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

From the Guidelines

Further cardiac testing is likely warranted for this 70-year-old patient with a history of isolated chest pain episodes, despite a normal treadmill stress test, due to the presence of lightheadedness during the test, which could represent an atypical presentation of cardiac ischemia. While the treadmill stress test showed no ECG changes or chest pain, the patient's symptoms and age suggest that a more comprehensive evaluation is necessary to rule out underlying coronary artery disease. According to the American Heart Association guidelines, exercise ECG testing should be used in most chest pain centers as the first-line noninvasive stress test for ambulatory patients when the resting ECG is normal and the patient is not on digoxin therapy 1. However, in this case, the patient's lightheadedness during the test and her age suggest that a more sensitive imaging-based stress test may be necessary to detect potential wall motion abnormalities or perfusion defects that may not be apparent on ECG alone.

Some key points to consider in this patient's evaluation include:

• The patient's age and symptoms, which suggest a potential increased risk for coronary artery disease
• The presence of lightheadedness during the treadmill stress test, which could represent hemodynamic compromise due to underlying coronary disease
• The limited sensitivity of standard treadmill testing, particularly in women and elderly patients
• The potential benefits of more definitive testing, such as a stress echocardiogram or nuclear perfusion study, in ruling out significant coronary artery disease and guiding management.

Given these considerations, proceeding with a more sensitive imaging-based stress test, such as a stress echocardiogram or nuclear perfusion study, would be a reasonable next step in this patient's evaluation. Additionally, consideration should be given to coronary CT angiography as an alternative, particularly if the patient has risk factors for coronary artery disease 1. The goal of further testing is to provide a more comprehensive evaluation of the patient's coronary artery disease risk and to guide management decisions to reduce her risk of adverse cardiac events.

From the Research

Patient Assessment

The patient, a 70-year-old with a history of two isolated chest pain episodes, underwent a treadmill stress test that showed no EKG changes and no chest pain, but she experienced lightheadedness.

Need for Further Testing

• The results of the treadmill stress test, as described, do not provide definitive evidence of coronary artery disease or other cardiac issues, but the presence of lightheadedness during the test may indicate a need for further evaluation 2.
• According to the study on treadmill test scores, patients with intermediate-risk profiles may benefit from additional noninvasive testing, such as stress myocardial perfusion imaging 2.
• The use of stress echocardiography, as outlined in the European Association of Cardiovascular Imaging consensus statement, may provide comprehensive risk stratification for patients with chronic coronary syndromes, including the assessment of regional wall motion abnormality, regional perfusion, diastolic function, and pulmonary B-lines 3.
• Given the patient's age and history of chest pain, further testing, such as stress echocardiography or stress myocardial perfusion imaging, may be warranted to provide a more accurate assessment of her cardiac risk and guide subsequent patient care 3, 2.