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Adenosine stress ECG
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Administration of sublingual nitroglycerin
Cardiac catheterization
Dobutamine stress echocardiogram
Exercise ECG
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This patient who presents with substernal pain that is exertional and relieved by rest, as well as a resting ECG without ischemic changes, most likely has stable angina. The most appropriate next step in the management of suspected stable angina is an exercise ECG to confirm the diagnosis and provide prognostic information.Stable angina is caused by a fixed, non-occlusive coronary artery obstruction that leads to myocardial ischemia when myocardial oxygen demand exceeds supply such as during exercise. In patients without contraindications to exercise such as physical disability or decompensated heart failure, an exercise ECG can be performed alone or in combination with an exercise echocardiogram to demonstrate ischemic changes during periods of increased myocardial oxygen demand. During acute anginal episodes, short-acting nitrates such as sublingual nitroglycerin can provide rapid symptomatic relief. Long-term management aims to prevent anginal episodes using monotherapy or combination therapy with beta-blockers, calcium channel blockers, and/or long-acting nitrates. Patients with stable angina should also receive aspirin and a statin, as well as possibly an angiotensin-converting enzyme inhibitor.Maron et al. studied invasive therapy versus optimal medical therapy for preventing cardiovascular events. They found that a composite outcome of cardiovascular death, myocardial infarction, hospitalization for unstable angina, or heart failure did not differ significantly between the invasive and medical therapy groups. An initial conservative strategy is a reasonable approach for patients with stable angina with moderate to severe ischemia.Figure/Illustration A shows a resting ECG without signs of acute ischemia and normal appearing waveforms (red circle). This finding is consistent with a diagnosis of stable angina. Incorrect Answers:Answer 1: Adenosine stress ECG is a pharmacologic stress test that can be used in patients with contraindications to exercise. Adenosine is contraindicated in patients with reactive airway disease.Answer 2: Administration of sublingual nitroglycerin can be used for symptom relief during an acute anginal episode. Nitroglycerin is a short-acting nitrate that causes systemic vasodilation. It is not indicated in this patient with no current anginal symptoms.Answer 3: Cardiac catheterization is the next step in the management of acute coronary syndrome. Worsening chest pain or chest pain at rest would be expected in ACS, along with ST-segment changes on resting ECG. Cardiac troponins would also be elevated in NSTEMI and STEMI.Answer 4: Dobutamine stress echocardiogram is a pharmacologic stress test used in patients with contraindications to exercise. Pharmacologic stress testing typically combines imaging with ECG to increase sensitivity. Dobutamine is a beta-1-adrenergic agonist with positive inotropic and chronotropic effects. It is not indicated in this patient who can exercise.Bullet Summary: A patient with suspected stable angina, a normal resting ECG, and no contraindications to exercise should be further evaluated with an exercise ECG.
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