A 45-Year-Old with Dyspnea and Weakness

A 45-year-old woman presents to her primary care physician complaining of not feeling well with generalized fatigue and symptoms of major depression. She states that her mother died two months ago and her father had a stroke shortly afterwards. She also reports exertional dyspnea and chest tightness of several weeks duration. Her past medical history is significant for Grave's disease that was treated with total thyroidectomy, allergic rhinitis, major depression, and hyperlipidemia. Her medications include levothyroxine, escitalopram, and Flonase. On physical exam she was hemodynamically stable and afebrile, not in any acute distress, lungs clear to auscultation, heart sounds normal with regular rate and rhythm, no jugular venous distention noted, no lower extremity edema. She was referred for an exercise stress single-photon emission computed tomography myocardial perfusion imaging (MPI) study to further evaluate her symptoms. Her resting ECG is shown (Figure 1).

Figure 1: Resting ECG

Figure 1

She completed stage 3 on the Bruce protocol achieving a peak heart rate and blood pressure of 144 beats/min and 186/57 mm Hg, respectively. She reported no chest pain and test was stopped due to fatigue. The stress ECG and MPI images are shown (Figures 2 and 3).

Figure 2: ECG at peak exercise

Figure 2

Figure 3: MPI images (stress)

Figure 3

What is the best next step in management of the patient?

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