What are the next steps for a 60-year-old male with unstable angina and a non-diagnostic exercise stress test?

From the Guidelines

For a 60-year-old male with unstable angina despite an unremarkable exercise stress test, the next steps should include diagnostic angiography to directly visualize the coronary arteries, as the patient is classified as not at low risk after stress testing. This approach is based on the guidelines from the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, which recommend diagnostic angiography for patients with unstable angina/non-ST-elevation myocardial infarction who are not at low risk after stress testing 1.

Key Considerations

• The patient's symptoms and high-risk presentation warrant further investigation, despite the unremarkable exercise stress test, to rule out possible false-negative stress testing or coronary vasospasm.
• Diagnostic angiography will provide valuable information on the presence and extent of coronary artery disease, guiding further management.
• While awaiting angiography, the patient should be started on dual antiplatelet therapy with aspirin and either clopidogrel or ticagrelor, as well as high-intensity statin therapy, to reduce the risk of further ischemic events 1.
• A beta-blocker and sublingual nitroglycerin should also be considered for symptom control and to reduce myocardial oxygen demand.

Management Strategy

• Diagnostic angiography should be performed to assess the coronary arteries and guide further management, as recommended by the guidelines 1.
• Dual antiplatelet therapy with aspirin 81mg daily and either clopidogrel 75mg daily or ticagrelor 90mg twice daily should be initiated.
• High-intensity statin therapy, such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily, should be started regardless of baseline lipid levels.
• A beta-blocker, such as metoprolol 25-50mg twice daily, and sublingual nitroglycerin 0.4mg should be added for symptom control and to reduce myocardial oxygen demand.
• The patient should be hospitalized for observation and expedited cardiac catheterization given the high-risk presentation of unstable angina.

From the Research

Next Steps for 60-year-old Male with Unstable Angina

Unremarkable Exercise Stress Test

• The patient's unremarkable exercise stress test results do not necessarily rule out the presence of coronary artery disease, as unstable angina can be caused by a variety of factors, including plaque rupture or thrombosis 2.
• The study by 2 suggests that patients who present with unstable coronary disease, such as acute myocardial infarction, may systematically differ from patients who present with relatively stable coronary disease, such as exertional angina.

Medication Therapy

• The use of statins and beta-blockers has been associated with a lower likelihood of presenting with an acute myocardial infarction than with stable angina 2.
• Patients presenting with myocardial infarction were less likely to have received statins and beta-blockers than patients presenting with exertional angina 2.

Considerations

• The patient's age, medical history, and other risk factors should be taken into account when determining the next steps in management.
• Further testing, such as coronary angiography, may be necessary to determine the extent of coronary artery disease and guide treatment decisions.
• The patient's medication regimen should be reviewed and optimized, with consideration given to the addition of statins and beta-blockers if not already prescribed 2.