Question of the Week # 100

Q100) A 52 year-old man 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 or shortness of breath now. He also reports no change in quality or intensity of his chest pain. His past medical history is significant for Hypertension and Smoking . His medications include lisinopril and hydrochlorthiazide. Physical examination is benign. The next best step in establishing the diagnosis in this patient is :

A) Electrocardiogram
B) 2 D -Echocadiogram
C) Exercise – EKG Stress Test
D) Persantin Stress Test
E) Cardiac Catheterization


19 Responses

  1. A.. EKG should be done first

    • Neha how will you diagnose with EKG alone? This patient has no symptoms of ischemia at rest. EKG will be normal. You will miss the diagnosis of Stable angina. In Stable angina, the best initial step to establish diagnosis is EKG plus Exercise Stress test because symptoms occur only with exercise.
      In UNSTABLE angina however, symptoms occur at rest and EKG (alone) can be used for diagnosis. If this patient is unstable, he has chest pain at rest then the best initial step would be Option A.
      The answer is Option C,
      STABLE – EKG – Exercise Stress test – physically healthy
      – Persantin Thallium – disabled individual
      – Stress Echo – EKG is unreliable
      – Holter Monitor – Intermittent arrhythmia
      – Outpatient Telemetry – Significant arrhythmia
      – Telemetry monitor – Intermittent arrhythmia
      – Serial cardiac enzymes
      This patient has stable angina.

      • answer is C, this patient has not symptoms of chest pain at rest at this time, so he cannot have ACS *acute coronary syndrome”, and there is no mentioning of worsening of his symptoms either R/O unstable angina. he is suitable for exercise stress test to assess whether myocardia ischaemia will be induced with exercise causing S-T segment depression (< 2mm) on EKG, and use Bruce protocol, the other test persantin is not indicated as he can walk, ie no symptoms of intermittent claudication.

      • I agree with Neha. The patient is in office . EKG first and cardiac enzymes. what if patient is having an MI at the time . You risking killing him to have your diagnosis? Good medicine Neha

  2. a then c

  3. the answer key says c is the correct…..but it is wrong.
    when there are baseline abnormalities on ekg you cannot do stress test the first step though it may be normal the answer should be electrocardiogram

    • Thank you the query , abnormalities on EKG alone are not a contraindication for exercise stress test because EKG component is almost always accompanied by nuclear component in exercise stress test.

      • the history itself is suggestive of angina…why put patient on exercise stress test may precipate MI…

  4. Chest pain, Cardiac in origin— EKG always! always! always!

    You won’t do your woman with clothes on, you need to follow a stepwise protocol! 😉

    • I think your blood’s Corad Fischer ‘s level is really low buddy!
      the next step in management of suspicious ischemic event (especially if patient is able to exercise and have legs and arms !is stress test no matter what) , read the q one more time , he is not having the chest pain NOW , otherwise yes , even nurse practitioner would order an EKG before even you tell them to do so!!!

    • OMG! Thy she heard O Caesar ‘Orgy! Orgy! dance for me Calpurnia the rivers are running dry ” I wish I did not read the last part of your comment. Now I have to go to the Tibetan mountains to spend my vacations. Guru jee! Dhanye! Dhanye! Dhanye!
      ‘Chest pain, cardiac in origin – EKG always! always! always!’ is correct but there is a context issue. EKG has to be done when the chances are best to catch an ST segment depression. In this patient, that chance occurs only when he exercises. His EKG has to be paired with Exercise Stress Test. If he had chest pain at rest, EKG will be productive all the time, meaning in UNSTABLE angina we can start with EKG alone as our best initial diagnostic step. But this patient has stable angina. Our best initial diagnostic test would be EKG plus Exercise Stress Test.
      Please read my comment below for more detail.

      Thank you for sharing.

  5. Next step should be A. Check out AHA guidelines since depending on whether the baseline ECG is interpretable or not, one decides whether do do simple exercise test w ECG or exercise test with imaging such as ECHO.

  6. For CAD always do EKG as the first step. Even have normal lungs, no leg pathology, on caffiene…. EKG is the best initial step.

    • Aatish, How can EKG be the best initial step when there is no sign of ischemia unless the patient exercises? No ischemia, no EKG change. THis patient does not have diabetes. Your EKG will come back normal every single time, unless his condition deteriorates to chest pain at rest. EKG is the best initial diagnostic step for UNSTABLE angina. When there is no chest pain, like in this patient who has STABLE angina, EKG has no diagnostic value independently. It is combined with Exercise stress test or Vasodilator stress to establish the diagnosis of STABLE angina. Please read my full comment below for more details.
      Thank you for sharing.

  7. Complaint- Exertional chest pain for 4 week
    Others – 52 year old male hypertensive smoker
    Question: what is the best initial step to establish the diagnosis?
    Diagnosis (clinical) – Stable Angina,
    Differentials – Coronary Artery Disease, Aortic stenosis, Variant Angina, Hypertensive cardiomyopathy,
    A. EKG?, Not a functional test, it can not establish the diagnosis alone in stable angina. However it is the best initial diagnostic step for UNSTABLE Angina.
    B. ECHO?,Not a functional test, Can identify MI or heart failure but not ischemia without an accompanying stress test. Then with Stress testing, it is called Stress Echo not 2D Echo.
    C. EKG – Exercise stress test, It is a combination of EKG and Exercise stress test and it will shown diagnostic signs of coronary ischemia. Done only for Stable angina, under control conditions, in the presence of a cardiologist and it’s stopped if there is any of the following findings: 1. early limitation to exercise, 2. Low work load tolerance, 3. ST segment depression for more than 3 min after exercise 4. or Chest pain anytime. Note that unstable angina is contraindication to stress testing but diagnostically resourceful in Stable Angina. The simple formula is, if the patient in your office has chest pain, you can not run a stress test. If there is no chest pain now, and pain occurs predictably on exertion, you can run a stress test. A stress test will help you to decide whether to proceed with PTCA or medical therapy. A strongly positive EKG – Exercise stress test requires a PTCA.
    Are there other subsequent diagnostic tests after this (option C)? Yes, Percutaneous Coronary Artery Angioplasty (PTCA). PTCA is an invasive procedure that will determine the location of coronary ischemia and fix it too. Studies have shown improvement in quality of life if PTCA is used in STABLE ANGINA compared to medical therapy. But PTCA is invasive, it can not used as initial diagnostic test in stable angina.
    D. Persantin Stress test?, a coronary vasodilator, Persantin mimics the physiologic change of exercise. Ischemic vessels do not expand efficiently resulting in diversion of blood to normal cardiac tissues. This is called coronary steel syndrome and it can be picked up using a radionuclide scan or echo. This test is used in physically disabled patients who can not attain maximum heart rate due to PHYSICAL disability not due to CAD. It is not as efficient as exercise stress test.
    E. Cardiac Catheterization? Not the best initial diagnostic test for stable angina. It is more invasive. The use of an IV radioactive contrast dye will show poor perfusion in ischemic coronary arteries. However, it is actually the best tool in UNSTABLE angina for diagnosis and urgent revascularization.

    My answer is Option C, EKG – Exercise Stress test.
    Cardiology, diagnosis of CAD

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