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High-risk non-ST-elevation acute coronary syndrome — ABIM Board MCQ

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HardCardiovascularHigh-risk non-ST-elevation acute coronary syndromeABIM Board

A 58-year-old man presents with chest pressure that began 3 hours ago. ECG shows 2-mm horizontal ST depression in V2 to V5 and ST elevation in aVR. Troponin is elevated. Blood pressure is 92/58 mm Hg despite fluids, and he has cool extremities. Which of the following is the most likely diagnosis?

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Correct answer: D — High-risk non-ST-elevation acute coronary syndrome

Diffuse ST depression with aVR elevation, elevated troponin, shock, and ongoing ischemic symptoms indicates high-risk NSTE-ACS, often reflecting left main, proximal LAD, or multivessel ischemia and requiring urgent invasive evaluation.

Reference: 2021 AHA/ACC Chest Pain Guideline; 2014 AHA/ACC NSTE-ACS Guideline