From the Guidelines
The patient should undergo further anatomical evaluation, such as coronary angiography, to assess for significant coronary artery disease, given the abnormal stress test results and new wall motion abnormalities. This 61-year-old female with chest pain has developed new wall motion abnormalities (anterior septal and anterior wall hypokinesis) during stress testing despite having normal resting cardiac function, as indicated by a left ventricular ejection fraction of 60% 1. Her left ventricular ejection fraction does not change post-stress, and she achieved only fair exercise tolerance (7.1 METs), suggesting limited cardiac reserve. These findings strongly suggest myocardial ischemia, likely involving the left anterior descending coronary artery territory. Given her symptoms and test results, she should also be started on anti-anginal therapy such as a beta-blocker (e.g., metoprolol 25-50mg twice daily) and sublingual nitroglycerin 0.4mg as needed for chest pain while awaiting definitive diagnosis, as recommended by recent guidelines 1. Additionally, aspirin 81mg daily should be considered if not contraindicated. The patient should be counseled to report worsening symptoms immediately and to seek emergency care for prolonged chest pain unrelieved by rest or nitroglycerin. Key considerations in her management include:
- The interpretation of chest pain is particularly difficult in women, and the classical symptom complex of chronic stable angina is not a reliable indicator of obstructive coronary disease in women 1.
- The use of non-invasive stress imaging testing, such as stress echocardiography or myocardial perfusion scintigraphy, is valuable in demonstrating the extent and localization of myocardial ischemia 1.
- Coronary computed tomography angiography (CCTA) has a high degree of accuracy in detecting complete graft occlusions and is useful in assessing bypass grafts, but may be less robust for assessing native coronary vessel stenosis 1.
From the Research
Patient Profile
- Female, 61 years old, experiencing chest pain
- Stress test results:
- Normal left ventricular systolic function with an ejection fraction of 60%
- Normal left ventricular segmental wall motion
- Normal right ventricular systolic function
- Normal inferior vena cava with >50% collapse upon inspiration
- No pericardial effusion
- Abnormal stress test due to anterior septal and anterior wall hypokinesis post-stress
Recommendations
- Consider further anatomical evaluation 2, 3, 4
- Coronary CT angiography (CCTA) may be a suitable option for further evaluation, as it has been shown to be effective in detecting coronary artery disease (CAD) and guiding therapeutic decisions 2, 3, 4, 5, 6
Rationale
- CCTA has been demonstrated to have high positive and negative predictive values for detecting obstructive CAD, allowing for rapid determination of the presence or absence of coronary plaque and triage of patients' need for further invasive evaluation and treatment 4
- CCTA can provide detailed anatomical information, which can be useful in planning potential interventional or surgical therapy 3, 4
- Studies have shown that CCTA is associated with a reduced incidence of myocardial infarction, but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins compared to functional stress testing 5
- The use of CCTA instead of invasive angiography before transcatheter aortic valve implantation (TAVI) has been shown to be feasible and safe, with similar procedural and clinical outcomes 6