MKSAP: 59-year-old woman with continued substernal chest pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 59-year-old woman is evaluated for continued substernal chest pain. She presented with exertional chest pain 6 months ago that occurred with minimal ambulation. She was evaluated with a stress nuclear medicine myocardial perfusion study that showed no ST-segment changes but a small area of inducible ischemia in the lateral area of the left ventricle and an ejection fraction of 45%. She was initially treated medically but has continued to have chest pain with exertion despite the addition of multiple antianginal agents. Medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She has a 30-pack-year smoking history but quit 1 year ago. Medications are aspirin, lisinopril, simvastatin, metformin, metoprolol, and long-acting nitroglycerin. On physical examination, the patient is afebrile, blood pressure is 132/72 mm Hg, pulse rate is 68/min, and respiration rate is 16/min. BMI is 28. The remainder of her physical examination is normal. Electrocardiogram is unchanged from the time of her stress test. Which of the following is the most appropriate next step in management? A. Cardiac catheterization B. CT angiography C. Dobutamine stress echocardiography D. Continued medical therapy Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Heart Source Type: blogs