Medicine

A 38-year-old man has episodic chest pain.

He states that the pain feels like tightness, located right behind his sternum, lasts less than 3 minutes and is relieved with rest. He takes no medications. He has no family history of coronary disease and has never smoked. His ECG in the office is normal. What is the most appropriate test to exclude cardiac ischemia?

  1. A Cardiac CT
  2. B Exercise ECG Correct answer
  3. C Resting echocardiogram
  4. D Creatine kinase enzyme

Explanation

Core Concept: Stable angina pectoris is characterized by predictable, exertional chest pain relieved by rest, caused by fixed atherosclerotic coronary artery stenosis.

Clinical Presentation:

  • Retrosternal pressure or tightness lasting <10 minutes, triggered by physical exertion or emotional stress.
  • Complications: Acute coronary syndrome (MI) and sudden cardiac death.

Diagnosis:

  • First-line: Resting 12-lead ECG (often normal when asymptomatic).
  • Gold Standard: For patients with an intermediate pre-test probability of CAD and a normal baseline ECG capable of exercising, an Exercise ECG (treadmill stress test) is the most appropriate initial non-invasive test to provoke and document ischemic ST-segment changes.

Management:

  • Acute: Sublingual nitroglycerin for immediate symptom relief.
  • Long-term/definitive: Antianginal therapy (beta-blockers, calcium channel blockers), high-intensity statins, aspirin, and aggressive lifestyle modification.

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