USMLE Step 2 CK Acute Coronary Syndrome Practice Questions

A 62-year-old man with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus presents to the emergency department with a 2-hour history of substernal chest pain radiating to his left arm. The pain is described as a pressure and is associated with diaphoresis and nausea. He takes metformin, atorvastatin, and lisinopril. His vital signs are: Temperature 37.0°C (98.6°F), Pulse 98/min, BP 145/90 mm Hg, Resp 18/min, O₂ Sat 96% on room air. Physical examination reveals S4 gallop, but is otherwise unremarkable. An ECG shows 2 mm ST-segment elevations in leads II, III, and aVF. Which of the following is the most appropriate initial management step?

A 55-year-old woman presents to the emergency department with new-onset chest discomfort that occurs at rest and has progressively worsened over the last 3 days. She describes the pain as a squeezing sensation, rated 6/10, lasting for 10-15 minutes, and not relieved by rest or sublingual nitroglycerin (which she has for occasional exertional chest pain). She has a history of dyslipidemia and smokes 1 pack of cigarettes per day. Vital signs are stable. Her initial ECG shows T-wave inversions in leads V3-V5, but no ST-segment elevation. Initial troponin I level is 0.02 ng/mL (reference range ≤0.04 ng/mL). Which of the following is the most likely diagnosis?

A 70-year-old man with a history of chronic kidney disease (eGFR 35 mL/min/1.73m²) and heart failure with preserved ejection fraction (HFpEF) is admitted with a non-ST-elevation myocardial infarction (NSTEMI). His initial treatment included aspirin, ticagrelor, unfractionated heparin, and a beta-blocker. His GRACE risk score indicates a high risk for adverse cardiac events. He is scheduled for coronary angiography. Which of the following medications should be used with caution or avoided in this patient?

A 48-year-old man presents with chest pain and is diagnosed with an NSTEMI. He undergoes successful PCI with stent placement. His discharge medications include aspirin, ticagrelor, atorvastatin, and metoprolol. He asks about his long-term prognosis and what he can do to prevent future events. Which of the following lifestyle modifications has the strongest evidence for reducing recurrent cardiovascular events in patients post-MI?

A 68-year-old woman with a history of hypertension and dyslipidemia presents with chest pain. Her ECG shows ST-segment depression in the lateral leads. Cardiac troponin I is elevated at 0.8 ng/mL. She is diagnosed with an NSTEMI. She is managed medically with aspirin, ticagrelor, unfractionated heparin, and metoprolol. Which of the following findings would indicate a need for urgent invasive strategy (coronary angiography within 2 hours)?