nupurdoc
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I would be very happy if you go for the following question!
A 62 yr old man with heavy smoking history comes to ER with H/O chest pain. He states that for the past few months he has been getting chest 'pressure' localized to the substernal region, radiating to 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 min. 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 burit is heard and his dorsalis pedis pulses are decreased. He has no H/O CAD but F/H of father having a MI at 56 yrs. 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 EKG
b. Emergent coronary angiography
c.schedule for cardiac echocardiogram
d. schedule for coronary angiography
e. schedule for exercise treadmill test
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| vasu1582
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i think it is d.
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| arlete
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A
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| cherryho
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At least do an EKG right? 
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| amnesia
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D or E....but as the q says what is the most approp diagnostic intervention >>>
i will choose D.
arlete >>the pain never occur at rest....how wod resting ECG be useful in this case??
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| nightflight1945
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I will go for E.He has a moderate risk of coronary artery disease (heavy smoking and PVD) , the best next test would be EST.IF he had high risk of CAD , I would go straight for D because in that situation the test had a very low NPV.However in moderate risk group the best next test is exercise stress test.Besides it can give us very valuable information regarding the "exercise capacity " of the patient.
A: He does not have any symptoms at rest so resting EKG will show very nonspecific changes or would be normal.It is also insufficient and I claim that the first part of exercise stress test is actually a resting EKG.
C:For sure he needs an echo , but it is not the best next step
D:eventually he may need a cardiac angiography however we first start with noninvasive tests.Only in critical situations or very high probability of IHD it is the first choice
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| arlete
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If I am not mistaken, this question (or a similar one) was posted and the answer was NOT A. The answer was another test.
But I am stubborn and I think the basic has to come first. There's no point in ordering a treadmill test if the patient has a LBBB and many times the ischemia is so important that there are changes in the EKG even at rest. The patient has clearly a stable angina, so B and D don't sound right to me. C could tempt me if it was a stress echo. E would be my next step after an EKG.
So I don't know what "they" expect us to answer, but in real life, if you send a patient to any other letter than A, people (including the insurance company) will ask you "but you didn't even order an EKG first????!!!!" 
Maybe "the most appropriate next step" is A, and "the most appropriate diagnostic intervention", meaning the one that's going to give more information is E. Don't we hate these word games? 
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| zen08
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I get what you mean Arlete....Grrrrr...I would have answered EKG as well, but you are right. It's more like best next step...It's frustrating to me, when I can't seem to grasp those nuances and I better start doing so if I want to take care of this exam
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| Eagle_303
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arlete wrote:
If I am not mistaken, this question (or a similar one) was posted and the answer was NOT A. The answer was another test. But I am stubborn and I think the basic has to come first. There's no point in ordering a treadmill test if the patient has a LBBB and many times the ischemia is so important that there are changes in the EKG even at rest. The patient has clearly a stable angina, so B and D don't sound right to me. C could tempt me if it was a stress echo. E would be my next step after an EKG.
LBBB is no Contraindication for stress test.The only change ,the patient is put to exercise ,interpretation is done with
- Either perfusion scintigraphy
- Or Echocardiography
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| kisna
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dont we do treadmill with thallium in LBBB bcoz exercise treadmill is nondiagnostic for LBBB
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| Eagle_303
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kisna wrote:dont we do treadmill with thallium in LBBB bcoz exercise treadmill is nondiagnostic for LBBB
Treadmill is meant for "exercise"
Treadmil + thallium means Exercise + Thallium scan
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| nupurdoc
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thanks guys for responding. In this question, thy asked for 'MOST APPROPRIATE' interverntion, not 'NEXT STEP', so I went for D (schedule for angiograhy, as pts of stable angina it is the most appropirate', In my sense excercise Stress test would be the NEXT STEP but not MOST APPROPRIATE!
If the patient would present with chest pain now, then the resting EKG is next step.
But the real answer is E, EST.
It made me so unhappy! Wonderring what they ment by most appropriate step!!!
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| arlete
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"Exercise treadmill test" is the one done with the EKG monitoring. With echo, it's "stress echo", with thalium, it's "stress cintilography".
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| arlete
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nupurdoc:
We don't always order angiography in stable angina. If the exercise treadmill test shows good functional capacity (especially more than 5 METS reached) and the patient gets better with the best medical treatment, we don't need to. If, eventually, the patient becomes unstable, he will end up having it.
So I agree with E now. 
A is for most appropriate next step.
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| Eagle_303
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arlete wrote:
"Exercise treadmill test" is the one done with the EKG monitoring. With echo, it's "stress echo", with thalium, it's "stress cintilography".
Stress is produced by two methods
- Either by standard execise test by using Treadmill ,bicycle or arm ergometery
- Or by drugs using by using IV dobutamine ,Dipyridamol or Adenosine
It depends upon t he condition of the patient if he is able to undergo standard exercise test or not.
Interpretation is done by three methods "
- EKG
- Perfusion scintigraphy
- Echocardiography
For Reference :Table 124-1 "Harrison's manual of medecine."
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| arlete
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Eagle, I think we are playing with words here. If one of the options were "stress test", then it could mean any of the three methods of interpretation (EKG, echo, cintilography) and any of the stressors (physical activity, drugs). But because it is "exercise treadmill test", it's the one with EKG. I am 100% sure of that. That's the term used for this particular test.
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| Eagle_303
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arlete wrote:
Eagle, I think we are playing with words here. If one of the options were "stress test", then it could mean any of the three methods of interpretation (EKG, echo, cintilography) and any of the stressors (physical activity, drugs). But because it is "exercise treadmill test", it's the one with EKG. I am 100% sure of that. That's the term used for this particular test.
No doubt option is exercise treadmill test.
We will produce stress with eXcercise ,But we can intereprest with
EKG ,if this not possible as you pointed sometime there is LBBB ,then it will be interpretted with
Either Perfusion scintigraphy or Echocardiography .
Harrison has given all these three option with Excercise stress test I have given you the reference.
We cannot say that in the presence of LBBB exercise stress test cannot be interepretted .It can be with the help of perfusion scintigraphy or Echocardiography. (of course EKG cannot) .
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| arlete
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I rest my case.
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| ngaybinhyen
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I feel tired with this word game sometimes but we know that we have to deal with anyway.
Arlete, what does it mean when they start the Q with this phrase "In addition to ascertaining his other coronary risk factors"? Does this make a difference from one w/o this phrase. Why don't they just simply ask "what is the most appropriate next step in ascertaining the Dx?"?
-t.
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| arlete
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I think it doesn't make any difference. They want to be fancier, as to say "obviously you will get a detailed history about dyslipidemia, DM, HTN, exercise habits, etc, and order the appropriate labs".
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