What is the best course of action for a middle-aged man with a history of anxiety, currently taking anxiety medication, who experienced a 3-minute episode of chest pain while walking 2 weeks ago, now presenting with hypertension (high blood pressure), and oxygen saturation (O2) of 98% on room air?

Immediate Cardiac Risk Stratification Required

This patient requires urgent cardiac evaluation despite his anxiety history—the combination of exertional chest pressure 2 weeks ago with ongoing dyspnea and current hypertension (170/100 mmHg) represents potential delayed presentation of acute coronary syndrome or unstable angina that demands immediate workup. 1

Why This Cannot Be Dismissed as Anxiety

While anxiety disorders are present in 30-50% of patients with chest pain and normal coronary arteries, you cannot make that diagnosis until cardiac disease is excluded. 2, 3 The key distinguishing features demanding cardiac evaluation in this patient are:

• Classic anginal characteristics: Exertional chest pressure ("someone pushing on chest") lasting 3 minutes that resolved with rest is textbook stable angina 1
• Persistent symptoms: Two weeks of dyspnea following the chest pain episode suggests possible myocardial injury or heart failure 1
• Uncontrolled hypertension: BP 170/100 mmHg is a major cardiac risk factor and potential trigger for acute coronary events 1, 4
• High-risk presentation pattern: The combination of exertional symptoms with subsequent persistent dyspnea is concerning for evolving cardiac pathology 1

Immediate Actions Required

Obtain ECG and Cardiac Biomarkers Now

• 12-lead ECG to assess for ST-segment changes, T-wave inversions, or Q waves indicating prior or ongoing ischemia 1
• Troponin levels (preferably high-sensitivity troponin) to detect myocardial injury—even 2 weeks post-event, troponins may reveal recent cardiac damage 1
• Complete metabolic panel including creatinine, electrolytes, and glucose (he appears to have diabetes risk factors) 4
• Chest X-ray to evaluate for pulmonary edema or other causes of dyspnea 1

Risk Stratification Based on Initial Testing

If ECG shows ischemic changes OR troponins are elevated:

• Immediate cardiology consultation and hospital admission 1
• Aspirin 162-325 mg chewed immediately unless contraindicated 1
• Consider sublingual nitroglycerin if BP remains elevated and no contraindications 1
• This represents either delayed STEMI presentation or high-risk unstable angina requiring urgent angiography 1

If ECG and initial troponins are normal:

• Proceed to stress testing (exercise ECG or stress imaging with echocardiography or nuclear perfusion) within 72 hours 1
• Do NOT send home without definitive cardiac evaluation given the exertional nature of symptoms and persistent dyspnea 1
• The illustrative case in the ACR guidelines describes an almost identical patient (54-year-old with chest pressure, diaphoresis, hypertension, and diabetes risk) who required coronary angiography and ultimately bypass grafting 1

Address the Hypertension Appropriately

This BP elevation (170/100 mmHg) is NOT a hypertensive emergency because there is no evidence of acute target organ damage (normal O2 saturation, patient "looks fine"). 4 However:

• Do not aggressively lower BP acutely in the emergency setting—excessive drops can precipitate cerebral, renal, or coronary ischemia, especially if underlying coronary disease exists 4
• Initiate or optimize oral antihypertensive therapy after cardiac evaluation is complete, targeting <130/80 mmHg over weeks to months 4, 5
• Consider ACE inhibitor or ARB plus calcium channel blocker as first-line combination therapy once cardiac status is clarified 4, 5

The Anxiety Factor: Important But Secondary

Yes, anxiety can cause chest pain and 25% of chest pain patients have panic disorder. 2, 3 However:

• Anxiety diagnosis is one of exclusion—cardiac disease must be ruled out first, especially with classic exertional angina symptoms 3, 6
• Even patients with known anxiety disorders can develop coronary disease, and anxiety may actually increase cardiovascular risk 3, 7
• The fact that he takes anxiety medication and sees a provider regularly does NOT exclude cardiac pathology 2
• Panic attacks typically have abrupt onset, peak within minutes, and include multiple associated symptoms (trembling, dizziness, paresthesias)—this patient's exertional pattern is more consistent with angina 1

Critical Pitfall to Avoid

Do not attribute exertional chest pressure with persistent dyspnea to anxiety without objective cardiac testing. Studies show that cardiac risk factors and symptoms are similar in patients with and without anxiety, and these patients warrant the same cardiac evaluation. 2 The 3-minute duration, exertional trigger, and pressure quality are classic for myocardial ischemia, not panic disorder. 1

Disposition

Refer to emergency department or arrange urgent outpatient cardiac evaluation (within 24-72 hours) depending on your clinical judgment and available resources. 1 The 2-week delay since symptom onset does not eliminate risk—this patient may have had a small MI or developed unstable angina that requires intervention to prevent a larger event. 1