A 53 year Old Man Presents With A Complain Of Chest Pain - Approach To The Case With Study Questions.

A 53-year-old male with a history of hypertension and smoking, but no family history of cardiac disease, presents to your office complaining of a chest pain.
The pain is substernal, radiates to his left arm, and is associated with exertion. The patient notes that this same pain has been going on for the last 6 months and has not changed at all in duration, intensity, or characteristic. It generally lasts 5 minutes or so and resolves with rest.

You tell the patient that:
A) Without doing any test, you know that the probability that this pain is cardiac is greater than 85%.
B) If his ECG in the office is normal, his pain is unlikely to represent cardiac disease.
C) Even with risk factors, his probability of having CAD with “typical angina” is still only 50% or so.
D) The only intervention indicated at this point are life style modifications (e.g., stop smoking) and
addressing his cholesterol and hypertension.
E) It is likely that he has unstable angina.

Answer and Discussion
The correct answer is “A.”
A 50-year-old male with “classic” angina symptoms has greater than a 90% probability of having CAD.
“B” is incorrect because patients with angina who are pain free may have a normal electrocardiogram (as will many patients with active angina or even a myocardial infarction). Thus, his pain could still be cardiac in origin.
“C” is incorrect because, based on demographic data, his risk of CAD is much higher than 50%. “D” is incorrect because he needs a further evaluation and treatment of his chest pain.
“E” is incorrect since this pain represents “stable angina.” There has been no change in quality, duration, amount of exertion required to bring on symptoms, etc., eliminating unstable angina as a diagnosis.

You send the patient home on aspirin with a prescription for sublingual nitroglycerin for PRN use and arrange for a stress test.
All of the following are considered absolute contraindications to exercise stress testing EXCEPT:
A) LBBB.
B) Presence of severe CHF.
C) Critical aortic stenosis.
D) Myocarditis.
E) Unstable angina.

Answer And Discussion

The correct answer is “A.”
An LBBB is a relative—not absolute—contraindication to stress testing. There are already repolarization abnormalities that limit the usefulness of the stress test. One should add an imaging modality, such as myocardial perfusion scanning in cases of LBBB. The rest are all “absolute” contraindications to exercise stress testing

Exercise stress testing is best suited to which group of individuals?
A) Men with an intermediate probability of cardiac disease.
B) Women with a high risk of cardiac disease.
C) Men at a high risk of cardiac disease.
D) Men at a low risk of cardiac disease.
E) Women with a low risk of cardiac disease.

Answer And Discussion
The correct answer is “A.”
Stress testing is best suited to patients with an intermediate pretest probability of cardiac disease (between 25% and 75%).
“B” and “C” are incorrect since patients with a high risk of cardiac disease should go directly to another study,such as thallium testing and stress echocardiography.
“D” and “E” are incorrect since these are not the best groups in whom to use exercise stress testing. There will be a greater proportion of false-positive results in these low-risk patients. Exercise stress testing in these groups is best used to allay patient fears that they do not have cardiac disease, not to prove they do have cardiac disease. However, a false-positive stress test may lead to other unnecessary invasive testing!

You decide to do an exercise stress test on this patient. It turns out to be negative.
Your next step is to:
A) Reassure the patient that he does not have cardiac disease.
B) Suggest a chest CTscan to rule out possible aortic aneurysm.
C) Schedule the patient for another cardiac test such as stress echocardiogram, exercise thallium test,
or angiography.
D) Schedule the patient for endoscopy to rule out gastroesophageal disease as a cause of these symptoms.
E) Start an anxiolytic to treat the panic disorder, which is the underlying cause of his chest pain.

Answer And Discussion
The correct answer is “C.”
This patient who is in
his 50's and who has a “classic” history for angina has greater than a 90% pretest probability of cardiac disease. Thus, it is likely that the negative stress test is a false negative. In fact, male patients >40 years of age and women >60 years of age who have classic angina have a pretest probability of cardiac disease of 87% and 91%, respectively. Thus, a stress test probably should not have been done in this patient in the first place, since a negative test just leads to further testing (as would have a positive test, probably resulting in angiography). For this reason, “A” is incorrect. “B,” “D,” and “E” are incorrect. Initiating evaluation and management for another cause of chest pain is premature, since we still have not proven that this patient does not have cardiac disease.

You are considering whether to do a thallium stress test or a stress echocardiogram.
Which of the following is true?
A) Stress echocardiography is more sensitive for cardiac disease than is a thallium test.
B) Stress echocardiography is more specific than is stress thallium.
C) Thallium testing is more specific for cardiac disease than is stress echocardiography.
D) None of the above is true.

Answer And Discussion
The correct answer is “B.”
Stress echocardiography is more specific for cardiac disease than is thallium testing. Alternatively, thallium testing is more sensitive. Remember that positive and negative predictive values of these tests will vary depending on the pretest probability of disease in the patient and severity of disease.

You decide to send the patient for a thallium stress test. However, since his exercise capacity is limited, you choose to stress him chemically. The patient is taking theophylline for chronic obstructive pulmonary disease (COPD)

The LEAST desirable method of stressing this patient is:
A) Adenosine.
B) Dobutamine.
C) Dipyridamole.
D) All of the above are equally acceptable methods of chemically stressing this patient.
E) Neither A nor C is desirable.

Answer And Discussion
The correct answer is “E.”
Theophylline (and caffeine) interact with both adenosine and dipyridamole, attenuating their effect; thus, neither is a good choice for stressing this patient.
Dobutamine is an acceptable method of chemically stressing those on theophylline or caffeine.

The patient’s thallium stress test shows a non reversible defect. The best interpretation of this is that it indicates:
A) Attenuation artifact from breast tissue.
B) Prior myocardial infarction.
C) Angina.
D) Anomalous cardiac circulation.
E) It is not significant and therefore adds no value to this test.

Answer and Discussion
The correct answer is “B.”
A non reversible defect suggests prior myocardial infarction. A reversible defect suggests inducible ischemia.
“A” is incorrect since breast attenuation occurs mostly in women.
“C” is incorrect since angina is manifested by a reversible deficit.

Since a reversible defect was not found on the thallium stress test, you conclude that there is no myocardium currently at risk. However, the patient continues to have chest pain and now at an increasing frequency with less exertion. He is asymptomatic when he presents to your office. He was noted at the last visit to have an elevated glucose at 350 mg/dL.

What is the next step in the evaluation or treatment of this patient?
A) Stress echocardiogram to document what segments are involved.
B) Start the patient on insulin to control his blood sugars.
C) Proceed directly to cardiac catheterization.
D) Since there were no reversible deficits on thallium stress, schedule the patient to see a gastroenterologist.
E) Give a trial of NSAIDs to help differentiate chest wall pain from other causes.

Answer And Discussion
The correct answer is “C.”
A” is incorrect since we already have done a noninvasive test. We already know what segment has previously been infarcted, as noted on the thallium stress test.
“B” is incorrect for two reasons. First, addressing his diabetes will not address the immediate problem of what you must presume is unstable angina. Second, insulin is not necessarily the first drug to use in this patient who presumably has type 2 diabetes. Certainly, the blood glucose needs to be addressed and so does the chest pain.
“D” is incorrect. The sensitivity of thallium testing is in the 88% range  so it will miss 12% of disease. Thus, we still have not proven in this high-risk patient that he does not have treatable cardiac disease causing his chest pain.
“E” is incorrect for the same reason.

The patient has a catheterization done that shows three-vessel disease including left main CAD. The cardiologist calls you with the report the next day and suggests PTCA with stenting, since, in his opinion, “this is the best modality for diabetics and diabetics are high-risk candidates when it comes to surgery.”

Your opinion is that:
A) Patients generally have better outcomes in terms of control of angina with stenting when compared with coronary artery bypass grafting (CABG).
B) Diabetic patients do particularly well with stenting when compared with CABG.
C) Medical control of symptoms is indicated as the best management in this diabetic patient with
three-vessel disease.
D) You would like to send this patient for CABG.
E) None of the above.

Answer And Discussion
The correct answer is “D.”
This patient should probably have surgery for his three-vessel disease because diabetic patients generally have worse outcomes with stenting than do non-diabetic patients.
“A” is incorrect because a proportion of patients with stents have to go on to have an open CABG. “B” is incorrect. Diabetic patients do particularly poorly with stents
when compared with other patients. Diabetic patients have a much higher rate of secondary occlusion.
“C” is incorrect. The indications for CABG are significant left main CAD (>50%) or three-vessel disease with evidence of LV dysfunction (ejection fraction <50%). This patient has left main vessel disease and thus medical control is not the best option for this patient.

Your patient has a CABG and comes into your office complaining of chest pain and fever 3 weeks after the surgery. He has had the pain and fever for 4 days and does not seem to be getting any better. He has no cough, no sputum production, and the pain seems to be worse when he breathes or lies down. He reports no dyspnea and has 97% oxygen saturation on room air. The wound from the surgery is well healed, and a chest radiograph shows no evidence of abnormalities.

Which of these studies is LEAST likely to be abnormal in this patient?
A) ECG.
B) V/Q scan.
C) Echocardiogram.
D) Sedimentation rate.

Answer And Discussion
The correct answer is “B.” A V/Q scan is not likely to be positive in this patient. This patient is unlikely to have a PE given the duration of symptoms, the fact that the patient has chest pain that worsens with inspiration (found in only 59% of those with PE), and that he is febrile, reports no dyspnea, and has a normal oxygen saturation. Certainly, this could still be a PE, but it would be less likely than other, more plausible, explanations.
The most likely diagnosis in this patient, given the lack of other symptoms, is postpericardotomy syndrome. This is similar to Dressler syndrome, which occurs after a myocardial infarction and presents with fever and chest pain several days to weeks after the inciting event. The white blood count is often elevated, as is the sedimentation rate. The ECG can also be helpful as can an echocardiogram.

You obtain an ECG on this patient that shows a pattern consistent with pericarditis.

Which of the following patterns can be seen in a patient with pericarditis?
A) Diffuse ST segment elevation.
B) Normal ECG.
C) LBBB.
D) A and B.
E) All of the above.

Answer And Discussion
The answer is “D.”
Both diffuse ST segment elevations and a normal ECG can be seen with pericarditis.
The initial ECG is only 80% sensitive for pericarditis. Small (low voltage) QRS complexes or electrical alternans can also be seen with pericarditis.
“C” is incorrect since bundle branch blocks have nothing to do with pericarditis.

You decide to treat this patient for pericarditis based on echocardiogram and an ECG consistent with this diagnosis.

Which of the following drugs might be helpful in this patient?
A) Heparin.
B) Warfarin.
C) Furosemide.
D) Indomethacin.
E) None of the above.

Answer And Discussion
“D” is correct.
You must prescribe an antiinflammatory in this patient. You can use aspirin, an NSAID, or steroids. Generally, indomethacin or aspirin are considered first-line drugs with steroids being reserved for those who fail NSAID therapy. Do not use anticoagulation, either heparin or warfarin, in patients with pericarditis. This can cause bleeding into the pericardial space and tamponade. Thus, “A” and
“B” are incorrect. “C” is incorrect because furosemide will likely make this patient worse. Patients with increased pericardial pressures are dependent on circulating preload volume in order to fill the right heart. Decreasing the preload may worsen this patient’s
dyspnea.

The patient returns the next day and is feeling more short of breath. On exam, you notice JVD and peripheral edema.

The best initial treatment of this patient is:
A) Furosemide.
B) Nitroglycerin.
C) IV saline.
D) Morphine.

Answer And Discussion
The correct answer is “C.”
This patient is in “pure” right heart failure secondary to cardiac tamponade. He is preload dependent. The treatment is to increase his preload by using IV saline. All the other options reduce the preload and will worsen this patient’s symptoms.

You give a bolus of IV saline, but he remains dyspneic with elevated neck veins and has a pulsus paradoxus of 14 mm Hg (normal <10 mm Hg).

The next step for this patient is:
A) Change the patient to steroids from indomethacin.
B) Perform a pericardiocentesis.
C) Start a positive inotrope (e.g., dopamine) to improve right heart function.
D) Start an afterload reducer to reduce cardiac demand.

Answer And Discussion
The correct answer is “B.”
The patient is clearly not doing well if he is getting more short of breath and not responding to your treatment. The pulsus paradoxus is 14 mm Hg. This is indicative of possible cardiac tamponade, but it may be seen in constrictive pericarditis, severe asthma, or anything else that reduces right heart filling (e.g., tension pneumothorax). This patient’s clinical picture is consistent with decompensated
cardiac tamponade, and drastic action is indicated to relieve the symptoms of right heart failure.
The definitive treatment is pericardiocentesis.
“A” is incorrect because more drastic action is required. You would be correct to change the patient if he were failing an NSAID but was not decompensated.
“C” is incorrect since an inotrope will do little to help this problem. “D” is incorrect for two reasons: the first is that this is a right heart problem and reducing afterload (systemic vascular resistance) will not help the right heart, which pumps against pulmonary resistance; second, most drugs that reduce systemic vascular resistance will also decrease preload to some degree, worsening the symptoms of tamponade.to prednisone.

You perform a pericardiocentesis and the patient gets better. 

This case study hopefully helped you to learn the following objectives:

• Evaluate a patient with typical anginal chest pain
• Describe the test characteristics of various types of noninvasive cardiac testing
• Become familiar with the interpretation of noninvasive cardiac testing
• Recognize various indications for PTCA with stent placement versus CABG
• Understand the physiology, presentation, and treatment of postpericardotomy syndrome
• Treat pericarditis and cardiac tamponade