Hotobhaga
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Please comment on this q.
32) A 62-year-old man with a 110 pack-year history of smoking presents with chest pain. He states that for the past few months, he has been getting chest "pressure" localized to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually last about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard, and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention?
A. Obtain a resting electrocardiogram
B. Schedule the patient for a cardiac echocardiogram
C. Schedule the patient for an exercise treadmill test
D. Schedule the patient for non-urgent coronary angiography
E. Schedule the patient for immediate coronary angiography
Explanation:
The correct answer is
C. This is a patient who has 3 clear risk factors for coronary artery disease (tobacco, family history and age) and based on his physical examination, likely has severe peripheral vascular disease. He has, by definition, typical chest pain, so called "new onset angina". He is a prime patient to have significant coronary disease, and thus we suspect ischemia as a cause for his pain. As a surrogate for coronary angiography, which actually shows anatomy, an exercise treadmill test allows us to detect ECG changes of ischemia with activity and thus stratify this patient as requiring intervention (such as percutaneous transluminal coronary angioplasty, or coronary artery bypass grafts), or perhaps angiography to better evaluate his anatomy.
A resting ECG (choice A) is appropriate, but not the most appropriate, given that he is pain-free at present and one would not expect to see any ECG changes associated with ischemia.
A cardiac echocardiogram (choice B) will likely be performed, given his dyspnea on exertion, but is not an appropriate test in the triaging of suspected ischemic chest pain. In some centers a "stress-echo", specifically a dobutamine echocardiogram, is used to evaluate ischemic potential.
A non-urgent coronary angiography (choice D) is also inappropriate since angiography is an invasive procedure reserved for people that have had equivocal results from less invasive diagnostic procedures, or are having signs of crescendo angina. This patient has new angina, but it is "typical" angina in that it is exertional.
An immediate coronary angiogram (choice E) is clearly not indicated as the patient is not having active ischemia or a myocardial infarction requiring reperfusion.
I think an resting EKG is needed to see if the pt will benefit from the excercise treadmill.
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| Justice
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Hotobhaga wrote:
I think an resting EKG is needed to see if the pt will benefit from the excercise treadmill.
What kind of benefit do you think about? Exercise treadmill is a diagnostic procedure, and the explanation is self-limiting... I personally agree with (C)
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| arlete
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Besides, one does a resting EKG before the treadmill test... It's part of the test, you'll get both at the same time!
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| Hotobhaga
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A resting EKG with for example a LBBB would make a Treadmill worthless. As you would not be able to see any changes secondary to ischemia. That is what Conrad Fisher teaches.
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| cirus
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The ans is C for sure
U don't need a resting EKG in this pt as there isn't any history of recent EKG Changes, or Drugs as Digitalis or Quinolones which would interfer with the stress EKG test..
Other Contraindic are LBBB, Young female (high +ve error) & wolf parkinson white disease..
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