What is the best course of action for a 53-year-old female with asthma, anxiety, and gastroesophageal reflux disease (GERD), no prior cardiac history, but a significant family history of cardiovascular disease, who presents with chest pain and has a negative ischemic evaluation, elevated low-density lipoprotein (LDL) cholesterol, and is experiencing stress and anxiety?

Management of Recurrent Stress-Related Chest Pain with Negative Cardiac Workup

Initiate low-dose propranolol 10 mg as needed for stress-related chest pain episodes, combined with continuation of buspirone for anxiety management, while maintaining annual cardiovascular surveillance given her elevated LDL and significant family history. 1

Cardiac Risk Has Been Adequately Excluded

Your patient has undergone comprehensive cardiac evaluation that definitively rules out ischemic heart disease:

• Exercise stress test with EKG changes (1 mm ST depressions in inferior and lateral leads) but normal SPECT imaging demonstrates no reversible ischemia or wall motion abnormalities 1
• Coronary CTA showing no evidence of coronary artery disease provides anatomic confirmation of absence of obstructive CAD 1
• Temporal relationship between stressful life events and symptom recurrence (initial episode, then resolution for weeks until relative's injury, then recurrence with new stressor) strongly supports anxiety-mediated chest pain 1

The 2021 ACC/AHA Chest Pain Guidelines emphasize that once cardiac etiology has been "carefully considered" through appropriate testing, and the American Gastroenterological Association explicitly states this threshold has been met when ischemic evaluation is comprehensively negative, you can confidently proceed with non-cardiac management. 1

Beta-Blocker Therapy for Physiologic Stress Response

Propranolol 10 mg as needed is the appropriate choice for several reasons:

• Blocks the physiologic manifestations of anxiety (tachycardia, palpitations, chest tightness) that patients interpret as cardiac symptoms 1
• Safe in asthma when used at low doses and as needed rather than scheduled, though you must monitor for bronchospasm 2
• Addresses the specific mechanism of her symptoms: stress-triggered autonomic activation causing chest discomfort that she catastrophizes given her family history 1

The key distinction here is that her chest pain is not reflux chest pain syndrome (which would require twice-daily PPI therapy per AGA guidelines), but rather anxiety-mediated chest pain with a clear stress trigger pattern. 1

Critical Caveat Regarding Asthma

Monitor closely for bronchospasm with propranolol initiation, even at low doses:

• Cardioselective beta-blockers (metoprolol, atenolol) would be safer alternatives if bronchospasm develops 2
• Instruct the patient to discontinue immediately if she experiences increased wheezing, shortness of breath, or need for rescue inhaler 2
• The "as needed" dosing strategy minimizes cumulative beta-blocker exposure compared to scheduled dosing 2

Lipid Management Requires Intervention Now

You should strongly recommend initiating statin therapy rather than continuing to defer:

• LDL 133 mg/dL with significant family history (mother with MI in 50s, relative with CHF in 70s) constitutes a risk-enhancing factor per 2022 ACC guidelines 1
• Early menopause is an additional risk-enhancing factor that increases her cardiovascular risk 1
• Elevated fasting blood glucose (you mention "elevated FBG") suggests metabolic syndrome, another risk enhancer 1
• Target LDL <100 mg/dL for primary prevention in the setting of multiple risk-enhancing factors 1

The 2022 ACC Expert Consensus states that family history of premature ASCVD (mother with MI before age 65) combined with LDL-C 160-189 mg/dL or persistently elevated LDL despite lifestyle modification warrants statin initiation. 1 While her LDL is 133 mg/dL (not 160+), the combination of family history, early menopause, and elevated glucose places her in a higher risk category. 1

Recommend moderate-intensity statin (atorvastatin 10-20 mg or rosuvastatin 5-10 mg daily) to achieve LDL <100 mg/dL. 1

Anxiety Management Optimization

Buspirone is appropriate for ongoing anxiety management as it does not interact with beta-blockers and addresses generalized anxiety rather than acute panic:

• Continue buspirone as prescribed for baseline anxiety control 1
• Propranolol serves as acute rescue therapy for stress-triggered episodes with physical symptoms 1
• Consider referral to cognitive-behavioral therapy (CBT) specifically for health anxiety and catastrophic thinking about cardiac symptoms, given her family history creates hypervigilance 1

Surveillance Strategy

Annual cardiovascular follow-up is appropriate given her risk factor profile:

• Repeat fasting lipid panel in 3 months after statin initiation (if she agrees to start) to assess LDL response 1
• Annual lipid panel if she continues to refuse statin, with repeated discussion of cardiovascular risk 1
• Reassess chest pain pattern at each visit to ensure no change in character, duration, or triggers that might suggest new cardiac pathology 1
• Repeat coronary CTA is not indicated unless she develops new symptoms distinctly different from her stress-related pattern or has interval development of diabetes or other major risk factors 1

What NOT to Do

Do not perform repeat stress testing or coronary imaging for recurrent symptoms with identical characteristics and clear stress triggers—this reinforces health anxiety and wastes resources. 1

Do not prescribe twice-daily PPI empirically without evidence of GERD symptoms (she has GERD history but her chest pain is not described as burning, worse after meals, or relieved by antacids). 1

Do not delay statin therapy indefinitely—she has had adequate time for lifestyle modification (multiple visits over time documented in your note), and her LDL remains elevated with multiple risk enhancers present. 1