What is the next step for a 69-year-old female with hypertension and hyperlipidemia, experiencing exertional dyspnea (shortness of breath) and chest tightness, with a negative nuclear perfusion myocardial imaging (MPI) stress test and an echocardiogram showing a normal ejection fraction with a hypokinetic mid-inferolateral segment?

From the Guidelines

The next step for this 69-year-old female with hypertension, hyperlipidemia, exertional shortness of breath, chest tightness, and an echocardiogram showing hypokinesis of the mid inferolateral segment despite a negative nuclear stress test would be cardiac catheterization (coronary angiography). This invasive procedure would directly visualize the coronary arteries to definitively assess for coronary artery disease, particularly in the circumflex artery territory which supplies the inferolateral wall. The discrepancy between the negative nuclear stress test and the regional wall motion abnormality on echocardiogram raises concern for possible coronary disease that may have been missed on the nuclear study, which can sometimes occur with balanced ischemia or disease in the circumflex territory 1.

While medical therapy with aspirin 81mg daily, a moderate-intensity statin (such as atorvastatin 20-40mg daily), and optimization of blood pressure control should be continued or initiated, the regional wall motion abnormality in the setting of typical anginal symptoms warrants direct coronary assessment. According to the 2012 guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons, cardiac catheterization is a reasonable next step for patients with suspected coronary artery disease and intermediate to high pretest probability of disease 1.

If catheterization is contraindicated, a coronary CT angiogram could be considered as an alternative, though it would not allow for immediate intervention if significant stenosis is identified. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also emphasizes the importance of blood pressure control in preventing cardiovascular events, including coronary artery disease 1.

Key points to consider in the management of this patient include:

• The need for direct coronary assessment with cardiac catheterization or coronary CT angiogram to evaluate for coronary artery disease
• The importance of optimizing medical therapy, including aspirin, statin, and blood pressure control
• The consideration of alternative diagnostic tests, such as coronary CT angiogram, if catheterization is contraindicated
• The emphasis on blood pressure control in preventing cardiovascular events, including coronary artery disease, as highlighted in the 2017 guideline 1.

From the Research

Next Steps for the Patient

The patient's nuclear perfusion myocardial imaging stress test was negative, but the echocardiogram showed a normal ejection fraction with a mid inferolateral segment being hypokinetic. Considering the patient's history of hypertension and hyperlipidemia, the following steps can be taken:

• Evaluate the patient's coronary artery calcium (CAC) score to determine the extent of coronary artery atherosclerotic plaque and future cardiovascular risk 2.
• Consider aspirin therapy for primary prevention of cardiovascular events if the patient has a high CAC score (>400) and is at high risk for atherosclerotic events, but weigh the benefits against the risk of bleeding complications 2, 3.
• Statin therapy may be beneficial for patients with nonobstructive coronary artery disease, as it has been associated with improved clinical outcomes 4.
• The patient's antithrombotic options should be carefully considered, taking into account the risk of bleeding complications and the potential benefits of antiplatelet and anticoagulant therapy 5.

Considerations for Aspirin Therapy

Aspirin therapy may be considered for primary prevention of cardiovascular events in patients with a high CAC score and elevated risk of atherosclerotic cardiovascular disease (ASCVD) 3. However:

• The risk of bleeding complications must be carefully weighed against the potential benefits of aspirin therapy 2, 3.
• The patient's bleeding risk should be assessed, and aspirin therapy should only be considered if the bleeding risk is low 3.
• The CAC score can be used to guide aspirin therapy in high-risk patients without an increased risk of bleeding 2, 3.