Does a 70-year-old patient with two episodes of isolated chest pain, a normal treadmill stress test with no electrocardiogram (ECG) changes, and symptoms of lightheadedness require further testing?

From the Guidelines

Further testing is recommended for this 70-year-old patient with isolated chest pain and lightheadedness during a treadmill stress test, despite no ECG changes. The combination of symptoms during the test raises concern for potential cardiac ischemia even without electrocardiographic evidence. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, additional evaluation should include either a stress echocardiogram, nuclear perfusion imaging (such as SPECT or PET), or coronary CT angiography to better assess for coronary artery disease. These imaging modalities can detect wall motion abnormalities or perfusion defects that may not be evident on ECG alone. The patient's age (70) places them in a higher risk category, and lightheadedness during exertion could represent hemodynamic compromise due to cardiac dysfunction.

Some key points to consider in the management of this patient include:

• The patient's symptoms and age suggest a higher risk for cardiac ischemia, despite the lack of ECG changes during the stress test
• The choice of further testing should be guided by local availability and expertise, as well as the patient's exercise capacity and resting electrocardiographic abnormalities
• Coronary CT angiography may be preferable in patients under 65 years of age who are not on optimal preventive therapies, while stress testing may be favored in those over 65 years of age 1
• If these non-invasive tests show abnormalities, referral for coronary angiography may be warranted
• While waiting for further testing, the patient should be advised to take aspirin 81mg daily unless contraindicated, and to seek immediate medical attention if chest pain worsens or becomes prolonged.

From the Research

Patient Assessment

The patient in question is a 70-year-old who experienced two isolated episodes of chest pain and underwent a treadmill stress test with no EKG changes, but reported lightheadedness.

Relevant Studies

• There are no research papers provided that directly address the need for further testing in a patient with these specific symptoms and test results 2, 3.
• The studies available focus on guidelines for pneumonia evaluation and treatment 2 and preoperative assessment in older adults 3, which do not directly relate to the patient's current condition and symptoms.

Considerations for Further Testing

• Given the lack of relevant studies, it's essential to consider general medical principles and the patient's presentation.
• The patient's symptoms of chest pain and lightheadedness, despite a normal treadmill stress test, may warrant further evaluation to rule out other potential causes of these symptoms.
• However, without specific studies to guide decision-making, the need for further testing would depend on a comprehensive clinical assessment and evaluation of the patient's overall health and medical history.