A 65-year-old man with a past medical history of diabetes, hypertension, hyperlipidemia, and coronary artery disease status post bypass grafting in 2012 (left internal mammary artery to first obtuse marginal, right internal mammary artery to left anterior descending coronary artery, saphenous vein graft to right posterior descending artery) presented for routine follow-up with exertional dyspnea and fatigue. He stated that he leaves his apartment on most days and is able to walk up to five blocks prior to stopping to rest. He felt he was able to walk farther a few months ago. He was also less capable of performing his usual activities around the house due to lack of energy. His current medication regimen included aspirin 81 mg daily, atorvastatin 80 mg at bedtime, metoprolol succinate 50 mg daily, and isosorbide mononitrate sustained release 60 mg daily. His vitals were as follows: heart rate 53 bpm, blood pressure 138/77 mmHg, and oxygen saturation 99% on room air. His physical exam was unremarkable. His electrocardiogram (ECG) in clinic showed sinus bradycardia with voltage criteria for left ventricular hypertrophy and a left bundle branch block.
Which of the following is the best initial step in evaluation and management of his symptoms?
The correct answer is: D. Order an exercise nuclear myocardial perfusion imaging test
Any patient with a history of ischemic heart disease who develops recurrent symptoms after having been symptom free for a period of time after revascularization warrants further evaluation for progression of atherosclerotic disease. According to the 2012 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for the diagnosis and management of patients with stable ischemic heart disease (SIHD), patients with known SIHD who have recurrent but stable symptoms not consistent with an acute coronary syndrome should undergo noninvasive testing. Those who are able to exercise should undergo a stress test with exercise rather than a pharmacologic agent. This patient had a left bundle branch block, rendering his ECG uninterpretable for ischemic changes, so he should have undergone nuclear perfusion imaging rather than an ECG (Class I recommendation, level of evidence B).
Neither answer A nor B would be appropriate as the next initial step in management because this patient presented with recurrent symptoms after undergoing revascularization with coronary artery bypass graft surgery and warranted further evaluation to establish a diagnosis. Answer E is not correct because the current guidelines recommend noninvasive rather than invasive imaging as the first step in diagnosis of recurrent symptoms. According to the 2017 ACC/AHA appropriate use criteria for coronary revascularization in SIHD, it is appropriate to consider percutaneous coronary intervention in patients with ischemic symptoms who have intermediate- or high-risk findings on stress testing and who are on at least one antianginal medication.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012;126:e354-471.
Fihn SD, Blankenship JC, Alexander KP, et al. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 2015;149:e5-23.
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