A 63-year-old man comes to the emergency department due to chest pain that occurred 2 hours ago when he was shopping for groceries. The patient experienced left-sided chest discomfort that was dull in nature and lasted 15 minutes. He had no shortness of breath, diaphoresis, palpitations, or lightheadedness. He has had no previous chest pain other than a similar episode 2 days ago when he was at home washing dishes. The pain at that time lasted 10 minutes and resolved spontaneously. The patient has hypertension and takes valsartan and amlodipine. Medical history also includes gout, peptic ulcer disease, kidney stones, and severe osteoarthritis of the right knee. He was offered knee replacement 2 years ago but refused. The patient walks with a cane. He has no known drug allergies. He is a lifetime nonsmoker. His father had a myocardial infarction at age 53 and his younger brother is healthy. The patient appears comfortable and has no complaints. Blood pressure is 147/90 mm Hg, and pulse is 82/min and regular. He has no heart murmurs or additional sounds. There are no carotid bruits. The lungs are clear on auscultation. There is no peripheral edema. ECG shows normal sinus rhythm without repolarization changes. Complete blood count and basic metabolic panel are unremarkable. Chest x-ray is normal. Two sets of cardiac troponin I drawn 4 hours apart are undetectable. Which of the following is the best next step in management of this patient?
A)Adenosine myocardial perfusion imaging
B)Coronary angiography
C)Discharge with 24-hour Holter monitoring
D)Discharge with pantoprazole prescription
E)Exercise ECG

Question

A 63-year-old man comes to the emergency department due to chest pain that occurred 2 hours ago when he was shopping for groceries.  The patient experienced left-sided chest discomfort that was dull in nature and lasted 15 minutes.  He had no shortness of breath, diaphoresis, palpitations, or lightheadedness.  He has had no previous chest pain other than a similar episode 2 days ago when he was at home washing dishes.  The pain at that time lasted 10 minutes and resolved spontaneously.  The patient has hypertension and takes valsartan and amlodipine.  Medical history also includes gout, peptic ulcer disease, kidney stones, and severe osteoarthritis of the right knee.  He was offered knee replacement 2 years ago but refused.  The patient walks with a cane.  He has no known drug allergies.  He is a lifetime nonsmoker.  His father had a myocardial infarction at age 53 and his younger brother is healthy.  The patient appears comfortable and has no complaints.  Blood pressure is 147/90 mm Hg, and pulse is 82/min and regular.  He has no heart murmurs or additional sounds.  There are no carotid bruits.  The lungs are clear on auscultation.  There is no peripheral edema.  ECG shows normal sinus rhythm without repolarization changes.  Complete blood count and basic metabolic panel are unremarkable.  Chest x-ray is normal.  Two sets of cardiac troponin I drawn 4 hours apart are undetectable.  Which of the following is the best next step in management of this patient?
A)Adenosine myocardial perfusion imaging
B)Coronary angiography
C)Discharge with 24-hour Holter monitoring
D)Discharge with pantoprazole prescription
E)Exercise ECG

Quizplus · Accepted Answer

Explanation: 11ec2b69_c115_6d32_8f63_4b8a145726a3_MD0005_00 When a patient has acute chest pain that may be due to myocardial ischemia, the first priority is to rule out acute coronary syndrome (ACS). In this patient: A normal ECG rules out ST-elevation myocardial infarction (STEMI). Negative serial troponin levels rule out non-STEMI. The absence of a history of exertional chest pain that gradually worsens over a period of several months (crescendo angina), associated symptoms (eg, dyspnea, diaphoresis), and ECG abnormalities suggestive of ischemia (eg, T-wave inversions) make unstable angina unlikely. Once ACS has been sufficiently ruled out, the diagnostic goal shifts to differentiating cardiac chest pain (stable angina) from noncardiac chest pain. This patient's chest pain is mostly nonanginal in nature (not substernal pressure and not reliably reproduced with exertion or relieved by rest); however, his age, male sex, family history of coronary artery disease (CAD), and personal history of hypertension raise reasonable suspicion for stable angina. In such patients with suspected clinically significant CAD, stress testing is the best initial diagnostic intervention. Exercise ECG is preferred when possible (Choice E); however, patients with conditions that prevent adequate walking exertion (eg, severe osteoarthritis) require pharmacologic stress testing (eg, adenosine myocardial perfusion imaging, dobutamine echocardiography). chest pain (Choice B) Coronary angiography is rarely performed as the initial diagnostic evaluation for stable CAD. If stress testing is positive with evidence of high risk features (eg, severe ischemia), subsequent coronary angiography is indicated to assess for amenability to revascularization. (Choice C) Ambulatory 24-hour Holter monitoring is often helpful in the diagnosis of suspected paroxysmal cardiac arrhythmia, but it has minimal diagnostic use for CAD. (Choice D) Discharge with a prescription for pantoprazole is appropriate for a patient with a low suspicion of CAD and chest pain accompanied by other symptoms suggestive of gastroesophageal reflux disease (eg, reflux, cough). However, it is not appropriate in this patient with reasonable suspicion of clinically significant CAD. Educational objective: Stress testing is the most appropriate initial diagnostic test in patients with reasonable suspicion of clinically significant, stable coronary artery disease. Exercise ECG is preferred when possible, but patients who are unable to perform exertional walking are best evaluated with pharmacologic stress testing. References: 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease. (http://www.ncbi.nlm.nih.gov/pubmed/23182125) Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/20660809)

A 63-Year-Old Man Comes to the Emergency Department Due to Chest