A 45-year-old male comes to your office for evaluation of chest pain. He reports substernal chest pressure, lasts a few minutes, does not radiate to his shoulder or jaw, occurs with exertion sometimes, and is relieved on its own in a few minutes. His risk factors include hypertension controlled on hydrachlorothiazide and amlodipine. He also was a 20 pack a year smoker, but quit a month ago. His electrocardiogram (ECG) shows no abnormalities. To evaluate his chest pain, what should the next step be?

1. Coronary angiography
   
2. Exercise stress echocardiogram
   
3. Exercise stress test
   
4. No testing needed at this time

The patient walked for 5 min on the treadmill (Bruce protocol) and had to stop the test due to substernal chest pressure. His peak stress blood pressure (BP) dropped to 90 mmHg from a resting pressure of 130 mmHg. His stress ECG shows 4 mm downsloping ST depressions in the anterior chest leads that last 5 min into recovery. He is nauseous and diaphoretic. What is the next step in his evaluation?

1. Nothing at present
   
2. Adenosine myocardial perfusion imaging (MPI)
   
3. Coronary angiogram to evaluate for obstructive CAD
   
4. Modify medical therapy

A 55-year-old male comes to your office for evaluation of chest pain. He reports no cardiac risk factors other than hypercholesterolemia. He describes his chest pain as a discomfort, in the central chest, occurs at rest, lasts a few minutes, and is relieved with aspirin. A resting ECG done in the office reveals preexcitation. What does the next step in his evaluation include?

1. Exercise stress test
   
2. Coronary angiogram
   
3. Referral to an electrophysiologist
   
4. Exercise myocardial perfusion

In the evaluation of a patient with chest pain and right bundle branch (RBBB) on ECG, which of the following is true regarding exercise stress testing?

1. Stress test is not useful in patients with RBBB
   
2. Stress testing should always be combined with imaging
   
3. Stress testing can be undertaken without affecting the predictive value of stress ECG
   
4. None of the above

A 50-year-old women presents to the emergency room (ER) with complaints of chest pain. Her chest pain started 3 days prior to presentation and radiates to her jaw, occurs with exertion, and is relieved with rest. Her risk factors include hypertension and hypercholesterolemia. Her ECG at presentation is normal. Three sets of cardiac biomarkers drawn at presentation and then 8 h apart are negative. What is the best next recommended step?

1. She is at low risk for ischemia; hence, discharge her home with advice regarding risk factor modification
   
2. Refer her for coronary angiography
   
3. Order a pharmacological stress nuclear study
   
4. Order an exercise stress test

Which of the following is not a contraindication to exercise ECG stress testing?

1. 75-year-old male with complaints of chest pain and one episode of frank syncope. On examination, he has slow rising carotid pulse and a harsh 3/6 ejection systolic murmur with radiation to both carotids.
   
2. A 35-year-old female with complaints of shortness of breath. On examination, jugular venous pressure is elevated, 15 cmH₂O, S3 gallop, and 2+ pedal edema. She has recently delivered her second baby.
   
3. A 68-year-old male with complaints of chest pain. He describes it as a sharp substernal chest pain, worse on deep inspiration. He gives a history of hip replacement 2 weeks ago.
   
4. A 44-year-old male with complaints of chest pain brought on by exertion, started a month ago. Physical examination is unremarkable except for an elevated BP of 140/78 mmHg. His ECG shows first-degree atrioventricular block and incomplete RBBB.
   
5. A 65-year-old male presents to the ER with exertional chest pain. Pain started 24 h prior to presentation. He is currently chest-pain free. His ECG showed sinus bradycardia with Q waves in anterior chest leads V1–V4. An ECG done 1 month ago at his doctor’s office was completely normal.

Which is an indication to stop an exercise treadmill test?

1. Drop of >10 mmHg from baseline BP despite an increase in workload with associated features of ischemia
   
2. Sustained ventricular tachycardia
   
3. Moderate to severe angina
   
4. Signs of cyanosis or pallor
   
5. All of the above

Which of the following is a class III indication for exercise stress testing without imaging (echo or nuclear perfusion)?

1. Patients with a high pretest probability of having CAD
   
2. Preexcitation on baseline ECG
   
3. Left ventricular hypertrophy with <1 mm ST depression on baseline ECG
   
4. Patient with vasospastic angina

A 45-year-old male is being evaluated by his primary care physician as part of his executive health checkup. He reports no risk factors and is asymptomatic. His baseline ECG shows no resting abnormalities. He is able to walk for 14 min (13.5 METS on a Bruce protocol). He reaches an exercise heart rate of 185 bpm, has no angina, and has no ST segment changes on his ECG. What would his Duke treadmill score be?

1. 9
   
2. 14
   
3. 2
   
4. 3.4

Based on the test results in Question 4.9, what is the next most appropriate step?

1. Stress imaging study
   
2. Computed tomography (CT) angiography
   
3. Coronary angiography
   
4. No further testing
   
5. Repeat testing in 1 year

Which one of the following is a class I recommendation in assessing asymptomatic adults with no known CAD?

1. Genomic testing
   
2. Obtain global risk score (Framingham)
   
3. Assessment of lipoprotein and apolipoprotein
   
4. Measurements of natriuretic peptides

Which one of the following is a class I recommendation in assessing asymptomatic adults with no known CAD?

1. Genomic testing
   
2. Obtain family history
   
3. Assessment of lipoprotein and apolipoprotein
   
4. Coronary CT angiogram

Measurement of C-reactive protein (CRP) is not recommended in which of the following?

1. In men over 50 years with a low-density lipoprotein (LDL) of <130 mg/dL
   
2. In women over 60 years with an LDL <130 mg/dL not on hormone replacement therapy, and without diabetes or chronic kidney disease
   
3. In asymptomatic high-risk adults
   
4. In asymptomatic intermediate-risk men 50 years and younger or women 60 years and younger

With one exception, the following are class III recommendations in assessing low-risk asymptomatic adults with no known history of CAD. Which is the exception?

1. Coronary CT angiogram
   
2. Magnetic resonance imaging (MRI) for plaque detection
   
3. Measurement of coronary calcium score
   
4. Resting ECG

In patients with diabetes mellitus, which of the following is not recommended?

1. Stress echocardiogram
   
2. Stress MPI
   
3. Coronary calcium score measurement
   
4. Measurement of hemoglobin A1C

In asymptomatic women, all of the following except one are not recommended. Which is the exception?

1. Obtaining global risk score
   
2. Obtaining natriuretic peptides
   
3. MRI for plaque detection
   
4. Measurement of lipoprotein

Stress MPI is recommended in which of the following situations?

1. In the assessment of a low-risk individual
   
2. In the assessment of an intermediate-risk individual
   
3. In an asymptomatic adult with diabetes mellitus
   
4. None of the above

Which of the following is not true?

1. Echocardiography is recommended to detect left ventricular hypertrophy in patients with hypertension
   
2. Echocardiography is recommended in risk assessment of asymptomatic adults without hypertension
   
3. A resting ECG is reasonable in asymptomatic adults with hypertension
   
4. All of the above

Which of the following is a class III indication in the assessment of asymptomatic adults?

1. Measurement of arterial stiffness
   
2. Obtaining a resting ECG
   
3. Obtaining an echocardiogram in a patient with hypertension
   
4. Stress MPI in an individual with diabetes mellitus

Which of the following is not indicated regarding assessment of an asymptomatic adult with diabetes mellitus

1. Measurement of hemoglobin A1C
   
2. Stress MPI
   
3. Testing for microalbuminuria
   
4. Coronary CT angiogram