Question

A 56-year-old man is brought to the emergency department due to chest pain. An hour ago, he woke up with burning retrosternal severe chest pain accompanied by sweating and left arm numbness. The patient's symptoms improved with aspirin and sublingual nitroglycerin administered by the paramedics; he currently rates his chest pain as 4 on a scale of 10. He has had no nausea, vomiting, or abdominal discomfort. The patient has a history of gastroesophageal reflux disease, diet-controlled diabetes mellitus, and 30 pack years of smoking. Temperature is 37.3 (99 F), blood pressure is 150/90 mm Hg on the right arm and 145/88 mm Hg on the left arm, and pulse is 95/min and regular. The lungs are clear on auscultation and heart sounds are normal with no murmur or gallop. ECG shows normal sinus rhythm with T-wave inversion in leads V1-V4. The troponin level is normal.

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

A. Administer lidocaine

B. Exercise stress testing

C. Intravenous alteplase

D. Intravenous heparin infusion

E. Oral proton pump inhibitor

Correct Answer: D. Intravenous heparin infusion 

The patient's symptoms and ECG findings are most consistent with ACS.

Intravenous heparin addresses the underlying thrombus and is the appropriate next step to stabilize the condition before definitive management.

🧠 Triggers

Risk factors: Smoking, diabetes, GERD (diet-controlled), history of poor cardiovascular health
⬇️

Acute triggers: Plaque rupture → endothelial injury
⬇️
🧠 Endothelial Injury

Platelet adhesion, activation, and aggregation
⬇️

Thrombus formation → Partial occlusion of coronary artery
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🧠 Myocardial Oxygen Supply-Demand Mismatch
⬇️
Ischemia of myocardial cells
⬇️
↓ ATP production
⬇️
Switch to anaerobic metabolism
⬇️
Lactic acid buildup → Acidosis → Myocardial dysfunction
⬇️
🧠 Symptoms

Retrosternal burning chest pain (due to ischemia)

Radiation to the left arm (cardiac nerve irritation via shared dermatomes)

Sweating (sympathetic activation)

🧠 ECG Changes

T-wave inversion in V1–V4:

Indicates ischemia in the anterior wall of the heart (left anterior descending artery distribution)
⬇️
Myocardial ischemia in this region (no infarction yet as troponin is normal)

Why Troponin is Normal?

Troponin release takes 3–6 hours after injury; this is likely very early ischemia.
⬇️
🧠 Still ACS: Troponin testing should be repeated.

Correct Management:

🧠 Why Heparin (Correct Answer):

Prevents further clot propagation → stabilizes thrombus
⬇️

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