A 62-year-old man comes to the office due to shortness of breath for the past 6 months. The patient, who describes his symptoms as progressive, has difficulty walking a block without becoming out of breath. He experiences chest tightness and midline "squeezing" that is relieved after 5 minutes of rest. He also has fatigue and poor sleep but no palpitations, orthopnea, cough, or syncope. His other medical problems include hypertension and gastroesophageal reflux disease. His medications are hydrochlorothiazide and ranitidine. The patient has smoked a pack of cigarettes daily for 35 years and drinks 1 or 2 beers daily. His father has high blood pressure and had a stroke in his 60s, and his mother died of breast cancer. On physical examination, the patient appears comfortable at rest. Blood pressure is 136/78 mm Hg and pulse is 84/min and regular. BMI is 41 kg/m². No cardiac murmurs are heard. The lungs are clear on auscultation. There is trace edema of the lower extremities bilaterally. Resting ECG shows normal sinus rhythm with no ST-segment or T-wave abnormalities. Exercise stress testing is performed and reveals a 1-mm ST depression in ECG leads I, aVL, V5, and V6 at minimal exertion. The patient is started on aspirin, atorvastatin, and metoprolol and counseled on smoking cessation. Which of the following is the most appropriate next step in management of this patient?

Question

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Explanation: 11ec2b69_be28_8708_8f63_636eff14302c_MD0005_00 Noninvasive stress testing provides both diagnostic and risk-stratification information regarding coronary artery disease (CAD) and is the initial evaluation of choice in patients with suspected clinically significant, stable CAD. Patients with positive stress testing results should be initiated on medical therapy, including aspirin, a high-intensity statin (eg, atorvastatin, rosuvastatin), and a beta blocker, as well as optimization of cardiovascular risk factors (eg, smoking cessation, blood pressure control, glucose control). In addition, patients with high-risk stress testing features (eg, ST depression at minimal exertion, as in this patient) likely have atherosclerotic disease that will benefit from revascularization and should undergo percutaneous coronary angiography to assess for stent placement or coronary artery bypass grafting. Patients without high-risk stress testing features but with anginal symptoms refractory to several months of optimal medical management should also undergo coronary angiography to assess for revascularization. stress testing features (Choice A) Medical management of CAD and stable anginal symptoms is appropriate in patients with positive stress testing results without high-risk features. However, this patient with ST depression in the lateral ECG leads at minimal exertion is likely to benefit from revascularization and should undergo percutaneous coronary angiography without delay. (Choice B) CT coronary angiography allows for visualization of atherosclerotic coronary artery lesions and risk assessment; however, it does not allow for therapeutic intervention at the time of testing. In patients with a high probability of significant atherosclerotic disease, percutaneous coronary angiography is preferred as it allows placement of coronary artery stents if appropriate. (Choice C) Dobutamine echocardiography is an alternate stress testing modality for patients unable to undergo exercise ECG stress testing. This patient's exercise ECG has already demonstrated high-risk features, so additional stress testing is not indicated. (Choice D) Pulmonary function testing is appropriate in patients with suspected obstructive lung disease (eg, chronic obstructive pulmonary disease). Although this patient's smoking history puts him at risk for this disease, his symptoms and stress testing results are consistent with stable angina. Educational objective: Stress testing is the initial evaluation of choice for patients with suspected stable coronary artery disease. Patients with positive stress testing results should be started on appropriate medical therapy, and those with high-risk stress testing features should undergo coronary angiography to evaluate for revascularization. References: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. (http://www.ncbi.nlm.nih.gov/pubmed/23182125)

A 62-Year-Old Man Comes to the Office Due to Shortness