Question

A 62-year-old man with a heavy smoking history comes to the ED with chest pain. He states that for the past few months, he has been getting chest 'pressure' localised to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually lasts about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnoea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention? a. Obtain a resting ECG b. Schedule the patient for a cardiac echocardiogram c. Schedule the patient for an exercise treadmill test d. Schedule the patient for non-urgent coronary angiography

Answer 1

The most appropriate diagnostic intervention for this patient is to schedule him for an exercise treadmill test ©. This is because he has a typical presentation of stable angina, which is chest pain that occurs with exertion and is relieved by rest. An exercise treadmill test can help confirm the diagnosis of angina by inducing chest pain and detecting any changes in the ECG that suggest myocardial ischemia (reduced blood flow to the heart muscle). An exercise treadmill test can also provide information about the patient’s functional capacity, prognosis, and response to anti-anginal therapy1.

A resting ECG (a) is not very helpful in diagnosing stable angina, as it may be normal or show nonspecific changes in patients with angina2. A cardiac echocardiogram (b) can assess the structure and function of the heart, but it cannot provoke or detect ischemia unless combined with a stress test3. A coronary angiography (d) is an invasive procedure that involves inserting a catheter into the heart arteries and injecting contrast dye to visualize any blockages. It is not indicated as a first-line diagnostic test for stable angina, unless the patient has high-risk features or fails to respond to medical therapy4.

Therefore, based on the patient’s history and physical examination, the best next step is to schedule him for an exercise treadmill test to confirm the diagnosis of stable angina and guide further management.

Step-by-step explanation: