An 82-year-old man comes to the office for an annual follow-up visit. The patient says, "Over the last 2 months I have had several episodes of shortness of breath and dizziness while walking up the stairs. I also don't have energy like I did before and feel fatigued even after a short stroll around the house." The symptoms improve spontaneously after several minutes of rest, and he has had no chest pain, cough, or palpitations. The patient has no leg swelling or difficulty sleeping at night. Medical history is significant for hypertension, hyperlipidemia, osteoarthritis, depression, and diet-controlled type 2 diabetes mellitus. He lives with his daughter and is independent in his activities of daily living. The patient is a former smoker, with a 15-pack-year history, and quit over 20 years ago. Temperature is 37 C (98.6 F), blood pressure is 146/84 mm Hg, pulse is 78/min, and respirations are 14/min. BMI is 27.6 kg/m². The patient's pulse oximetry shows 98% while resting and breathing ambient air. He is comfortable and engaging and exhibits a full range of affect. Mucous membranes are pink and moist. There is no jugular venous distension or lymphadenopathy. The thyroid is normal to palpation. Bilateral breath sounds are normal with no wheezing or crackles. Cardiac examination reveals that the point of maximal impulse is slightly displaced to the left and that there is an S4 gallop with no murmurs. The abdomen is nondistended, soft, and nontender with normoactive bowel sounds. There is no hepatosplenomegaly. The patient has mild crepitus of the knee joints with no effusion or tenderness. There is no lower extremity edema. Blood cell counts and serum chemistry studies are within normal limits. ECG shows sinus rhythm, evidence of left ventricular hypertrophy, and nonspecific ST-segment and T-wave changes. Which of the following is likely to be most helpful in determining the cause of this patient's symptoms? A)High-resolution CT scan of the chest B)Pharmacologic stress testing C)Pulmonary function testing D)Transthoracic echocardiography E)Ventilation/perfusion scan

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Explanation: 11ec2b69_c116_0973_8f63_0b92cb0a9945_MD0005_00 This patient has multiple risk factors for cardiovascular disease (eg, advanced age, hypertension, diabetes mellitus), and his symptoms raise suspicion for stable coronary artery disease (CAD). Elderly patients (eg, age >80) are more likely to experience anginal symptoms other than chest pain (eg, shortness of breath, lightheadedness, fatigue). Such patients with suspected stable CAD are best evaluated initially with noninvasive stress testing. Exercise ECG stress testing is preferred for patients able to achieve adequate exertion levels on a treadmill (eg, >85% of maximum heart rate). However, for those with limited exertional walking capacity (eg, due to osteoarthritis), pharmacologic stress testing (eg, adenosine myocardial perfusion imaging, dobutamine echocardiography) is most appropriate. (Choice A) High-resolution CT scan of the chest is useful in diagnosing interstitial lung disease. Although the typical presentation is with progressive shortness of breath, this patient's lack of cough and absence of fine crackles on pulmonary examination make this diagnosis less likely. (Choice C) Pulmonary function testing is appropriate in patients with shortness of breath and fatigue that may be due to chronic obstructive pulmonary disease (COPD). This patient's history of smoking increases his risk of developing COPD; however, the lack of cough and absence of wheezing on physical examination make this diagnosis less likely. (Choice D) Transthoracic echocardiography allows evaluation for ventricular systolic or diastolic dysfunction and for valvular abnormalities (eg, aortic stenosis) that may cause dyspnea and fatigue. This patient's ECG findings and S4 gallop are consistent with left ventricular hypertrophy, which can cause diastolic heart failure. However, the normal jugular venous pressure and absence of lower extremity edema and pulmonary crackles make heart failure an unlikely cause of this patient's symptoms. In addition, the absence of a murmur makes significant valvular abnormality unlikely. Stress testing is most likely to confirm CAD as the cause of this patient's symptoms. (Choice E) Ventilation/perfusion scan is appropriate for evaluating for acute pulmonary embolism in patients who cannot undergo CT pulmonary angiography (eg, those with renal insufficiency). However, the gradual onset of symptoms and absence of pleuritic chest pain and hypoxemia in this patient make acute pulmonary embolism unlikely. Educational objective: Elderly patients (eg, age >80) are more likely to experience anginal symptoms other than chest pain (eg, shortness of breath, lightheadedness, fatigue). Patients with suspected stable coronary artery disease should undergo initial evaluation with noninvasive stress testing. References: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: 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/23166210)

An 82-Year-Old Man Comes to the Office for an Annual