From the Guidelines
The next step for this 52-year-old female with exertional chest pain and a positive stress test (EKG changes and chest pain during exercise) despite negative troponin, Holter monitoring, and nuclear imaging would be cardiac catheterization (coronary angiography). This invasive procedure is indicated because the patient has typical angina symptoms with a strong family history of coronary artery disease (CAD) and a positive stress test based on clinical and EKG findings, even though nuclear imaging was negative, as suggested by the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes 1. Coronary angiography will directly visualize the coronary arteries to identify any significant stenosis that may have been missed by non-invasive testing. This is particularly important given the discordance between her symptoms during stress testing and the negative nuclear imaging results, which could represent balanced ischemia or microvascular disease.
While awaiting catheterization, the patient should be started on medical therapy including aspirin 81mg daily, a moderate-intensity statin such as atorvastatin 20mg daily, and a beta-blocker like metoprolol 25mg twice daily for symptom control, as recommended by the guidelines 1. Sublingual nitroglycerin 0.4mg should be prescribed for as-needed use during chest pain episodes. The catheterization results will guide further management, which may include percutaneous coronary intervention, medical therapy optimization, or consideration of microvascular angina if epicardial coronary arteries appear normal.
Key considerations in managing this patient include:
- Assessment of risk to identify patients at high event risk who may derive prognostic benefit from revascularization, including evaluation of LV function 1
- Implementation of healthy lifestyle behaviors to decrease the risk of subsequent cardiovascular events and mortality, in addition to appropriate secondary prevention therapy 1
- Selection of anti-ischaemic treatment adapted to the individual patient based on comorbidities, co-administered therapies, expected tolerance and adherence, and patient preferences, with beta-blockers and/or CCBs remaining the first-line drugs in patients with CCS 1.
From the Research
Patient Profile
- 52-year-old female with a strong family history of Coronary Artery Disease (CAD)
- Experiences chest pain with exertion
- Negative troponin levels
- Holter monitor results were negative
- Echocardiogram showed diastolic dysfunction grade 1
- Nuclear imaging was negative, but the patient had EKG changes and chest pain during the stress test on the treadmill
Next Steps
- Consider the patient's high risk of CAD due to family history and current symptoms
- The presence of diastolic dysfunction grade 1 on the echocardiogram suggests some level of cardiac involvement 2
- The negative nuclear imaging results but positive stress test suggest the need for further evaluation of coronary artery disease
- Medications such as beta-blockers, ACE inhibitors, or statins may be considered for patients with CAD or those at high risk of CAD 3, 4
- However, the use of calcium channel blockers may be associated with aspirin resistance in patients with CAD 5
- The underutilization of aspirin, beta-blockers, ACE inhibitors, and lipid-lowering drugs in older patients with CAD is a concern, and their use should be optimized 6
Potential Treatment Options
- Lifestyle modifications as first-line therapy for hypertension, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 2
- Pharmacologic therapy with beta-blockers, ACE inhibitors, or calcium channel blockers for hypertension and CAD management 2, 3
- Consideration of statins for lipid-lowering and cardioprotection 4, 6