A 45-year-old man presents to the emergency department with a complaint of chest pain that started an hour ago. He describes the pain as a pressure-like sensation that radiates to his left arm. His past medical history is significant for hypertension and hyperlipidemia. On examination, his vital signs are: blood pressure 140/90 mmHg, heart rate 78 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 98% on room air. An electrocardiogram (ECG) shows normal sinus rhythm without any ST-segment changes. Which of the following is the most appropriate next step in the management of this patient? (Select All that Apply.)
Explanation & Rationale
A. Perform a stress test immediately is Incorrect. Stress testing is contraindicated in the acute phase of chest pain or suspected acute coronary syndrome (ACS) because it increases myocardial oxygen demand and may precipitate infarction. Stress tests should be performed only after stabilization. B. Discharge the patient with instructions to follow up with his primary care physician is incorrect. The patient’s chest pain and risk factors suggest possible ACS. Discharging without cardiac enzyme evaluation and treatment is unsafe and could result in life-threatening complications. C. Administer sublingual nitroglycerin and obtain cardiac enzymes is correct. The patient has symptoms suggestive of unstable angina or NSTEMI. Cardiac enzymes help detect myocardial injury, and nitroglycerin relieves ischemic pain by dilating coronary vessels. Early evaluation and treatment prevent progression to myocardial infarction. D. Start the patient on oral aspirin and a statin is correct. Aspirin inhibits platelet aggregation, reducing thrombus risk in ACS. Statins stabilize atherosclerotic plaques, managing hyperlipidemia and providing both acute and long-term cardiovascular protection. E. Reassure the patient and provide analgesics for pain relief is incorrect. Providing reassurance or analgesics alone ignores the possibility of ACS. Delaying evaluation and treatment increases the risk of adverse cardiac events.