What non‑invasive cardiac testing is recommended for a 33‑year‑old man with hypertension and gastro‑esophageal reflux disease who presents with intermittent chest pain, T‑wave inversions in leads V3‑V6, tachycardia, negative serial cardiac troponins, a normal resting echocardiogram with left ventricular ejection fraction approximately 56 %, and low low‑density lipoprotein cholesterol?

Non-Invasive Cardiac Testing Recommendations

In this 33-year-old man with intermittent chest pain, T-wave inversions in V3-V6, and a normal echocardiogram, stress testing (preferably stress echocardiography) should be performed to evaluate for obstructive coronary artery disease, as the T-wave inversions represent an abnormal ECG finding that mandates further cardiac evaluation despite negative troponins. 1

Rationale for Stress Testing

ECG Abnormalities Mandate Further Evaluation

• Echocardiography is recommended in patients with hypertension when the ECG is abnormal, which applies to this patient who has documented T-wave inversions in leads V3-V6. 1

• The 2024 ESC guidelines explicitly state that echocardiography is recommended in patients with hypertension and ECG abnormalities or signs or symptoms of cardiac disease. 1

• T-wave inversions in the precordial leads (V3-V6) represent an abnormal ECG finding that cannot be dismissed, even with negative troponins, as 30-40% of acute myocardial infarctions present with a normal or nondiagnostic initial ECG. 2

Stress Echocardiography is Preferred Over Other Modalities

• In hypertensive patients with chest pain, stress echocardiography is preferentially recommended over myocardial perfusion scanning because stress-induced wall motion abnormalities are highly specific for coronary artery disease, whereas perfusion defects in hypertensive patients may arise from abnormal myocardial flow reserve not due to epicardial coronary disease. 1

• The 2015 European Association of Cardiovascular Imaging guidelines emphasize that stress echocardiography has superior specificity in hypertensive patients compared to perfusion imaging, which can produce false-positive results due to subendocardial ischemia from left ventricular hypertrophy and increased afterload. 1

Clinical Context Supporting Stress Testing

• The patient's chest pain was significantly relieved with Toradol (ketorolac), which suggests a possible musculoskeletal or inflammatory component, but this response does not exclude cardiac ischemia and should not be used as a diagnostic tool. 2

• The presence of GERD as a comorbidity creates diagnostic complexity, as GERD is the most common gastrointestinal cause of non-cardiac chest pain and can coexist with coronary artery disease. 3, 4

• Studies show that GERD is twice as frequent in patients with coronary heart disease (50-65%) compared to the general population (30-40%), meaning these conditions commonly coexist rather than exclude one another. 5

Specific Testing Algorithm

First-Line Test: Exercise Stress Echocardiography

• Perform exercise stress echocardiography to a high workload (≥85% of age-predicted maximum heart rate) because a normal stress test performed to a high workload has a high negative predictive value for excluding obstructive coronary disease. 1

• If the patient achieves adequate exercise capacity and the stress echo is normal, this effectively rules out flow-limiting epicardial coronary disease. 1

Alternative if Exercise is Not Feasible

• If the patient cannot exercise adequately, pharmacologic stress echocardiography with dobutamine is the preferred alternative, as it maintains the superior specificity for detecting wall motion abnormalities indicative of true epicardial coronary stenosis. 1

Additional Considerations

• Coronary artery calcium (CAC) scoring may be considered as a complementary test when it is likely to change patient management, particularly given the patient's young age and the need to assess long-term cardiovascular risk. 1

• The 2024 ESC guidelines give CAC scoring a Class IIb recommendation (Level B evidence) in patients with elevated blood pressure or hypertension when it is likely to influence management decisions. 1

Critical Pitfalls to Avoid

Do Not Assume GERD Explains Everything

• The coexistence of GERD and chest pain does not exclude cardiac disease—one case report documented a 73-year-old with known GERD and postprandial chest pain who was ultimately found to have near-complete occlusion of the LAD and left circumflex arteries on catheterization. 6

• The relationship between GERD and coronary disease may involve vagal reflexes (esophageal-cardiac reflex) where acid reflux can trigger coronary hypoperfusion, creating a vicious cycle. 5

Do Not Rely on Single Negative Troponin

• Although troponins were negative at 2 and 3 hours, T-wave inversions that "improved slightly" on repeat ECG suggest evolving ischemic changes that warrant functional testing rather than reassurance alone. 2

Do Not Screen Asymptomatic Hypertensive Patients

• Screening for coronary disease is not recommended in asymptomatic hypertensive patients because of the risk of false-positive results and uncertain management responses, but this patient is symptomatic with chest pain and ECG abnormalities. 1

Why Not Coronary CT Angiography?

• While coronary CT angiography is an option for chest pain evaluation, stress echocardiography is specifically preferred in hypertensive patients due to the superior specificity for detecting hemodynamically significant coronary stenosis and avoiding false-positive findings from coronary calcification or microvascular dysfunction. 1

Summary of Recommended Approach

Proceed with exercise stress echocardiography as the next diagnostic step, targeting ≥85% of maximum predicted heart rate. If the test is normal with adequate exercise capacity, obstructive coronary disease is effectively excluded. If abnormal wall motion develops, proceed to coronary angiography. Consider CAC scoring for long-term risk stratification if stress testing is normal but cardiovascular risk factors warrant further assessment. 1