What is the appropriate outpatient workup for a patient with prolonged angina (chest pain) that occurs with activity and at rest, who had a recent normal stress electrocardiogram (EKG) and was cleared by cardiology the day before?

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, I strongly recommend prompt reevaluation with additional cardiac testing to rule out any underlying cardiac conditions that may be contributing to the symptoms. This approach is based on the most recent and highest quality study available, which emphasizes the importance of thorough evaluation in patients with symptoms suggestive of cardiac ischemia 1.

Key Considerations

• The patient's symptoms of prolonged angina at rest and with activity are concerning and warrant further investigation, as they may indicate unstable angina or another acute coronary syndrome.
• A normal stress EKG does not entirely rule out significant coronary artery disease, especially single-vessel disease or disease affecting the circumflex artery, as noted in guidelines for the diagnosis and management of patients with stable ischemic heart disease 1.
• The patient should undergo a comprehensive blood panel with cardiac enzymes (troponin, CK-MB) and a 12-lead EKG during symptoms to assess for any signs of cardiac ischemia or infarction.
• Consideration of more sensitive imaging studies such as coronary CT angiography or cardiac MRI may be necessary to fully evaluate the coronary arteries and cardiac function.

Management Approach

• While waiting for further evaluation, the patient should be started on anti-anginal therapy including sublingual nitroglycerin 0.4mg as needed for chest pain, aspirin 81mg daily, and potentially a beta-blocker such as metoprolol 25mg twice daily if not contraindicated.
• The patient should be instructed to go to the emergency department immediately if pain is severe, lasts more than 15-20 minutes, or is accompanied by shortness of breath, nausea, or diaphoresis.
• The approach to the patient should be guided by the principles outlined in the ACCF/AHA guideline for the diagnosis and management of patients with stable ischemic heart disease, which emphasizes the importance of individualized care and risk stratification 1.

Rationale

• The discrepancy between ongoing symptoms and normal testing is concerning and necessitates a thorough evaluation to determine the underlying cause of the symptoms.
• Microvascular angina or coronary vasospasm may not be detected on standard stress testing but can cause significant symptoms and require specific treatment approaches, as discussed in guidelines for the management of patients with unstable angina and non-ST-elevation myocardial infarction 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Outpatient Workup for Prolonged Angina

• The patient's recent normal stress EKG and clearance by cardiology the day before suggest that the patient's condition may not be immediately life-threatening, but still requires careful evaluation and management 2, 3.
• The patient's symptoms of prolonged angina with activity and at rest are concerning and warrant further investigation to determine the underlying cause of the symptoms 4, 5.
• The use of aspirin and nitroglycerin in the prehospital setting has been shown to be beneficial in patients with suspected acute coronary syndrome, although the certainty of evidence is very low 6.

Diagnostic Approach

• Electrocardiography should be performed immediately to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS) 3.
• High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 3.
• Stress testing may be used to further assess the likelihood of coronary heart disease in patients with intermediate probability of disease 4.

Management

• Medical therapy, including aspirin, beta-blockers, and statins, should be initiated to manage the patient's symptoms and reduce the risk of future events 2, 4.
• Cardiac catheterization and revascularization may be necessary for patients with high-risk unstable angina or NSTEMI 3, 4.
• Intense coronary risk-factor modification should be undertaken to reduce the risk of future events 4.