**Question:** A 50 year old man with a history of smoking, hypertension, and chronic exertional angina develops several daily episodes of chest pain at rest compatible with cardiac ischemia. The patient is hospitalized. All the following would be part of an appropriate management plan except

A. Discontinue smoking
B. Start antihypertensive medication
C. Perform a coronary angiogram
D. Withhold all medications

**Correct Answer:** D. Withhold all medications

**Core Concept:** Coronary artery disease, angina, and hospitalized management

**Why the Correct Answer is Right:**

In this scenario, the patient is experiencing acute coronary ischemia due to the combination of risk factors (smoking, hypertension, and chronic exertional angina). The appropriate management plan focuses on stabilizing the patient and addressing the underlying causes of their chest pain. Discontinuing smoking, initiating antihypertensive medication, and performing a coronary angiogram are essential steps to manage and prevent further coronary artery disease progression.

**Why Each Wrong Option is Incorrect:**

A. Discontinuing smoking: Smoking cessation is crucial in preventing further damage to the coronary arteries and reducing the risk of angina and myocardial infarction.

B. Start antihypertensive medication: Controlling blood pressure is essential in reducing the workload on the heart and preventing further damage to the coronary arteries.

C. Perform a coronary angiogram: Coronary angiography is a diagnostic test to visualize the coronary arteries, identify blockages, and guide treatment decisions. In this case, it is an appropriate step to assess the patient's coronary artery condition and guide further management.

D. Withhold all medications: Withholding vital medications, such as antihypertensive drugs and analgesics, could lead to worsening hypertension, angina, and myocardial ischemia, culminating in a more severe clinical condition and potentially life-threatening complications.

**Clinical Pearl:**

In hospitalized patients with acute coronary ischemia, withholding medications should be avoided to prevent further exacerbation of the underlying condition. Instead, focus on interventions like smoking cessation, antihypertensive therapy, and performing diagnostic tests (coronary angiography) to identify the cause and guide appropriate treatment.