What is the appropriate workup and management plan for a 60-year-old male with a past medical history (pmhx) of hypertension (HTN) presenting with chest pain for 2 weeks and exertional dyspnea?

Workup and Management Plan for a 60-Year-Old Male with Chest Pain and Exertional Dyspnea

The appropriate workup for this 60-year-old male with hypertension presenting with 2 weeks of chest pain and exertional dyspnea should include immediate ECG, cardiac biomarkers, and risk stratification followed by appropriate cardiac imaging to evaluate for coronary artery disease.

Initial Assessment

History

• Characterize chest pain:
  • Location, quality (pressure, tightness, heaviness, burning)
  • Duration (typical angina lasts <10 minutes)
  • Radiation pattern (to arms, jaw, back)
  • Precipitating factors (exertion, emotional stress)
  • Relieving factors (rest, nitroglycerin)
  • Associated symptoms (diaphoresis, nausea, dizziness)
• Assess for angina equivalents (unexplained dyspnea is most common) 1
• Risk factors: hypertension (already known), diabetes, smoking, family history
• Previous cardiovascular testing or events

Physical Examination

• Vital signs with emphasis on blood pressure control
• Cardiovascular exam: heart sounds, murmurs, signs of heart failure
• Pulmonary exam: crackles, wheezes
• Peripheral vascular exam: pulses, edema
• Signs of other potential causes (musculoskeletal tenderness)

Immediate Diagnostic Testing

1. 12-lead ECG (within 10 minutes of presentation) 1

   • Look for ST-segment depression, transient ST-elevation, or T-wave inversion
   • Rule out STEMI requiring immediate reperfusion

2. Cardiac biomarkers

   • High-sensitivity troponin (initial and serial at 1-3 hours) 1
   • Risk stratification based on troponin levels (low, intermediate, high) 2

3. Chest X-ray

   • To evaluate for pulmonary causes, aortic pathology, or heart failure 1

Risk Stratification

• Apply validated risk scores:
  • HEART score (History, ECG, Age, Risk factors, Troponin)
  • TIMI risk score 3
  • Both scores have high diagnostic accuracy for ACS

Further Diagnostic Testing Based on Initial Results

If Initial Tests Suggest Intermediate to High Risk:

1. Cardiac imaging:

   • Stress testing with imaging (preferred over exercise ECG alone) 1

     • Stress echocardiography
     • Nuclear myocardial perfusion imaging

   • Coronary CT angiography (CCTA) 1

     • Particularly useful for intermediate-risk patients
     • Can detect coronary stenosis and vulnerable plaque features
     • More rapid and cost-effective than stress imaging in low-risk patients 1

2. Echocardiography:

   • Assess for regional wall motion abnormalities
   • Evaluate left ventricular function
   • Rule out other causes (pericardial effusion, valvular disease)

If High Clinical Suspicion Despite Negative Initial Tests:

• Invasive coronary angiography with fractional flow reserve (FFR) measurement 1
  • Indicated for patients with:
    • Severe symptoms refractory to medical therapy
    • High-risk clinical profile
    • Significant abnormalities on non-invasive testing

Management Plan

Immediate Management

1. Antiplatelet therapy:

   • Aspirin 325 mg chewed 1
   • Consider P2Y12 inhibitor (clopidogrel, ticagrelor) if ACS likely 1

2. Antianginal therapy:

   • Sublingual nitroglycerin for acute symptoms
   • Beta-blockers (especially with tachycardia or hypertension) 1
   • Consider calcium channel blockers if beta-blockers contraindicated 1

3. Anticoagulation if ACS suspected:

   • Enoxaparin or unfractionated heparin 1

Blood Pressure Management

• Target BP <130/80 mmHg 1, 4
• For older patients (≥65 years), target systolic BP 130-140 mmHg 1
• First-line agents:
  • ACE inhibitors/ARBs (especially with diabetes or LV dysfunction)
  • Beta-blockers (particularly with angina)
  • Calcium channel blockers
  • Thiazide diuretics 4

Long-term Management (Based on Diagnostic Results)

If Coronary Artery Disease Confirmed:

1. Optimal medical therapy:

   • Antiplatelet therapy (aspirin ± P2Y12 inhibitor)
   • High-intensity statin
   • Beta-blockers
   • ACE inhibitor/ARB (especially with hypertension, diabetes, or LV dysfunction)
   • Nitrates for symptom relief

2. Revascularization if indicated:

   • PCI or CABG based on coronary anatomy and patient factors

3. Risk factor modification:

   • Blood pressure control
   • Lipid management (target LDL-C)
   • Diabetes management (if applicable)
   • Smoking cessation
   • Weight management
   • Physical activity

4. Cardiac rehabilitation 1

Common Pitfalls to Avoid

1. Delayed ECG interpretation - ECG should be obtained and interpreted within 10 minutes 1

2. Relying on a single troponin measurement - Serial measurements are essential, especially with high-sensitivity assays 1

3. Missing non-coronary causes of chest pain - Consider aortic dissection, pulmonary embolism, pneumothorax 1

4. Overlooking atypical presentations - Older patients and those with diabetes may present with atypical symptoms 1

5. Inadequate risk stratification - Use validated risk scores to guide management decisions 3

6. Failure to recognize hypertensive emergency - Severe hypertension with end-organ damage requires immediate treatment 5