Evaluation of Chest Pain in a Young Woman
A 24-year-old female presents with intermittent chest pain described as pressure on both sides of her sternum, as though someone were pushing on her chest. This is accompanied by a sharp sensation that extends out toward the shoulder. It occurs intermittently every few days and is more noticeable with exertion, though it can also happen at rest. The pain is accompanied by shortness of breath, which resolves with rest. She also experienced two episodes of presyncope with chest pain and facial drooping during exertion a few months ago, which resolved without deficits.
Her past medical history includes iron deficiency anemia, depression, and unspecified vasculitis. She has been on steroids for the past 5 years, beginning at the time of right leg claudication, when she was found to have a distal femoral artery occlusion with extensive collateralization. A year later, she experienced right arm claudication and was found to have subclavian artery stenosis. Her symptoms have improved with treatment, though she reports ongoing leg cramping and fatigue, which limit activity.
Physical examination is notable only for borderline low blood pressure and a weak right radial pulse. An echocardiogram was normal with no resting wall motion abnormalities.
Which of the following is the next best step in evaluation?