A 56-year-old man comes to the emergency department due to chest pain that occurred at home. He was watching television when he developed left-sided chest pain described as dull and pressure-like. The pain progressively worsened and radiated to the throat but spontaneously resolved within 20 minutes. During the past week, the patient had 2 similar episodes with exertion at his job as a construction worker. He has had no palpitations, syncope, shortness of breath, or diaphoresis. He has a history of hypertension treated with lisinopril and is a lifetime nonsmoker. Family history is significant for stroke at a young age in a paternal uncle. The patient is currently free of chest pain and comfortable. Blood pressure is 150/80 mm Hg and pulse is 78/min. Physical examination is otherwise unremarkable. ECG shows sinus rhythm with T-wave inversion in leads V5 and V6. Chest x-ray is normal. Cardiac troponin I level is normal (

Question

A 56-year-old man comes to the emergency department due to chest pain that occurred at home.  He was watching television when he developed left-sided chest pain described as dull and pressure-like.  The pain progressively worsened and radiated to the throat but spontaneously resolved within 20 minutes.  During the past week, the patient had 2 similar episodes with exertion at his job as a construction worker.  He has had no palpitations, syncope, shortness of breath, or diaphoresis.  He has a history of hypertension treated with lisinopril and is a lifetime nonsmoker.  Family history is significant for stroke at a young age in a paternal uncle.  The patient is currently free of chest pain and comfortable.  Blood pressure is 150/80 mm Hg and pulse is 78/min.  Physical examination is otherwise unremarkable.  ECG shows sinus rhythm with T-wave inversion in leads V5 and V6.  Chest x-ray is normal.  Cardiac troponin I level is normal (<0.012 ng/dL).  Aspirin, metoprolol, atorvastatin, clopidogrel, and subcutaneous enoxaparin are initiated.  Eight hours later, he is still without chest pain.  ECG is unchanged and repeat troponin I level is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be02_fd93_8f63_616d7b72b4cb_MD0005_00 This patient's clinical presentation-recent onset of anginal pain at rest, T-wave inversions on ECG, and normal cardiac troponin I levels-is consistent with unstable angina. The diagnosis of unstable angina is based largely on history; it is defined as symptoms suggesting acute coronary syndrome but without elevated cardiac biomarkers (eg, troponin). Patients may or may not have signs of myocardial ischemia on ECG (eg, ST depression, new T-wave inversions). Non-ST elevation myocardial infarction (NSTEMI) is characterized by similar symptoms but with elevated cardiac biomarkers. anginal pain The risk of serious complications (eg, need for revascularization, death) varies significantly among patients with unstable angina or NSTEMI. Therefore, these patients should undergo early risk stratification to determine the need for early coronary angiography versus noninvasive stress testing. A commonly used risk stratification tool is the Thrombolysis in Myocardial Infarction (TIMI) risk score, which counts 1 point each for age >65, >3 risk factors for coronary artery disease (CAD), known CAD with >50% stenosis, recent use of aspirin, multiple episodes of angina in the last 24 hours, elevated troponin I, and ST-segment deviation >0.5 mm on ECG. This patient has a low-risk TIMI score (0) and should be evaluated with an exercise stress test prior to discharge. (Choice A) Discharge home with pharmacologic treatment for CAD is appropriate if exercise stress testing is negative for inducible myocardial ischemia; however, it is not appropriate prior to further evaluation. (Choice B) Coronary calcium scan with multidetector CT is occasionally used for screening asymptomatic patients for CAD. However, it has no role in evaluating patients with acute cardiac symptoms. (Choice D) Early coronary angiography (within 24 hours of presentation) is indicated in patients with an intermediate- or high-risk assessment (TIMI score >3). This patient is clinically stable with a low-risk TIMI score and requires angiography only if his stress test is positive for inducible myocardial ischemia. (Choice E) Reassurance and discharge home with no new pharmacologic treatment is not appropriate. This patient with acute coronary syndrome has a new diagnosis of CAD for which the addition of aspirin, a beta blocker, and a high-intensity statin is indicated. Stress testing will help determine whether the patient may benefit from revascularization in addition to pharmacologic therapy. Educational objective: Clinically stable patients with unstable angina or non-ST elevation myocardial infarction should have early risk stratification using validated risk prediction models. Low-risk patients should have noninvasive stress testing prior to hospital discharge; intermediate- or high-risk patients should be referred for early coronary angiography. References: 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22800849)

A 56-Year-Old Man Comes to the Emergency Department Due to Chest