A 69-year-old male from home is brought to the emergency department complaining of substernal non-radiating chest pain along with diaphoresis. He experienced significant pressure in the anterior chest after eating dinner and while cleaning the kitchen. The patient has a history of hypertension, hyperlipidemia, poorly controlled diabetes, COPD, gout, hypothyroidism, and severe osteoarthritis. He has no significant surgical history but is waiting to see orthopedic surgery next week. The patient has a family history of coronary artery disease. He is a long-term heavy smoker, drinks two beers daily, but denies recreational drug use. BP is 158/93, HR is 79, saturating 95% on room air. Serial ECGs shows normal sinus rhythm with no ST or T wave changes. Labs are unremarkable except a glucose of 482 and an elevated creatinine of 1.2. Serial troponins are negative.
Which of the following is the next step in management?
- A) Urgent coronary angiogram
- B) Provide reassurance and discharge home with education on lifestyle changes
- C) Outpatient dobutamine stress echocardiogram
- D) Admit to the hospital and administer insulin
- E) Outpatient exercise stress test ECG
C) Outpatient dobutamine stress echocardiogram
This patient initially presents with symptoms concerning for acute coronary disease. It is important to rule out ischemia with serial ECGs, troponins, and closely monitoring his symptoms. The absence of significant ECG findings and troponin elevation rule out STEMI and Unstable angina/NSTEMI. Therefore, urgent coronary angiogram is not indicated at this time. However, the patient’s chest pain and significant risk factors still raise concern for coronary artery disease. The next best step would be a dobutamine stress test as the patient has limited ability to perform an exercise stress test- the most appropriate initial test when there is a concern for stable coronary artery disease – due to his severe osteoarthritis pending surgical evaluation. Management of this patient’s risk factors are essential as well, however, these require chronic outpatient management.
Dr. Raj Dasgupta