In a patient with 10 days of exertional dyspnea, left‑sided chest pain radiating to the back, intermittent four‑limb numbness, bilateral leg edema, a normal resting ECG, and an exercise stress test showing inferior ST‑segment depression with reciprocal anterior‑lateral ST‑segment elevation, what is the appropriate next step in management?

Management of Abnormal Exercise ECG with Normal Resting ECG

This patient requires urgent coronary angiography given the high-risk exercise ECG pattern showing inferior ST-segment depression with reciprocal anterior-lateral ST-segment elevation, which strongly suggests obstructive coronary artery disease requiring revascularization. 1

Interpretation of the Exercise ECG Findings

The exercise stress test demonstrates a clearly abnormal result that is highly specific for obstructive coronary artery disease:

• Inferior ST-segment depression with reciprocal anterior-lateral ST-segment elevation during exercise is a high-risk ECG pattern that indicates significant myocardial ischemia at a potentially low workload 1
• Exercise ECG with clearly abnormal results remains a specific indicator of obstructive CAD and is associated with future coronary revascularization and risk of myocardial infarction 1
• The pattern of ST-segment depression in one territory with reciprocal ST-segment elevation suggests transmural ischemia rather than simple subendocardial ischemia 2

Immediate Next Steps

Proceed directly to coronary angiography rather than additional non-invasive testing:

• Patients with marked ischemia at low workload benefit from anatomical testing (coronary angiography) rather than additional functional imaging 1
• The combination of exertional chest pain radiating to the back, 10 days of symptoms, and high-risk ECG changes indicates possible acute coronary syndrome requiring urgent evaluation 1
• Admission to a telemetry unit is mandatory given the definite acute coronary syndrome with positive stress test 1

Additional Urgent Diagnostic Testing

While arranging coronary angiography, obtain:

• Transthoracic echocardiography to assess left ventricular ejection fraction, regional wall motion abnormalities, and exclude non-coronary cardiac disease such as valvular pathology or cardiomyopathy 1
• Cardiac biomarkers (troponin) to determine if there is ongoing myocardial injury 1
• BNP or NT-proBNP to assess for heart failure, particularly given the bilateral leg edema 3

The bilateral leg edema and intermittent four-limb numbness raise concern for systemic involvement that requires evaluation beyond the cardiac workup.

Risk Stratification

This patient has multiple high-risk features:

• Marked ischemia on exercise ECG places the patient at high risk for major adverse cardiovascular events 1
• The pattern of inferior ST-depression with anterior-lateral ST-elevation may indicate multi-vessel disease or proximal left anterior descending artery involvement 4
• Exertional dyspnea combined with chest pain suggests significant ischemic burden 3, 5

Medical Management Pending Angiography

Initiate guideline-directed medical therapy immediately:

• Dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) for acute coronary syndrome 1
• Beta-blocker therapy to reduce myocardial oxygen demand 1
• High-intensity statin therapy 1
• Sublingual nitroglycerin for symptom relief 1

Common Pitfalls to Avoid

• Do not dismiss the abnormal exercise ECG simply because the resting ECG is normal—exercise-induced ischemia is highly specific for obstructive coronary disease when the resting ECG is interpretable 1
• Do not order additional non-invasive imaging (stress echocardiography, nuclear perfusion imaging, or CCTA) in this high-risk patient, as it will only delay definitive diagnosis and treatment 1
• Do not discharge the patient for outpatient follow-up—the combination of ongoing symptoms and high-risk stress test mandates inpatient admission 1
• Do not attribute the ST-segment changes to reciprocal changes without angiographic confirmation—while reciprocal changes can occur, this pattern in a symptomatic patient requires exclusion of obstructive disease 2

Alternative Diagnoses to Consider

While obstructive coronary disease is most likely, the constellation of symptoms warrants consideration of:

• Aortic dissection given chest pain radiating to the back, though this would typically show abnormalities on resting ECG or imaging 1
• Left main or proximal left anterior descending artery disease given the pattern of widespread ST changes 4
• Pulmonary embolism given dyspnea and bilateral leg edema, though less likely with this ECG pattern 1

The four-limb numbness is atypical for cardiac ischemia alone and may suggest concurrent neurological or systemic pathology requiring evaluation after cardiac stabilization.