What is the appropriate workup for a 61-year-old female with intermittent chest pain and transient left-sided facial numbness, given a maternal family history of Coronary Artery Disease (CAD) with percutaneous coronary interventions (PCI) using stents?

From the Guidelines

A comprehensive cardiovascular and neurological workup is essential for a 61-year-old female with intermittent chest pain, transient left-sided facial numbness, and a maternal family history of Coronary Artery Disease (CAD). The initial evaluation should include a detailed history and physical examination, followed by basic testing such as an electrocardiogram (ECG), complete blood count, comprehensive metabolic panel, lipid profile, and cardiac biomarkers such as troponin 1. Given the patient's symptoms and family history, cardiac testing should include a stress test, preferably with imaging such as a nuclear stress test or stress echocardiogram, to evaluate for coronary artery disease, as recommended by the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes 1. A transthoracic echocardiogram should be performed to assess cardiac structure and function, and to evaluate left ventricular (LV) function, which is crucial for risk stratification and revascularization decisions 1. The selection of the initial non-invasive diagnostic test should be based on the patient's pre-test probability (PTP), the test's performance in ruling-in or ruling-out obstructive CAD, patient characteristics, local expertise, and the availability of the test 1. Given the neurological symptoms, carotid ultrasound is necessary to evaluate for carotid stenosis, and brain imaging with either CT or MRI should be obtained to rule out stroke or TIA. Additional testing may include 24-48 hour Holter monitoring or longer-term event monitoring to detect arrhythmias that could cause both cardiac and neurological symptoms. If initial testing suggests significant coronary disease, a coronary angiogram may be warranted, and the patient should undergo invasive investigation for consideration of revascularization, even if they have mild or no symptoms, as recommended by the guidelines 1. Implementation of healthy lifestyle behaviors, such as supporting patients to set realistic goals, self-monitor, plan how to implement changes, and deal with difficult situations, is also essential to decrease the risk of subsequent cardiovascular events and mortality 1. The patient's treatment plan should be individualized, and anti-ischaemic treatment must be adapted to the individual patient based on comorbidities, co-administered therapies, expected tolerance and adherence, and patient preferences 1. Beta-blockers and/or calcium channel blockers (CCBs) remain the first-line drugs in patients with chronic coronary syndromes, and statins are recommended in all patients with CCS 1. Regular follow-up visits are necessary to assess potential changes in risk status, adherence to treatment targets, and the development of comorbidities, and to provide repeated therapeutic education to increase adherence to treatment 1.

From the Research

Diagnostic Approach

The appropriate workup for a 61-year-old female with intermittent chest pain and transient left-sided facial numbness, given a maternal family history of Coronary Artery Disease (CAD) with percutaneous coronary interventions (PCI) using stents, involves a combination of non-invasive cardiac imaging tests. The choice of imaging method should be tailored to each person based on the clinical judgment of the a priori risk of cardiac event, clinical history, and risk factors profile 2.

Imaging Modalities

Several imaging modalities can be used to diagnose and manage CAD, including:

• Stress echocardiography: a well-established non-invasive technique for diagnosing CAD, with a relatively high sensitivity and specificity 2, 3
• Cardiac magnetic resonance imaging (CMRI): a comprehensive cardiac evaluation that includes wall motion analysis, myocardial tissue morphology, rest and stress first pass myocardial perfusion, and systolic ventricular function 2, 4
• Coronary computed tomography angiography (cCTA): a non-invasive anatomic imaging of the coronary tree, with high clinical utility especially in select intermediate risk patient population 2, 4, 5, 6

Study Findings

Studies have compared the diagnostic accuracy of different imaging modalities, including:

• A study that found cCTA had significantly higher diagnostic accuracy compared to stress ECG in patients at moderate risk 5
• A randomized controlled trial that compared cCTA and stress echocardiography in acute chest pain patients, finding that stress echocardiography resulted in a smaller proportion of patients being hospitalized with a shorter length of stay 3
• A multicenter registry study that found a strong correlation between cCTA findings and invasive coronary angiography results, but not between stress test results and cCTA findings 6

Considerations

When choosing an imaging modality, considerations should include:

• The patient's risk factors and clinical history
• The availability and expertise of the imaging modality
• The potential risks and benefits of each modality, including radiation exposure 3, 5
• The need for a comprehensive cardiac evaluation, including assessment of cardiac structure and function 2, 4