From the Guidelines
For an obese 72-year-old male with chronic dyspnea on exertion (DOE) and chest pain, I recommend a comprehensive cardiac and pulmonary evaluation, prioritizing the identification of life-threatening conditions such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and esophageal rupture, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1. This approach is necessary because the patient's symptoms could indicate coronary artery disease, heart failure, or pulmonary disease, all of which are common in obese elderly patients and require different management strategies. The evaluation should include:
- A 12-lead ECG to assess for signs of ischemia or infarction
- Comprehensive metabolic panel, complete blood count, lipid panel, and cardiac biomarkers (troponin, BNP) to evaluate for underlying metabolic and cardiac conditions
- Imaging studies, including a chest X-ray and transthoracic echocardiogram, to assess cardiac structure and function
- Exercise stress testing or pharmacological nuclear stress testing to evaluate for coronary artery disease, with coronary CT angiography or cardiac catheterization if stress testing suggests ischemia
- Pulmonary function tests to assess for obstructive or restrictive lung disease While awaiting evaluation, the patient should be started on aspirin 81mg daily, a moderate-intensity statin like atorvastatin 20mg daily, and potentially a beta-blocker such as metoprolol 25mg twice daily if there are no contraindications, as these medications have been shown to improve outcomes in patients with coronary artery disease 1. The patient's obesity should be addressed with a referral to a nutritionist and recommendation for a calorie-restricted diet with moderate exercise as tolerated, as obesity is a significant risk factor for cardiovascular disease and other comorbidities. It is also important to consider the "obesity paradox" in which obese patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) may have better in-hospital and 1-year outcomes, including lower bleeding risk, although this should not influence the decision to provide evidence-based therapies 1. The combination of age, obesity, and symptom presentation places this patient at high risk for cardiovascular events, necessitating prompt and thorough evaluation.
From the Research
Evaluation of Obese 72-Year-Old Male with Chronic DOE and Chest Pain
- The patient's symptoms of chronic dyspnea on exertion (DOE) and chest pain may be indicative of coronary artery disease (CAD) or other cardiovascular conditions 2.
- A study published in the American Heart Journal found that combination therapy with aspirin, a statin, and blood pressure-lowering agents was associated with a lower risk of vascular events and total mortality in patients with CAD 3.
- The use of antihypertensive drug treatment is recommended for patients with hypertension, with a goal of reducing systolic blood pressure to below 140 mmHg 4.
- A review of cardiovascular diseases and their associated risk factors found that obesity, hypertension, and hyperlipidemia are major contributors to the development of CAD and other cardiovascular conditions 2.
- A study published in the Medical Archives found that different combinations of antihypertensive therapy were equally effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension 5.
- Another study published in Radiology: Cardiothoracic Imaging found that baseline statin use was associated with improved clinical outcomes in patients with nonobstructive CAD, but not in those without detectable plaque 6.
Risk Factors and Treatment Options
- The patient's obesity and potential hypertension increase their risk for developing CAD and other cardiovascular conditions 2.
- Treatment options may include lifestyle modifications, such as diet and exercise, as well as pharmacologic agents like statins, antihypertensives, and antiplatelet therapy 3, 2, 5, 6.
- The choice of treatment will depend on the patient's specific risk factors and medical history, as well as the results of diagnostic tests and imaging studies 3, 4, 2, 5, 6.