A 34-year-old woman comes to the physician with a several-month history of chest pain. The pain is left-sided, does not change with deep inspiration, and typically lasts several hours. She currently has the pain; it is unrelated to physical activity but worsens with emotional stress. The patient has no cough, syncope, or shortness of breath. She has no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes no medications and has no drug allergies. Her blood pressure is 110/70 mm Hg and pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation. ECG shows normal sinus rhythm with no significant abnormalities. Which of the following is the best next step in the management of this patient?

Question

A 34-year-old woman comes to the physician with a several-month history of chest pain.  The pain is left-sided, does not change with deep inspiration, and typically lasts several hours.  She currently has the pain; it is unrelated to physical activity but worsens with emotional stress.  The patient has no cough, syncope, or shortness of breath.  She has no significant family history and does not use tobacco, alcohol, or illicit drugs.  She takes no medications and has no drug allergies.  Her blood pressure is 110/70 mm Hg and pulse is 78/min.  Heart sounds are normal.  Lungs are clear to auscultation.  ECG shows normal sinus rhythm with no significant abnormalities.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d345_657c_bc81_61a23d1c037f_MD0003_00 The pretest probability of coronary artery disease (CAD) is based on age, gender, cardiac risk factors, and chest pain characteristics. Low-risk patients include women age <50 with atypical chest pain and no significant cardiac risk factors (eg, non-smoker, no family history of premature CAD). pretest probability chest pain characteristics A positive stress test in patients at low risk for CAD is likely to be a false positive, which can lead to further unnecessary testing or procedures. Conversely, a negative test in high-risk patients is likely a false negative. For this reason, patients with high-risk features for symptomatic CAD should be definitively evaluated with coronary angiography. Stress testing (eg, exercise electrocardiography, myocardial perfusion imaging) is most helpful for risk stratification in patients with intermediate-risk features (Choices A and B). The choice of test is determined based on baseline electrocardiogram (ECG) findings and the ability to exercise. This patient has had chest pain for several months that is unrelated to physical activity. She is young, has no risk factors for development of premature CAD, and her ECG was normal. In light of this, she has a low pretest probability of CAD and additional testing for CAD not advised. (Choice C) This patient has no symptoms or signs suggesting deep venous thrombosis or pulmonary embolism (eg, pleuritic pain, dyspnea, tachycardia). Lower-extremity venous ultrasonography is therefore not indicated. (Choice E) A transthoracic echocardiogram (TTE) can assess for segmental wall motion abnormalities during an episode of chest pain, or after exercise in a diagnostic stress test. It can be helpful in diagnosing Takotsubo (stress-induced) cardiomyopathy, but this condition typically presents in older patients (commonly postmenopausal women) following significant stress (eg, death of a loved one) and is commonly associated with ECG abnormalities. TTE can also be used to look for valvular pathology (eg, aortic stenosis, mitral valve prolapse) in patients with exertional chest pain and a suspicious murmur or other signs of valve disease. Educational objective: Diagnostic testing for coronary artery disease (CAD) should not be performed routinely in low-risk patients as they frequently can have false-positive test results. Patients with intermediate probability of CAD should receive appropriate stress testing based on ECG findings and their ability to exercise. High-risk patients should be started on appropriate medical therapy, with expert evaluation to consider coronary angiography. References: The chest pain choice decision aid: a randomized trial. (http://www.ncbi.nlm.nih.gov/pubmed/22496116)

A 34-Year-Old Woman Comes to the Physician with a Several-Month