A 62-Year-Old Woman Comes to the Physician Due to Chest

A 62-year-old woman comes to the physician due to chest and epigastric discomfort over the last 6 months.  She feels dull chest pressure while walking uphill at a fast pace.  The patient says, "It is unusual.  I feel this pressure only once in a while, even when doing the same thing.  Sometimes it is worse when I walk fast after a heavy meal."  She has a history of nonulcer dyspepsia and acid reflux disease and occasionally takes over-the-counter omeprazole.  She has no shortness of breath, palpitations, lightheadedness, lower extremity swelling, or syncope.  The patient is physically active and has a very hectic social lifestyle.  Medical history includes "borderline" hypertension and anxiety disorder.  She stopped taking antihypertensive medications 5 years ago.  She is a lifetime nonsmoker.  The patient does not use alcohol or illicit drugs.  Her mother suffered a stroke at age 70 and her father died of prostate cancer.  Blood pressure is 145/90 mm Hg and pulse is 80/min and regular.  BMI is 29 kg/m².  No heart murmurs are heard on cardiac auscultation.  There are no carotid bruits.  The lungs are clear and the rest of the physical examination is unremarkable.  Resting ECG shows normal sinus rhythm, normal voltage, and T-wave flattening in leads V5 and V6.  Laboratory studies show fasting blood glucose of 102 mg/dL and LDL cholesterol of 110 mg/dL.  Which of the following is most appropriate management for this patient's chest pain?

A) Initiate antihypertensive therapy with no diagnostic testing
B) Obtain a dobutamine echocardiogram
C) Obtain an exercise ECG
D) Obtain exercise myocardial perfusion imaging
E) Proceed with coronary angiography