What is the workup for prolonged angina (chest pain) that occurs with activity and at rest in a patient with a recently normal stress electrocardiogram (EKG)?

From the Guidelines

For a patient with prolonged angina occurring both with activity and at rest, despite a recent normal stress EKG, I recommend prompt evaluation by a cardiologist, ideally within 1-2 days, as this presentation suggests possible unstable angina. Initial workup should include a comprehensive cardiac panel (troponin, CK-MB, BNP), complete blood count, comprehensive metabolic panel, lipid profile, and a 12-lead ECG, as suggested by the guidelines for the diagnosis and management of patients with stable ischemic heart disease 1. Additional imaging should include a transthoracic echocardiogram and consideration of coronary CT angiography or cardiac catheterization depending on risk factors and symptom severity. While awaiting specialist evaluation, the patient should be started on aspirin 81-325mg daily, sublingual nitroglycerin 0.4mg as needed for chest pain (with instructions to call emergency services if pain persists after 3 doses 5 minutes apart), and a statin such as atorvastatin 40-80mg daily, in line with recommendations for acute coronary syndromes without persistent ST-segment elevation 1. A beta-blocker like metoprolol 25-50mg twice daily may be added if there are no contraindications. The patient should be advised to restrict physical activity until cleared by cardiology. The discrepancy between symptoms and the normal stress test could indicate microvascular angina, coronary vasospasm, or progressive coronary artery disease that wasn't detectable during the previous stress test, as discussed in the context of variant angina and its management 1. Stress tests have known false negative rates, particularly in certain populations, and angina at rest raises concern for unstable coronary syndromes requiring prompt evaluation regardless of prior test results, highlighting the importance of clinical judgment and further investigation as outlined in guidelines for acute coronary syndromes 1.

Some key points to consider in the management of such patients include:

• The importance of prompt evaluation by a cardiologist
• The need for a comprehensive initial workup including cardiac panels, imaging, and other diagnostic tests
• The role of aspirin, nitroglycerin, statins, and beta-blockers in the initial management
• The consideration of coronary CT angiography or cardiac catheterization based on risk factors and symptom severity
• The advice to restrict physical activity until cleared by cardiology
• The recognition of potential conditions such as microvascular angina, coronary vasospasm, or progressive coronary artery disease that may not have been detected by the initial stress test.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Prolonged Angina with Activity and at Rest

• Prolonged angina with activity and at rest can be a sign of unstable angina or a myocardial infarction, and requires immediate medical attention 2, 3.
• A recent normal stress EKG does not rule out the possibility of coronary artery disease or other cardiac conditions 4, 5.

Diagnostic Approach

• Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina, and can help detect nonobstructive atherosclerosis 4.
• Other diagnostic tests, such as echocardiography and cardiac catheterization, may also be used to evaluate patients with prolonged angina 2, 3.

Treatment Options

• Pharmacologic therapy for angina includes β-blockers, nitrates, calcium channel blockers, and other agents 2, 4.
• Revascularization, such as percutaneous coronary intervention, may be indicated in certain high-risk individuals, and can help improve angina symptoms and quality of life 4, 6.
• Lifestyle modifications, such as diet and exercise, and preventive medications, such as lipid-lowering and antiplatelet agents, are also important in managing angina and reducing the risk of cardiovascular events 4, 6.

Management of Refractory Angina

• Refractory angina that is not amenable to usual pharmacologic therapies or revascularization procedures may require alternative treatments, such as enhanced external counterpulsation, transmyocardial revascularization, or stem cell therapy 2.
• Shared decision-making with an informed patient is important in the management of refractory angina, and can help determine the best course of treatment 4.