From the Guidelines
For an 83-year-old male patient with exertional chest pain and a negative cardiac CT for significant coronary disease, the next step should be a thorough evaluation of his symptoms and a comprehensive assessment to determine the cause of his chest pain, considering the information provided in the 2013 ESC guidelines on the management of stable coronary artery disease 1. Given the patient's symptoms of exertional chest pain, it is essential to consider the characteristics of discomfort related to myocardial ischemia, as outlined in the guidelines 1. The patient's moderate aortic stenosis, although not directly related to coronary disease, should also be taken into account. Some key points to consider in the evaluation of this patient include:
- The characteristics of the patient's chest pain, including location, character, duration, and relationship to exertion and other exacerbating or relieving factors, as described in the guidelines 1
- The possibility of atypical angina, which may present with chest pain resembling that of typical angina in location and character, but without precipitating factors 1
- The use of sublingual nitrates to rapidly relieve angina, as mentioned in the guidelines 1 A comprehensive echocardiogram with Doppler studies should be performed to better evaluate the severity of the aortic stenosis and its potential contribution to the patient's symptoms, as well as to assess left ventricular function and rule out other potential causes of chest pain 1. Additionally, an exercise stress echocardiogram may be valuable to assess whether the patient's chest pain correlates with hemodynamic changes during exertion. Medical management should include optimizing risk factors, such as statin therapy (e.g., atorvastatin 20-40mg daily), blood pressure control if hypertensive, and consideration of low-dose aspirin (81mg daily). For symptom management, a trial of sublingual nitroglycerin 0.4mg as needed for chest pain episodes may be appropriate. The patient should be referred to a cardiologist with expertise in valvular heart disease for ongoing monitoring, as moderate aortic stenosis can progress over time and may eventually require intervention if it becomes severe and symptomatic. Regular follow-up echocardiograms every 1-2 years are recommended to track disease progression.
From the Research
Next Steps for the Patient
Given the patient's complaints of exertional chest pain and a negative cardiac CT scan for significant coronary disease, the next steps in diagnosis and management can be considered as follows:
- The patient's moderate gnosis and otherwise normal heart function should be taken into account when deciding on further testing 2.
- Since the cardiac CT scan was negative for significant coronary disease, stress testing could be considered as the next step to evaluate for myocardial ischemia 3, 4.
- The choice of stress test should be based on the patient's ability to perform physical exercise and other individual factors, with options including treadmill stress test, stress echocardiography, or nuclear stress test 4.
- It is essential to select the most appropriate stress test for the patient, considering the available guidelines and test indications 3, 4.
- The results of the stress test will guide further management, which may include lifestyle modifications, medical therapy, or referral to a cardiologist for further evaluation and treatment 2, 3, 4.