Item ~?Mark <?

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A 34-year-old woman comes to the physician with a several-month history of chest pain.
The pain is left-sided, does not change with deep inspiration, and typically lasts several
hours. She currently has the pain; it is unrelated to physical activity but worsens with
emotional stress. The patient has no cough, syncope, or shortness of breath. She has
no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes
no medications and. has no drug allergies. Her blood pressure is 11 0/70 mm Hg and
pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation.
Electrocardiogram (ECG) shows normal sinus rhythm with no significant abnormalities.
Which of the following is the best next step in the management of this patient?

0 A. Exercise electrocardiogram testing

0 B. Exercise myocardial perfusion imaging
0 C. Lower-extremity venous ultrasonography
0 D. No further testing for coronary artery disease
0 E. Transthoracic echocardiography

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Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
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A 34-year-old woman comes to the physician with a several-month history of chest pain.
The pain is left-sided, does not change with deep inspiration, and typically lasts several
hours. She currently has the pain; it is unrelated to physical activity but worsens with
emotional stress. The patient has no cough, syncope, or shortness of breath. She has
no significant family history and does not use tobacco, alcohol, or illicit drugs. She takes
no medications and has no drug allergies. Her blood pressure is 11 0/70 mm Hg and
pulse is 78/min. Heart sounds are normal. Lungs are clear to auscultation.
Electrocardiogram (ECG) shows normal sinus rhythm with no significant abnormalities.
Which of the following is the best next step in the management of this patient?

A Exercise electrocardiogram testing [21%]

B. Exercise myocardial perfusion imaging [5%]
C. Lower-extremity venous ultrasonography [1%]
D. No further testing for coronary artery disease [65%]
E. Transthoracic echocardiography [8%]

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Explanation: User ld

Evaluation of chest pain

Pretest probability of
coronary artery disease

Low Intermediate High

No additional Able to exercise Start pharmacologic

diagnostic testing therapy for CAD
Yes No

Normal ECG Pharmacologic stress

imaging test
IExpert evaluation I
Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
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Evaluation of chest pain

Pretest probability of
coronary artery disease

Low Intermediate High

No additional Able to exercise Start pharmacologic

diagnostic testing therapy for CAD
Yes No

Normal ECG Pharmacologic stress j Expert evaluation I

imaging test
Yes No

Exercise Exercise
ECG test imaging test
Positive Positive Positive

Coronary
angiography
©UWorld

The pretest probability of coronary artery disease (CAD) is based on age, gender,
cardiac risk factors, and chest pain characteristics. Low-risk patients include men age
<40 and women age <50 with atypical chest pain and no significant cardiac risk factors
(eg, non-smoker, no family history of premature CAD).
A positive stress test in patients at low risk for CAD is likely to be a false positive, which
can lead to further unnecessary testing or procedures. Conversely, a negative test in
high-risk patients is likely a false negative. For this reason, patients with high-risk
features for symptomatic CAD should be definitively evaluated with coronary
angiography. Stress testing (eg, exercise electrocardiography, myocardial perfusion
imaging) is most helpful for risk stratification in patients with intermediate-risk features
(Choices A and B). The choice of test is determined based on baseline
electrocardiogram (ECG) findings and the ability to exercise.

This patient has had chest pain for several months that is unrelated to physical activity.
She is vouno. has no risk factors for develooment of oremature CAD. and her ECG was

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 ©UWorld

The pretest probability of coronary artery disease (CAD) is based on age, gender,
cardiac risk factors, and chest pain characteristics. Low-risk patients include men age
<40 and women age <50 with atypical chest pain and no significant cardiac risk factors
(eg, non-smoker, no family history of premature CAD).

A positive stress test in patients at low risk for CAD is likely to be a false positive, which
can lead to further unnecessary testing or procedures. Conversely, a negative test in
high-risk patients is likely a false negative. For this reason, patients with high-risk
features for symptomatic CAD should be definitively evaluated with coronary
angiography. Stress testing (eg, exercise electrocardiography, myocardial perfusion
imaging) is most helpful for risk stratification in patients with intermediate-risk features
(Choices A and B). The choice of test is determined based on baseline
electrocardiogram (ECG) findings and the ability to exercise.

This patient has had chest pain for several months that is unrelated to physical activity.
She is young, has no risk factors for development of premature CAD, and her ECG was
normal. In light of this, she has a low pretest probability of CAD and additional testing for
CAD not advised.

(Choice C) This patient has no symptoms or signs suggesting deep venous thrombosis
or pulmonary embolism (eg, pleuritic pain, dyspnea, tachycardia). Lower-extremity
venous ultrasonography Is therefore not indicated.

(Choice E) A transthoracic echocardiogram can assess for segmental wall motion

abnormalities during an episode of chest pain, or after exercise in a diagnostic stress
test. It can also be used to look for valvular pathology (eg, aortic stenosis) in patients
with exertional chest pain and a suspicious murmur or other signs of valve disease.

Educational objective:
Diagnostic testing for coronary artery disease (CAD) should not be performed routinely in
low-risk patients as they frequently can have false-positive test results. Patients with
intermediate probability of CAD should receive appropriate stress testing based on
electrocardiogram (ECG) findings and their ability to exercise. High-risk patients should
be started on appropriate medical therapy, with expert evaluation to consider coronary
angiography.

References:
1. The chest pai n choice decision aid: a randomized trial.

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 Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
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Media Exhibit

probability of coronary artery disease I

Pretest probability of coronary artery disease

Low • Asymptomatic people of all ages

(<10%) • Atypical chest pain in women age <50

• Atypical angina in men of all ages

Intermediate
• Atypical angina in women age >50
(20%-80%)
• Typical angina in women age 30-50

High • Typical angina in men age >40

(>90%) • Typical angina in women age >60
~UWortd

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 Item ~?'Mark <] C> !j ~~ ~ , 0I[AJ
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Media Exhibit

:ation of angina

Classification of angina

• Typical location (eg, substernal), quality (eg, pressure)

& duration (eg, >20 min)
Classic
• Provoked by exercise/emotional upheaval
• Relieved with nitroglycerin or rest

Atypical • 2 of 3 classic angina characteristics

Non-anginal • 0 or 1 of 3 classic angina characteristics

© UWorld

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