A 54-year-old man comes to the physician with chest discomfort. During the last 6 months, the patient has had left-sided chest pain radiating to the left shoulder, which is commonly provoked by exertion but also occurs at rest. The chest pain lasts a few seconds to several minutes, and he can usually "walk it off." Past medical history includes hypertension, hyperlipidemia, and peptic ulcer disease. The patient received a permanent pacemaker 6 years ago after an episode of syncope. His father also had a pacemaker. Current medications include lisinopril, amlodipine, famotidine, and rosuvastatin.
His blood pressure is 111/70 mm Hg and pulse is 67/min. Chest is clear to auscultation. No cardiac murmurs or carotid bruits are appreciated. The abdomen is nontender. Pulses are full and symmetric bilaterally.
Electrocardiogram shows normal sinus rhythm with paced ventricular complexes (atrial sensed, ventricular paced rhythm).
Which of the following is the best next step in management of this patient?

Question

A 54-year-old man comes to the physician with chest discomfort.  During the last 6 months, the patient has had left-sided chest pain radiating to the left shoulder, which is commonly provoked by exertion but also occurs at rest.  The chest pain lasts a few seconds to several minutes, and he can usually "walk it off."  Past medical history includes hypertension, hyperlipidemia, and peptic ulcer disease.  The patient received a permanent pacemaker 6 years ago after an episode of syncope.  His father also had a pacemaker.  Current medications include lisinopril, amlodipine, famotidine, and rosuvastatin.
His blood pressure is 111/70 mm Hg and pulse is 67/min.  Chest is clear to auscultation.  No cardiac murmurs or carotid bruits are appreciated.  The abdomen is nontender.  Pulses are full and symmetric bilaterally.
Electrocardiogram shows normal sinus rhythm with paced ventricular complexes (atrial sensed, ventricular paced rhythm).
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_974e_bd30_853d_0f6db621be50_MD0002_00 The pretest probability of coronary heart disease (CHD) is used to determine the need for noninvasive diagnostic evaluation or coronary angiography in patients with suspected chest pain symptoms. Chest pain symptoms are categorized into 3 groups: Classic or typical angina-substernal chest discomfort with three characteristics: typical quality and duration, provoked by exertion or stress, and relieved with rest or nitroglycerinProbable or atypical angina-chest pain with two of the above three featuresNonanginal chest pain-chest pain with one or none of the above features Classic or typical angina-substernal chest discomfort with three characteristics: typical quality and duration, provoked by exertion or stress, and relieved with rest or nitroglycerin Probable or atypical angina-chest pain with two of the above three features Nonanginal chest pain-chest pain with one or none of the above features This patient has probable but not classic chest pain and an intermediate pretest probability of CHD (between 20%-80%) based on his age, gender, and symptoms. The next step in management is to perform a noninvasive evaluation with exercise or pharmacologic stress testing. intermediate pretest probability Current guidelines recommend an exercise electrocardiogram (ECG) stress test without imaging as the preferred initial test in most patients with an intermediate pretest probability of CHD as the test also provides useful information about symptoms, functional capacity, and hemodynamic response to exercise. However, ST-segment changes during exercise ECG testing provide no diagnostic information in patients with paced ventricular rhythm or underlying left bundle branch block (LBBB) (Choice C). Also, a paced ventricular rhythm produces false-positive perfusion defects on exercise radionuclide myocardial perfusion imaging (Choice D). In such patients, pharmacologic radionuclide imaging (with adenosine, dipyridamole, or regadenoson) is preferred for evaluation of suspected CHD. (Choice A) Coronary angiography is a reasonable alternate test in patients with a high probability of CHD (greater than 90%). However, this patient has an intermediate probability of CHD and should be evaluated initially with a pharmacologic stress test. (Choice B) In patients with paced ventricular rhythm, a resting echocardiogram shows paradoxical septal motion due to early activation of the right ventricle. These findings can become more pronounced with exercise and lead to false-positive abnormalities. Educational objective: Pharmacologic radionuclide perfusion imaging should be performed to evaluate suspected coronary heart disease in patients with paced ventricular rhythm or left bundle branch block. __________ References: ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed (http://www.ncbi.nlm.nih.gov/pubmed/24355759) Predictive value of a positive exercise stress testing and correlations with cardiovascular risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/24741776)

A 54-Year-Old Man Comes to the Physician with Chest Discomfort