What is the appropriate management for a 47-year-old patient with fatigue, taking Lisinopril (lisinopril) 20mg, experiencing occasional chest pain with exertion, and a history of smoking, who is requesting a referral to cardiology?

From the Guidelines

This 47-year-old patient should be referred to cardiology promptly due to her reported exertional chest pain, which is concerning for possible cardiac ischemia, especially given her smoking history. I recommend continuing lisinopril 10mg daily rather than the 20mg she reports taking from Dr. Ike, as this may help address her fatigue which could be due to hypotension from the higher dose. Before starting tirzepatide, she should complete cardiac evaluation first since GLP-1 agonists can affect heart rate 1. An EKG is strongly advised despite her reluctance, as it provides crucial baseline information before cardiology consultation. The patient should be counseled about smoking cessation and informed about financial assistance programs that might help cover her cardiology visit. Her symptoms of exertional chest pain in a smoker warrant urgent evaluation to rule out coronary artery disease, and medication adjustments should be made after cardiac clearance.

The evaluation of suspected coronary artery disease (CAD) should include assessment of cardiovascular risk factors, including smoking, hyperlipidemia, diabetes mellitus, hypertension, family history of premature CAD, and postmenopausal status in women 1. The initial evaluation should also include a careful history to determine the characteristics of chest pain, such as quality, location, duration, and the presence of factors that trigger and relieve the pain 1.

However, the most recent and highest quality study 1 suggests that clinical risk assessment is necessary to determine the pretest probability of CAD, and that imaging is valuable in determining and documenting the presence, extent, and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions.

Given the patient's symptoms and risk factors, an urgent cardiology referral is warranted to rule out CAD, and medication adjustments should be made after cardiac clearance. The patient's fatigue may be addressed by adjusting her lisinopril dose, and her smoking history increases her risk of CAD, making urgent evaluation crucial 1.

From the Research

Patient Presentation

• The patient is a 47-year-old female presenting with fatigue and chest pain during activity.
• She has a history of smoking and has been taking lisinopril 20mg.
• The patient is requesting a referral to cardiology and a compounded medication, tirezaptide.

Relevant Studies

• A study published in 1996 2 discusses the various types of stress tests and their indications for use in cardiovascular disease diagnosis.
• The study highlights the importance of selecting the appropriate stress test based on the patient's individual characteristics and the strengths and limitations of each technique.
• Another study published in 2014 3 emphasizes the role of the electrocardiogram (ECG) in diagnosing and managing patients with acute coronary syndromes.
• The study notes that the ECG should be interpreted in conjunction with the patient's clinical assessment and that ST segment elevation and depression can indicate acute occlusion of an epicardial artery or subendocardial ischemia.

Cardiology Referral and ECG

• A study published in 2019 4 recommends against performing an ECG in asymptomatic patients, but suggests that patients with cardiac symptoms, such as chest pain, should have an ECG performed in the office.
• The patient's symptoms and history of smoking may indicate the need for an ECG and further evaluation by a cardiologist.
• A study published in 2020 5 discusses the use of stress echocardiography in assessing coronary artery disease and other cardiac conditions.
• The study highlights the importance of respecting protocols, indications, and contraindications to minimize risks of complications during the procedure.

Potential Next Steps

• Referral to cardiology for further evaluation and management of the patient's chest pain and cardiovascular risk factors.
• Consideration of an ECG to assess for any underlying cardiac abnormalities.
• Discussion of the patient's medication regimen, including the potential benefits and risks of compounded tirezaptide.