What is the workup for a patient with prolonged angina (chest pain) that occurs with activity and at rest, despite a recent normal stress electrocardiogram (EKG) and cardiology clearance the previous day?

From the Guidelines

For a patient with prolonged angina occurring both with activity and at rest, despite a recent normal stress EKG and cardiology clearance, further evaluation is still warranted. I recommend immediate reassessment with a comprehensive cardiac workup including a 12-lead EKG, cardiac biomarkers (troponin), and consideration of coronary CT angiography or cardiac catheterization 1. While awaiting these results, initiate or optimize anti-anginal therapy with sublingual nitroglycerin 0.4mg as needed for acute symptoms, along with a daily regimen of aspirin 81mg, a moderate-intensity statin such as atorvastatin 20mg daily, and potentially a beta-blocker like metoprolol 25mg twice daily if not contraindicated. The discrepancy between ongoing symptoms and recent normal findings raises concern for unstable angina, variant angina (Prinzmetal's), or microvascular angina which may not be detected on standard stress testing 1. Stress tests have known false negative rates, particularly in women and certain populations. Persistent angina at rest is particularly concerning as it may indicate unstable coronary syndromes requiring urgent intervention, even with prior normal testing. Close follow-up within 24-48 hours is essential regardless of initial test results. Key considerations in the management of such patients include:

• Clinical risk stratification to guide the intensity of care and the need for invasive versus conservative management strategies 1
• The use of cardiac biomarkers, such as troponin, to assess for myocardial injury and guide therapy 1
• The importance of a comprehensive cardiac workup to rule out other causes of chest pain and to assess for signs of cardiac ischemia or infarction 1
• The role of anti-anginal therapy, including nitrates, beta-blockers, and statins, in reducing symptoms and improving outcomes 1

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 significant cause of morbidity, as stated in the study 2.
• Despite a recent normal stress EKG and clearance by cardiology, it is essential to consider the patient's symptoms and medical history.

Diagnostic Approach

• Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina, as mentioned in the study 3.
• This test allows for the detection of nonobstructive atherosclerosis, which can improve risk assessment and guide preventive therapies.

Management of Stable Angina

• The management of stable angina should focus on optimizing lifestyle factors and preventive medications, such as lipid-lowering and antiplatelet agents, to reduce the risk of cardiovascular events and death 3.
• Antianginal medications, including β-blockers, nitrates, or calcium channel blockers, can be initiated to improve angina symptoms.
• Revascularization with percutaneous coronary intervention may be considered for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy 3.

Patient Support and Education

• Patients with stable angina may suffer from emotional disorders, such as stress, anxiety, and depression, which can further impair their quality of life 4.
• It is essential to provide constant emotional support and offer a space for dialogue with healthcare professionals to address patients' concerns and provide comprehensive information 4.