DrVirgo
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A 58-year-old man comes to the clinic for a health care
checkup. He wishes to discuss his risk for having a
myocardial infarction in the next 10 years, as his brother,
who is 48 years old, recently suffered from a near fatal
one. He denies any chest pain, shortness of breath,
orthopnea, or other cardiac symptoms, though he admits
he has been ill in the past. Past medical history is remarkable
for diabetes mellitus, diagnosed 8 years ago, and a
stroke 2 years ago. He recently quit smoking after a 40
pack-year history and is mildly overweight. Physical
examination is unremarkable, though an electrocardiogram
shows high voltages in the precordial leads. Given
this patient’s risk factors, which of the following is the
most appropriate strategy for cardiac risk stratification
and to determine treatment goals?
(A) Coronary computed tomography
(B) Electrocardiographic exercise testing
(C) Exercise-stress echocardiography
(D) Myocardial perfusion scintigraphy
(E) No further testing necessary
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| robin082006
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E
Sorry, no test here
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| webjeee
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why not c
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| paviraj
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SO MANY RISK FACTORS Y NOT C?
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| mjl1717
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I say no testing perhaps give a statin if needed and ASA per day or clopidogrel. ,lifestyle modification!
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| drashishmahajan
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C--- so mny risk factors n the stress exercise test is used 4 risk strtification
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| young_doc
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The patient is asymptomatic. I don't think Risk factors alone warrant stress-testing?
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| DrVirgo
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E. This patient is a high-risk
patient who almost certainly has coronary artery disease
and should be treated as such.Noninvasive testing is not
required to determine the treatment goals of this
patient. Aggressive risk reduction with a focus on tight
glucose control, meeting tight lipid goals (LDL cholesterol
level of less than 100 mg/dL), reinforcing smoking
cessation, and so on are all appropriate, regardless of
what may show up on noninvasive testing. In general,
low-risk and high-risk asymptomatic patients do not
require testing to determine their risk for coronary
artery disease. For low-risk patients, the positive predictive
value of a test is too low, whereas high-risk patients
warrant treatment regardless of the results of the test.
Coronary computed tomography (choice A) is a relatively
new technology that looks for calcium deposits in
the coronary arteries. The area and density of calcium
are used to generate a coronary calcium score that correlates
with the extent of atherosclerosis, though not
necessarily the patient’s prognosis. There are no clear
guidelines on the use of this modality. Blue Cross Blue
Shield finds the technique experimental and does not
recommend it, whereas the American College of
Cardiology and American Heart Association state that
coronary CT can be used on “selected” intermediate
risk patients. It can be expected that this patient has
some calcium in his arteries; what to do with a quantified
version of this information is unclear.
Electrocardiographic exercise testing (choice B) should be
used on intermediate risk patients to further risk-stratify
them.Unfortunately, despite its wide use, EKG-stress testing
has a sensitivity that ranges from 25 to 75% in asymptomatic
populations. Given this patient’s numerous risk
factors, including baseline EKG abnormalities, this test is
unlikely to provide much additional useful information.
This patient should be treated as if he has coronary artery
disease. Exercise-stress echocardiography (choice C) and
myocardial perfusion scintigraphy (choice D) have a
higher sensitivity but are expensive, not always available,
and have been studied mainly in symptomatic patients.
Were this patient to have cardiac symptoms (which he has
a high likelihood of having in the near future), these
would be excellent tests to determine his near-term risk
for a major event and to determine if invasive testing and
treatment (i.e., cardiac catheterization) are appropriate.
At this point, however, further testing is not necessary to
determine this patient’s cardiac risk and treatment goals.
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