Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
62 years · male
A 62-year-old male presents to the emergency department with a 3-hour history of severe, central crushing chest pain that radiates to his left shoulder and jaw. The pain began while he was resting at home and is accompanied by profuse diaphoresis and mild nausea. His medical history is significant for type 2 diabetes mellitus and hypertension, for which he takes metformin and ramipril. He has a 25-pack-year smoking history. Physical examination reveals an anxious, diaphoretic man. Cardiovascular examination demonstrates normal S1 and S2 heart sounds with no murmurs, gallops, or pericardial friction rub. Respiratory examination reveals clear lung fields bilaterally.
Vital signs
- HR
- 92 bpm
- BP
- 145/88 mmHg
- RR
- 18/min
- Temp
- 36.8 °C
- SpO₂
- 96%
Examination findings
- Profuse diaphoresis and mild distress from pain
- Normal heart sounds S1/S2 with no murmur or S3/S4
- Lungs clear to auscultation bilaterally
- ECG demonstrates 1.5 mm horizontal ST-segment depression in leads V4-V6 and T-wave inversion in leads I and aVL, with no ST elevation
Investigations
| High-sensitivity Troponin T | 450 ng/L | reference: < 14 |
| Haemoglobin | 14.2 g/dL | reference: 13.0-17.0 |
| Serum Creatinine | 95 µmol/L | reference: 60-110 |
| Potassium | 4.2 mmol/L | reference: 3.5-5.0 |
Question 1 of 3
Based on the clinical presentation, ECG, and laboratory findings, what is the most likely diagnosis?
The patient presents with ischaemic symptoms, ST-segment depression on ECG, and elevated serum high-sensitivity troponin T levels, which confirms a diagnosis of Non-ST-elevation myocardial infarction (NSTEMI). STEMI is incorrect because there is no ST-segment elevation or new left bundle branch block. Unstable angina is incorrect because it involves myocardial ischaemia without elevation of cardiac troponins. Acute pericarditis typically presents with sharp, pleuritic chest pain that improves on sitting forward, along with widespread PR depression and diffuse concave ST-segment elevation, rather than localized horizontal ST depression and elevated troponin.
Teaching point: NSTEMI is diagnosed when there are clinical features of acute coronary syndrome and elevated cardiac biomarkers without persistent ST-segment elevation on ECG.
Question 2 of 3
Following loading doses of aspirin and sublingual nitroglycerin, which of the following is the most appropriate initial antithrombotic management step?
NICE guidelines for NSTEMI recommend dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor such as ticagrelor or clopidogrel) combined with parenteral anticoagulation (fondaparinux is the preferred agent unless patient is undergoing immediate angiography or has severe renal impairment). Option A (alteplase) is incorrect because thrombolytic therapy is contraindicated in NSTEMI as it increases mortality and risk of bleeding without providing benefit. Option D is incorrect because CABG is not an immediate initial medical therapy for acute NSTEMI prior to angiography. Option B (warfarin) is incorrect as oral vitamin K antagonists have no role in the acute management of NSTEMI.
Teaching point: Acute NSTEMI management includes dual antiplatelet therapy and parenteral anticoagulation (such as fondaparinux); thrombolysis is contraindicated.
Question 3 of 3
Which of the following is the most appropriate next investigation to guide definitive management?
Invasive coronary angiography is the gold-standard investigation for NSTEMI to visualize coronary anatomy and guide revascularization (PCI or CABG). It is recommended within 24–72 hours for intermediate- to high-risk patients. Exercise tolerance testing (Option B) is strictly contraindicated in acute coronary syndromes due to the risk of precipitating severe ischaemia or cardiac arrest. Myocardial perfusion scanning (Option C) is used for stable chest pain or risk stratification in non-acute settings, not during an acute NSTEMI presentation. CT pulmonary angiogram (Option D) is used to diagnose pulmonary embolism, which is unlikely given the classic cardiac presentation, diagnostic ECG findings, and high troponin level.
Teaching point: Invasive coronary angiography is the definitive investigation for risk stratification and potential revascularization in patients with NSTEMI.
Key learning points
- NSTEMI is distinguished from unstable angina by the presence of elevated cardiac necrosis markers (troponins).
- Thrombolysis/fibrinolysis is contraindicated in NSTEMI; treatment relies on antiplatelet, antithrombotic, and anti-ischaemic medications.
- Coronary angiography is the definitive investigation following initial medical stabilization in intermediate- to high-risk NSTEMI cases.
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