Chest Pain (2026)

CHEST PAIN

Room 1

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patient cp

Patient CP is a 55 year old woman who presents to the emergency department (ED) with chest pain and is diagnosed with an NSTEMI. The patient undergoes risk stratification and scores high enough to undergo an early invasive strategy. She is scheduled to go to the catheterization lab today.

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The patient's past medical history is significant for a cerebrovascular accident (CVA) for which she has been on aspirin 325 mg PO daily per neurology recommendations. During her percutaneous intervention a bare-metal stent was placed. Which of the following P2Y12 inhibitors is MOST appropriate?

prasugrel

ticagrelor

clopidogrel

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The team is planning to discharge the patient. An echocardiogram prior to discharge showed an EF of 55%. Which of the following medications is recommended to be continued indefinitely in this patient following an NSTEMI for secondary prevention for atherosclerotic cardiovascular disease?

aspirin + P2Y12 inhibitor + statin

aspirin + beta blocker + statin

aspirin + statin

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This patient also has a past medical history significant for rheumatoid arthritis. During this hospitalization, her DMARD therapy was held and was accidentally NOT continued on discharge resulting in a flare up of her rheumatoid arthritis. Given her recent ACS event, which of the following medication classes would be most appropriate to manage her rheumatoid arthritis at this time?

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CLOPIDOGREL

CORRECT Although there is some data to indicate that prasugrel and ticagrelor are more efficacious than clopidogrel, safety concerns (increased bleeding risk) often outweigh this benefit.

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PRASUGREL

The patient is readmitted 1 week later due worsening confusion; repeat imaging showed concerns for intracranial bleed. INCORRECT Prasugrel is contraindicated in patients with a history of stroke or TIA due to increased risk of significant or fatal bleeding.

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TICAGRELOR

The patient is readmitted 1 week later due chest pain; repeat catherization showed a stent thrombosis. INCORRECT A maintenance dose of aspirin > 100 mg daily reduces the effectiveness of ticagrelor.

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ASPIRIN + p2y12 INHIBITOR + STATIN

INCORRECT In general, patients who receive a bare-metal stent should be continued on a P2Y12 inhibitor for at least 12 months. Consideration for a longer duration of therapy may be indicated in patients who have a DAPT score greater than or equal to 2.

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ASPIRIN + BETA BLOCKER + STATIN

INCORRECT Beta blocker therapy should be started and continued for 1 to 3 years in patients with normal left ventricular function following an ACS event. Evidence suggests short-term use reduces the risk of reinfarction and angina. However, there is less evidence to support continuing beta blockers beyond 3 years as chronic therapy, and further studies are needed.

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aspirin + statin

CORRECT In general, patients should be continued on aspirin and statin therapy indefinitely following an ACS event.

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