Sample · RACGP
Chest pain after sildenafil: acute coronary syndrome in a regional practice
Cardiovascular health · 4 parts · 10 marks. Decide what you would write, then compare with the rubric and model answer. In the app you write it under time and it comes back marked.
Darko Petrovic, 58, walks into your practice in a regional town at 8.30 am with 40 minutes of central, heavy chest pain spreading to his jaw. He is sweaty and nauseated. He smokes 20 cigarettes a day and takes perindopril 5 mg for hypertension. He mentions, embarrassed, that he took sildenafil 100 mg at about 10 pm last night. He has no known allergies.
Blood pressure (BP) 148/92 mmHg, heart rate 96/min regular, oxygen saturation (SpO2) 97% on room air. The nearest hospital with a cardiac catheter laboratory is 3 hours away by road; the local hospital emergency department is 10 minutes away.
(a) What are the most appropriate immediate actions? Choose 3. A. Sublingual glyceryl trinitrate (GTN) spray 400 microgram B. 12-lead electrocardiogram (ECG) within 10 minutes of arrival C. Point-of-care troponin, transferring only if it is positive D. Oxygen 8 L/min by mask E. Aspirin 300 mg chewed F. Call 000 for an ambulance G. Ask his wife to drive him to the local emergency department H. Clopidogrel 600 mg orally 3 marks
Show the rubric and model answer
- B. 12-lead ECG within 10 minutes (1)
- E. Aspirin 300 mg chewed (1)
- F. Call 000 for an ambulance (1)
- B. ECG within 10 minutes: identifies ST-elevation myocardial infarction (STEMI) and drives the reperfusion decision.
- E. Aspirin 300 mg chewed: no allergy or contraindication, and it reduces mortality in acute coronary syndrome (ACS).
- F. Ambulance: a suspected ACS needs monitored transport with defibrillation; paramedics can also start prehospital reperfusion pathways.
Not: GTN (sildenafil within 24 hours: risk of profound hypotension); a single point-of-care troponin cannot exclude ACS and must not delay transfer; oxygen only if SpO2 is below 90%; private car transport is unsafe; P2Y12 loading is decided by the receiving team once the ECG and reperfusion plan are known.
The ECG shows 3 mm ST elevation in leads II, III and aVF with ST depression in I and aVL.
(b) What are the most appropriate next steps while awaiting the ambulance? Choose 2. A. Record right-sided chest leads (V4R) B. Repeat the ECG in 30 minutes before deciding on transfer C. Contact the regional STEMI service / emergency physician for an immediate reperfusion decision D. Give metoprolol 25 mg orally to slow his heart rate E. Arrange an urgent outpatient stress echocardiogram F. Give a further 300 mg aspirin 2 marks
Show the rubric and model answer
- A. Right-sided leads (V4R) to look for right ventricular infarction (1)
- C. Contact the STEMI service / emergency physician for an immediate reperfusion decision (fibrinolysis likely, as primary PCI is more than 2 hours away) (1)
- A. V4R: inferior STEMI is often accompanied by right ventricular infarction, which makes him preload-dependent and changes fluid and nitrate decisions.
- C. Reperfusion decision now: with percutaneous coronary intervention (PCI) more than 120 minutes away, prehospital or local fibrinolysis is usually indicated within the first hours; this is time-critical and made with the regional STEMI service.
Not: repeating the ECG delays reperfusion; oral beta-blocker in the acute phase risks bradycardia and hypotension in inferior infarction; outpatient testing is inappropriate; aspirin has already been given.
(c) List the two features in this case that make glyceryl trinitrate unsafe for him right now. 2 marks
Show the rubric and model answer
- Phosphodiesterase-5 (PDE5) inhibitor (sildenafil) taken within the last 24 hours: risk of severe hypotension (1)
- Inferior STEMI with possible right ventricular infarction: preload-dependent, nitrates can cause collapse (1)
- Sildenafil within 24 hours (48 hours for tadalafil): combined with nitrates it causes profound, potentially fatal hypotension.
- Inferior STEMI with possible right ventricular involvement: cardiac output depends on preload, so venodilation from nitrates can precipitate hypotension.
Seven weeks later, after fibrinolysis and a drug-eluting stent to his right coronary artery, he returns. He is pain free, has stopped smoking and asks about driving his car and resuming sildenafil. He has been prescribed GTN spray to carry.
(d) Which advice is correct? Choose 3. A. He must not drive a private car for 6 months after a myocardial infarction B. He could have resumed private driving after 2 weeks if he was otherwise well C. Sildenafil is permanently contraindicated after a myocardial infarction D. He must not use his GTN spray within 24 hours of taking sildenafil, and should tell paramedics if he has taken it E. He should be referred to a cardiac rehabilitation program if he has not already started one F. He may hold a commercial (heavy vehicle) licence without restriction from 1 week 3 marks
Show the rubric and model answer
- B. Private driving permissible after at least 2 weeks following myocardial infarction if no other disqualifying condition (1)
- D. No GTN within 24 hours of sildenafil; tell paramedics (1)
- E. Cardiac rehabilitation referral (1)
- B. Austroads Assessing Fitness to Drive: private drivers should not drive for at least 2 weeks after acute myocardial infarction; commercial standards are stricter and need cardiologist input.
- D. PDE5 inhibitors can be resumed once he is stable, but the nitrate interaction remains: no GTN within 24 hours of sildenafil, and he must tell emergency staff.
- E. Cardiac rehabilitation reduces mortality and readmission after ACS and is under-referred.
Not: 6 months and permanent sildenafil contraindication are wrong; commercial licences are not unrestricted at 1 week.
Where candidates lose marks here
- Selecting GTN for chest pain despite the stem telling you he took sildenafil last night: the single most common way to lose this case.
- Waiting for a point-of-care troponin before calling the ambulance: a negative early troponin does not exclude acute coronary syndrome.
- Giving oxygen routinely to a patient with normal saturation.
- Over-selecting in part (d): choosing four "reasonable" statements loses marks in the real paper.
- Not adapting to the regional setting: in a long-transfer location, fibrinolysis decisions are time-critical.
Original content written for Fellowship Ready, for exam preparation only, not clinical advice. Not affiliated with the RACGP.