From the Guidelines
Given the patient's symptoms of exertional shortness of breath, chest pain during stress testing with EKG changes and arrhythmias (NSVT and SVT), but normal coronary arteries on catheterization, I recommend further evaluation for non-coronary causes of her symptoms. The next steps should include an echocardiogram to assess cardiac structure and function, particularly looking for diastolic dysfunction, valvular disease, or hypertrophic cardiomyopathy, as suggested by the American College of Radiology 1. Pulmonary function testing would be valuable to rule out respiratory causes. Consider a cardiac MRI to evaluate for myocardial fibrosis, infiltrative diseases, or myocarditis. Holter monitoring for 24-48 hours would help characterize her arrhythmias. Laboratory tests should include thyroid function, complete blood count, comprehensive metabolic panel, and BNP levels. For symptom management, consider a trial of a beta-blocker such as metoprolol 25mg twice daily, which may help control both her arrhythmias and blood pressure, as recommended for patients with cardiovascular risk factors 1. Optimization of her diabetes and hypertension management is also essential, including the use of aspirin, statin, and ACE inhibitor therapy, unless there are contraindications to a particular drug class 1. Additionally, lifestyle modifications such as smoking cessation, improving diet, moderate alcohol consumption, reducing dietary salt, reducing fat, increasing fruit and vegetable consumption, and increasing physical activity should be encouraged 1. These recommendations are based on the understanding that cardiac ischemia has been ruled out, shifting our focus to other cardiac and non-cardiac causes that could explain her exertional symptoms and arrhythmias, such as heart failure with preserved ejection fraction, arrhythmogenic disorders, or pulmonary disease. Key considerations in her management include:
- Close monitoring of her symptoms and adjustment of her treatment plan as needed
- Regular follow-up with her primary care physician and cardiologist to assess her response to treatment and adjust her management plan accordingly
- Education on the importance of adherence to her medication regimen and lifestyle modifications to reduce her cardiovascular risk factors.
From the Research
Patient Management
The patient has a history of hypertension, hyperlipidemia, diabetes, and a strong family history of coronary artery disease, and has been experiencing shortness of breath on exertion. The stress test results showed chest pain, shortness of breath, EKG changes, and arrhythmias, including NSVT and SVT. However, the cardiac catheterization showed no coronary artery disease.
Treatment Options
Considering the patient's symptoms and test results, the following treatment options can be considered:
- Beta-blockers: Studies have shown that beta-blockers can be effective in controlling cardiac arrhythmias and reducing the risk of sudden cardiac death 2, 3, 4, 5.
- Antiarrhythmic therapy: The patient's arrhythmias, including NSVT and SVT, can be managed with antiarrhythmic therapy, and beta-blockers have been shown to be effective in this regard 2, 3, 4, 5.
Key Considerations
When selecting a treatment option, the following factors should be considered:
- The patient's medical history and current symptoms
- The results of the stress test and cardiac catheterization
- The potential benefits and risks of beta-blockers and antiarrhythmic therapy
- The need for ongoing monitoring and follow-up to adjust treatment as needed
Potential Benefits of Beta-Blockers
The use of beta-blockers in this patient can provide several potential benefits, including: