What is the next step in the workup for a 53-year-old male with intermittent, non-radiating chest pain that worsens with exercise, a history of GERD on omeprazole, normal cardiac exam, hypercholesterolemia, and an EKG showing LBBB?

Stress Imaging Test is the Next Step in Workup for This Patient with LBBB and Exercise-Induced Chest Pain

For a 53-year-old male with chest pain that worsens with exercise, LBBB on ECG, and history of GERD on omeprazole, the next appropriate step is a stress imaging test (pharmacologic stress echocardiography, nuclear imaging, or cardiac MRI) rather than standard exercise ECG testing.

Rationale for Stress Imaging Test

Patient Risk Assessment

• 53-year-old male with intermediate pre-test probability of CAD
• ASCVD risk score of 5.6% (intermediate risk)
• Concerning symptoms: chest pain worsening with exercise for 2 months
• Normal cardiac exam but significant ECG abnormality (LBBB)
• Cholesterol profile: Total cholesterol 210, HDL 55

Why Standard Exercise ECG Is Contraindicated

• The presence of LBBB on ECG is a critical finding that makes standard exercise ECG testing inappropriate
• Per European Society of Cardiology guidelines, "Exercise ECG testing is not of diagnostic value in the presence of LBBB, paced rhythm and Wolff-Parkinson-White syndrome, in which cases the ECG changes are not interpretable" 1
• American College of Cardiology guidelines similarly note LBBB as a contraindication for exercise ECG testing 1

Appropriate Testing Options

Pharmacologic Stress Imaging

• Recommended by ESC guidelines: "An imaging stress test is recommended as the initial test for diagnosing SCAD if the PTP is between 66–85% or if LVEF is <50% in patients without typical angina" (Class I, Level B) 1
• Also indicated when "resting ECG abnormalities which prevent accurate interpretation of ECG changes during stress" are present (Class I, Level B) 1

Specific Imaging Modalities to Consider:

1. Stress Echocardiography:

   • Provides assessment of wall motion abnormalities
   • Can evaluate baseline ventricular function
   • Recommended for intermediate-risk patients 1

2. Nuclear Perfusion Imaging (SPECT or PET):

   • Provides assessment of myocardial perfusion
   • High sensitivity for detecting CAD

3. Stress Cardiac MRI:

   • Excellent for assessing both perfusion and wall motion
   • Can identify myocardial scarring

Management Algorithm

1. Initial Assessment:

   • Confirm symptoms are consistent with possible cardiac etiology (exercise-induced, non-radiating chest pain)
   • Rule out acute coronary syndrome with cardiac biomarkers if symptoms are recent/ongoing
   • Evaluate GERD control on current omeprazole therapy (may need optimization if inadequate)

2. Testing Pathway:

   • Proceed directly to pharmacologic stress imaging test due to LBBB
   • Choose modality based on local expertise and availability
   • Consider transthoracic echocardiography first to establish baseline ventricular function

3. Based on Results:

   • Negative test: Consider non-cardiac causes or GERD optimization
   • Positive test: Proceed to coronary angiography
   • Equivocal results: Consider coronary CT angiography or direct invasive angiography

Important Considerations

• GERD vs. Cardiac Pain: While the patient has GERD, the exercise-induced nature of the pain strongly suggests a cardiac etiology that requires evaluation 2, 3

• Medication Considerations: Omeprazole is generally effective for GERD but may not completely control symptoms in all patients 4, 5; however, the exercise-induced pattern suggests cardiac rather than GERD etiology

• Potential Pitfall: Attributing chest pain solely to GERD without cardiac evaluation, especially with exercise-induced symptoms and LBBB

• Caution: Long-term omeprazole use may have some biochemical effects 6, but addressing the potentially life-threatening cardiac cause takes priority

Follow-up Recommendations

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

  1. Optimizing GERD therapy
  2. Coronary CT angiography to evaluate coronary anatomy
  3. Evaluation for other non-cardiac causes of chest pain

• If stress imaging is positive, proceed to coronary angiography for definitive diagnosis and potential intervention