But in kaplan they use both modalities for the sake of investigating a possible ischemic event during stressing, and hence my question: if a patient comes with history of Angina, he has a previous EKG with LBBB abnormality from long time ago that is present on the current EKG, clearly this person cannot undergo EKG stress testing, but rather would require either a nuclear or echocardiographic testing: which one would you choose?
Let me put it this way:
A 45 year old man is referred to the cardiology outpatient clinic for evaluation of substernal chest pain not responding to PPIs. He has had this pain for 3 years. He says his pain is relieved somewhat with ibuprofen. He has a 20 pack-years history of smoking and medically controlled hypertension. His physical examination and EKG is normal. What is the best next step?
a) Standard exercise EKG test
b) Stress echocardiography
c) Stress myocardial perfusion nuclear imaging
d) Coronary angiography
e) Energy beam CT coronary angiography
There are three questions that need to be answered in this patient:
(1) Does he need a stress test?
(2) Can he physically handle exercise?
(3) Are there contraindications for the standard exercise stress test?
For (1), we have to talk about the pretest probability of the patient. Basically, patients are grouped into low (pretest probability <%10), intermediate (%10-90) and high risk (>%90) categories based on their age, gender and symptoms (1-Substernal pain 2-Increased with exercise 3-Relieved by rest). He has a relatively young age and has only one of the three classical symptoms, which puts him in the intermediate category. Since he belongs to intermediate category, he needs a stress test. If he were 30 years of age, his pretest probability would be lower than <%10, which would put him into low risk category. In that case, he wouldn't need a stress that.
So, he satisfies (1)
For (2), there's nothing in the question stem that would prevent him from exercising. But if he had severe exercise-induced asthma, that would have prevented him from exercising.
For (3), he doesn't have the contraindications for the stress that, such as LBBB, digoxin therapy, ventricular paced rhythm, previous CABG, etc. You've already written about these contraindications in your first post.
Therefore, a standard exercise EKG stress test is the most appropriate choice.
A 45 year old man is referred to the cardiology outpatient clinic for evaluation of substernal chest pain not responding to PPIs. He has had this pain for 3 years. He says his pain is relieved somewhat with ibuprofen. He has a 20 pack-years history of smoking, medically controlled hypertension and severe exercise-induced asthma. His physical examination reveals a 2/6 harsh systolic ejection murmur at second right intercostal space, which radiates to his neck. His EKG shows LVH and 1 mV ST segment depressions at leads V2 and V3. What is the best next step?
a) Standard exercise EKG test
b) Stress echocardiography
c) Stress myocardial perfusion nuclear imaging
d) Coronary angiography
e) Energy beam CT coronary angiography
Since exercise induced asthma would prevent him from exercising, a pharmacologic stress imaging study is required (choices B and C). Since he has a cardiac murmur consistent with aortic stenosis and that would also be needed to be controlled, echocardiogaphy is superior to nuclear imaging for this patient. Therefore, the answer is B.
A 45 year old man is referred to the cardiology outpatient clinic for evaluation of substernal chest pain not responding to PPIs. He has had this pain for 3 years. He says his pain is relieved somewhat with ibuprofen. He has a 20 pack-years history of smoking and medically controlled hypertension. He has a note from his primary physician that his medical records are incomplete and he may had an acute coronary event one year ago. His physical examination reveals no apparent murmurs. His EKG shows LBBB. What is the best next step?
a) Standard exercise EKG test
b) Stress echocardiography
c) Stress myocardial perfusion nuclear imaging
d) Coronary angiography
e) Energy beam CT coronary angiography
Now this is somewhat contrived by I didn't want to change the whole question stem
🙂 Since he has LBBB, he's not eligible for the standard stress test. In addition, he may have had a previous coronary event, so determination of the location and extent of ischemia is needed and nuclear imaging is superior for this purpose. Therefore, the answer is C.
Hope this helps.
