How should new exertional dyspnea be evaluated and managed in an 87‑year‑old patient with coronary artery disease, prior coronary‑artery bypass grafting, on a beta‑blocker and a statin, and a recent normal echocardiogram?

Evaluation and Management of New Exertional Dyspnea in an 87-Year-Old Post-CABG Patient

This patient requires urgent evaluation for recurrent myocardial ischemia with stress testing or coronary angiography, as new exertional dyspnea with relief at rest in a patient with prior CABG is classic for angina-equivalent symptoms indicating possible graft failure or progression of native coronary disease.

Immediate Clinical Assessment

Obtain a 12-lead ECG immediately to evaluate for ischemic changes, as abnormal EKG consistent with ischemia is a high-risk feature warranting an invasive strategy 1. Look specifically for:

• ST-segment depression or T-wave inversions suggesting active ischemia
• New Q waves indicating prior unrecognized infarction
• Conduction abnormalities that may have developed

Check high-sensitivity troponin even in the absence of chest pain, as dyspnea can be an anginal equivalent in elderly patients, particularly those with prior coronary disease 2.

Risk Stratification

This patient falls into a high-risk category based on multiple factors 1:

• Age 87 years with known CAD and prior CABG
• New exertional symptoms with relief at rest (classic anginal pattern)
• Remote CABG with potential for graft failure or disease progression

The American College of Cardiology recommends that patients with angina-equivalent symptoms (exertional dyspnea) and prior CABG be considered high-risk and referred for coronary angiography to evaluate for graft patency and progression of native vessel disease 1.

Diagnostic Workup Priority

First-Line Testing

Coronary angiography is the preferred diagnostic approach in this high-risk patient rather than noninvasive stress testing 1. The rationale includes:

• Prior CABG makes stress testing interpretation more complex
• Direct visualization of graft patency and native vessel disease
• Immediate opportunity for revascularization if indicated

If angiography is not immediately available or the patient is deemed too high-risk for invasive evaluation, pharmacologic stress testing with imaging (nuclear or stress echocardiography) is reasonable as an alternative, though this delays definitive diagnosis 2.

Additional Evaluation

While cardiac ischemia is the primary concern, also evaluate:

• Brain natriuretic peptide (BNP) to assess for heart failure, though the recent normal echocardiogram makes this less likely
• Complete blood count to exclude anemia as a contributor to exertional symptoms
• Thyroid function in this elderly patient on beta-blockers
• Pulmonary function testing or chest CT only if cardiac evaluation is unrevealing

Medical Optimization During Workup

Antianginal Therapy Adjustment

Optimize beta-blocker dosing to achieve resting heart rate of 55-60 bpm unless contraindicated by bradycardia 1. The patient is already on a beta-blocker, but dosing may be suboptimal.

Add or increase long-acting nitrate therapy (isosorbide mononitrate 30-60 mg daily or isosorbide dinitrate 20-40 mg three times daily) for symptom relief 1. Provide sublingual nitroglycerin for acute symptom episodes 1.

Consider adding ranolazine 500-1000 mg twice daily if symptoms persist despite beta-blocker and nitrate therapy, as this provides additional antianginal benefit without affecting heart rate or blood pressure.

Statin Intensity

Verify the patient is on high-intensity statin therapy (atorvastatin ≥40 mg or rosuvastatin ≥20 mg daily), as high-intensity statins following CABG are associated with significantly improved long-term outcomes compared to low/moderate-intensity regimens 3. A 2025 study demonstrated that beyond 2 years post-CABG, high-intensity statin use was associated with significantly lower incidence of major adverse cardiovascular events (5.3% vs 9.1%, p=0.047) 3.

Antiplatelet Therapy

Ensure the patient is on aspirin 81 mg daily at minimum 4. While dual antiplatelet therapy is not routinely indicated for stable CAD post-CABG beyond 12 months, aspirin monotherapy is essential 2.

Management Algorithm Based on Angiography Findings

If Significant Graft or Native Vessel Disease Amenable to Revascularization

Proceed with percutaneous coronary intervention (PCI) or repeat CABG based on anatomy and Heart Team discussion 1. In octogenarians:

• PCI is generally preferred over repeat CABG due to lower perioperative risk
• If repeat CABG is necessary, in-hospital mortality in experienced centers is 3.9-16.8% for patients ≥80 years 5, 6
• Survival at 3 years post-CABG in octogenarians is approximately 83% 6

Following revascularization, initiate dual antiplatelet therapy with aspirin 81 mg plus clopidogrel 75 mg daily for 12 months 4. Add a proton pump inhibitor to reduce gastrointestinal bleeding risk given the patient's age 4.

If No Significant Obstructive CAD

Reassess the diagnosis and consider:

• Coronary microvascular dysfunction
• Diastolic dysfunction (though recent echo was normal)
• Pulmonary causes (interstitial lung disease, pulmonary hypertension)
• Deconditioning

Continue optimal medical therapy with high-intensity statin, aspirin, and beta-blocker for secondary prevention 1, 3.

Critical Pitfalls to Avoid

Do not attribute symptoms to "normal aging" or deconditioning without excluding recurrent ischemia, as cardiac complications remain the leading cause of morbidity and mortality in elderly patients with prior CABG 2.

Do not delay evaluation because the recent echocardiogram was normal—echocardiography at rest may not detect ischemia-induced wall motion abnormalities that only occur during exertion 2.

Avoid empiric diuretic therapy without establishing the diagnosis, as this patient's symptoms are exertional with immediate relief at rest, which is not typical for volume overload 2.

Do not discontinue beta-blocker therapy thinking it may be causing dyspnea, as beta-blockers provide mortality benefit in CAD patients and are essential for angina management 2, 1.

Post-Evaluation Management

Refer to cardiac rehabilitation regardless of whether revascularization is performed, as structured exercise programs improve functional capacity and quality of life in elderly post-CABG patients 7, 5.

Provide patient education on recognizing anginal symptoms and when to seek emergency care, as elderly patients may have atypical presentations 1.

Schedule close follow-up within 2-4 weeks after initial evaluation to reassess symptoms and adjust medical therapy as needed 1.