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A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about three blocks and goes away with rest. He has developed a habit of taking rest when the chest pain comes and he did not think it needed medical attention until his friend told him yesterday that it might be a symptom of heart disease. He is concerned and requests your recommendation. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain. His past medical history is significant for pacemaker insertion for a symptomatic second degree heart block, Hypertension, and Smoking . His medications include lisinopril, atenolol and hydrochlorthiazide. Physical examination is benign. An EKG is obtained which reveals pacemaker rhythm with secondary ST-T changes. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization

Do we do the ekg first or excercise stress test .i am confused.




it's > A) 2 D -Echocadiogram


This pt. has stable angina. EKG has been obtained in the question. Next best step will be Exercise stress test to see evidence of inducible ischemia with exertion; if any.


waiting for answer


Woww very nice medication in human health in use.!


I would go with stress test, and then cathether if stress is positve. Has echo ever been used on MI/angina? I know in peds echo trumps ecg for all heart issues. I would like to know does having a pacemaker changes things.


i think stress test will not be reliable becoz he is having pacemaker rhythm.
cardiac catheterization should be done.
not sure.


A) 2 D -Echocadiogram: The patient has been having symptoms of stable angina. 2-d echo will not help in evaluation for cause of chest pain
B) Exercise Stress Test ( Treadmill Stress Test): Patient has secondary SST changes which can interfere with results of stress test
C) Dobutamine Stress Echocardiogram; can be an option
D) Persantin Stress Test: to me its best option 
E) Cardiac Catheterization: 


dobutamine stress echo due to presence of baseline ekg abnormality!! or you can do nuclear stress test with technitium or sestamibi...


2D Echo...coz he s wearin a pacemaker...


Dobutamine Echo coz hes wearing a pacemaker


From the history you know that he has exertional angina AND that it is a reproducible event, not just a one time thing where the diagnosis is still up in the air. Therefore, 2-D echo would tell you exactly NOTHING about the extent of his atherosclerotic disease. What would be the purpose of a nuclear medicine stress test that would tell you what you already know (ischemic heart disease on exertion) but without sufficient detail about which vessels and how severe the narrowing is? The answers of dobutamine or persantine are essentially the same type of stress test, just using different drugs (the type of stress test you MUST use in a patient with a pacemaker). Remember that nuclear medicine stress tests are physiologic, not anatomic, so it is an unnecessary step because he will have to go to cardiac catheterization anyway (see below). Contrast this workup with a patient who MIGHT have angina; a negative stress test would essentially exclude exertional ischemia (but not Prinzmetal's, but his history is not consistent with that diagnosis) and he would not need to go to cardiac catheterization.

For these reasons, he needs to go straight to cardiac catheterization to find out where (which vessels) and how severe his atherosclerotic disease is. This will also be a necessary step before bypass surgery (stents are less desirable long term in a patient like this, but still a possibility depending on the cardiologist).

Although not given as an option, doing the newer CT calcium scoring tests would also fail to tell you enough information; it is to establish a "risk profile" but is fundamentally flawed because most heart attacks (and much atherosclerosis) is caused by "vulnerable plaque," which by definition is not calcified, therefore is not detected by CT. MIR coronary angiography is also out because he has a pacemaker. Bottom line; cardiac catheterization is still the gold standard.


due to pacemaker, he has a baseline ekg abnormality, so anything related 2 ekg is out.
best option for these cases is a nuclear stress test (in which derez no role of ekg)... persantine thallium is best for dis condition.


So is Longoria dating again? And what's the new TV show she's working?


Dipyridamole (persantine) stress testnod

answer !!!! sad Help


Hi everyone. im having dilemna with this case as well. I've been using different sources.
From Archer's: A stress test should be done first before Cardiac Cath

--for this case, having a paced rhythm would require the Persantin Stress test to avoid the false positive results.

Kaplan, old reviewer: a stress test is useless because it is clear that the patient has angina...Cardiac cath/angiography should follow to determine if an angioplasty/cabg should be needed.

I tried to look for other sources.. 2002 AHA algorithms for chronic stable angina posts Stress testing prior to Angiography.

I'm leaning on the same answer as tomclay...Cardiac cathetherization..the stress testing would provide little diagnostic value to the next step in mgt.

pls share your thoughts as well...


Choice d)
If persentine stress test includes thallium then i think this is the right answer b/c ecg cant be confirm diagnosis of angina we have to do a stress test.persentine is used for execersise and thallium for scaning the heart instead of ecg.cardiac catheterization is not the next best step


I think the answer is cardiac catheterisation as well, all investigations involving ekg's would not be useful in this case b/c of pacemaker artifact

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