What is the next step in workup for a 70-year-old female with ongoing chest pain and exhaustion, despite a negative cardiac catheterization (cardiac cat) for coronary artery disease (CAD)?

Diagnostic Workup for Ongoing Chest Pain After Negative Cardiac Catheterization

For a 70-year-old female with ongoing chest pain despite a negative cardiac catheterization, stress imaging with echocardiography, nuclear perfusion imaging (SPECT/PET), or cardiac MRI is recommended as the next step in evaluation to assess for myocardial ischemia and guide therapeutic decision-making. 1

Understanding the Clinical Scenario

This patient presents with several concerning features:

• Advanced age (70 years) - higher pretest probability of coronary artery disease
• Female gender - may present with atypical symptoms
• Ongoing chest pain despite negative cardiac catheterization
• Reported exhaustion - potential anginal equivalent

Recommended Diagnostic Algorithm

Step 1: Evaluate for Non-Obstructive Coronary Artery Disease (NOCAD)

• Patients with chest pain and non-obstructive CAD generally fall into three categories 1:
  1. Flow-limiting coronary lesions not apparent on angiography
  2. Epicardial or microvascular reactivity abnormalities
  3. Non-cardiac causes of chest pain

Step 2: Functional Assessment

• Stress imaging is recommended to evaluate for ischemia despite negative catheterization 1
  • Options include:
    • Stress echocardiography
    • Nuclear perfusion imaging (SPECT or PET)
    • Stress cardiac MRI
  • PET is preferred over SPECT when available due to improved diagnostic accuracy and fewer nondiagnostic results 1

Step 3: Consider Microvascular or Endothelial Dysfunction

• Persistent chest pain with normal coronaries may indicate microvascular dysfunction
• Assessment of coronary flow reserve with PET or stress CMR can be useful 1
• Addition of myocardial blood flow reserve to stress PET or CMR is useful to improve diagnostic accuracy 1

Step 4: Assess for Non-Cardiac Causes

• If cardiac workup remains negative, consider:
  • Gastrointestinal causes (GERD, esophageal spasm)
  • Musculoskeletal pain
  • Pulmonary conditions
  • Anxiety-related symptoms

Special Considerations

Coronary CT Angiography (CCTA)

• CCTA is reasonable after inconclusive stress imaging 1
• Can be useful to evaluate bypass graft or stent patency if patient has previous revascularization 1
• Consider adding CAC (coronary artery calcium) testing if undergoing stress testing 1

Invasive Physiologic Assessment

• If symptoms persist despite negative catheterization, consider:
  • Fractional flow reserve (FFR) assessment for intermediate lesions 1
  • Assessment of endothelial function in patients with NOCAD 1
  • Evaluation of coronary vasospasm with provocative testing

Common Pitfalls to Avoid

1. Assuming negative catheterization rules out cardiac causes: Up to 20% of patients referred for cardiac catheterization have no significant angiographic CAD but may still have cardiac causes of chest pain 1

2. Overlooking microvascular dysfunction: Women particularly may have microvascular disease not visible on conventional angiography

3. Failing to consider non-coronary cardiac causes: Valvular heart disease, hypertrophic cardiomyopathy, and pericardial disease can cause chest pain

4. Premature closure on diagnosis: Persistent symptoms warrant thorough evaluation even after negative initial testing

Follow-up Recommendations

• If stress imaging is negative but symptoms persist, consider:

  • Optimizing preventive therapies 1
  • Evaluating for non-cardiac causes
  • Consider CCTA if high clinical suspicion persists 1

• If stress imaging shows ischemia:

  • Consider repeat cardiac catheterization with FFR/iFR assessment 1
  • Optimize guideline-directed medical therapy 1

By following this systematic approach, the underlying cause of this patient's persistent chest pain can be identified and appropriately managed to reduce morbidity and mortality and improve quality of life.