain, diaphoresis, nausea) require immediate 12-lead ECG to identify STEMI or ischemic changes.
Question 2: Which TIMI Risk Score component specifically addresses prior coronary artery disease history?
- Age ≥65
- Known CAD with stenosis ≥50% (Correct answer)
- Use of aspirin in past 7 days
- ST deviation on ECG
Correct answer: Known CAD with stenosis ≥50%
Known CAD with stenosis ≥50% is a discrete TIMI variable that increases the score by 1 point.
Question 3: A patient's HEART score totals 7. What is the recommended management pathway?
- Discharge with outpatient stress test
- Observation and repeat troponin only
- Early invasive strategy within 72 hours (Correct answer)
- Immediate PCI regardless of ECG findings
Correct answer: Early invasive strategy within 72 hours
A HEART score of 7–10 indicates high risk (>50% MACE) and warrants early invasive evaluation.
Question 4: Which laboratory finding is most useful for ruling OUT acute MI when measured at presentation AND 3 hours later?
- BNP < 100 pg/mL
- High-sensitivity troponin with serial negative results (Correct answer)
- LDH within normal limits
- Normal CK-MB at presentation
Correct answer: High-sensitivity troponin with serial negative results
Serial high-sensitivity troponin (0h/3h protocol) has a negative predictive value >99% for ruling out NSTEMI.
Question 5: In the GRACE Risk Score, which hemodynamic variable carries the highest weight for predicting in-hospital mortality?
- Heart rate
- Killip class (Correct answer)
- Systolic blood pressure
- Creatinine level
Correct answer: Killip class
Killip class carries the highest weight in GRACE scoring because it directly reflects the degree of heart failure and hemodynamic compromise.
Question 6: A diabetic woman presents with unexplained fatigue and mild dyspnea. ECG shows no ST changes. What risk assessment principle applies here?
- Low-risk symptoms mean ACS is unlikely
- Diabetics commonly have silent or atypical ischemia requiring heightened suspicion (Correct answer)
- Order BNP only since ECG is normal
- No further workup is needed in absence of chest pain
Correct answer: Diabetics commonly have silent or atypical ischemia requiring heightened suspicion
Diabetic neuropathy blunts pain perception, making silent ischemia common and requiring a lower threshold for ACS workup.
Question 7: What does a negative exercise stress test with good functional capacity (≥10 METs) indicate in a stable patient with chest pain?
- Definitive rule-out of CAD
- Low probability of significant obstructive CAD and favorable prognosis (Correct answer)
- Immediate coronary angiography is still required
- The test is unreliable; CT angiography must follow
Correct answer: Low probability of significant obstructive CAD and favorable prognosis
Achieving ≥10 METs without ischemia indicates low short-term cardiac event risk and typically warrants conservative management.
ECC Risk Assessment & Management 2
A 58-year-old male presents with diaphoresis, nausea, and jaw pain but denies chest pain.
What is the most appropriate initial risk stratification step?