A 53-year-old woman with no known medical history presents to her primary care physician’s office to establish care. The patient reports she has not seen a doctor since her teenager years because hospitals make her nervous. She reports experiencing intermittent chest pain that is exacerbated by exertion and is alleviated by rest. She reports her mother died of MI at age 74, and her father is receiving dialysis for renal failure. She also mentions both of her hands have been very stiff in the morning for a couple hours which improves as the day goes on, and she has been somewhat fatigued. She has been taking over the counter ibuprofen daily for pain and discomfort. Otherwise, she denies hair loss, headache, oral ulcers, dyspnea, abdominal pain, rash, joint swelling, fever. An ECG was obtained in office which showed no significant ST/T wave changes and a stress test is scheduled for the patient.
What is the next best immediate step in management?
- A) Order troponin as an outpatien
- B) Obtain bilateral hand x-ray
- C) Order ANA
- D) Discontinue ibuprofen
- E) Refer to physical therapy
D) Discontinue ibuprofen
This patient’s presentation is concerning for rheumatoid arthritis as her pain is consistent with an inflammatory arthritis picture with significant morning stiffness and pain that improves with activity. Rheumatoid arthritis patients have an approximately 3x increased risk of atherosclerotic cardiovascular disease which may lead to sudden death due to MI. The patient has been taking ibuprofen daily, remember that all NSAIDs increase the risk for cardiovascular events including MI and stroke. Therefore, it is best to advise the patient to discontinue ibuprofen at this time as she is currently showing symptoms concerning for coronary artery disease.
Troponin is not ordered as an outpatient lab, and it is not indicated at this time as patient’s chest pain pattern is most consistent with stable angina. Bilateral x-ray is used to identify joint changes, however, the immediate next step would be to advice the patient on risks of taking ibuprofen. ANA is non-specific and can be positive in a small percentage of healthy patients as well, it is rarely the correct answer on board exams. Anti-RF and anti-CCP are ordered for RA. Physical therapy is not indicated at this time as patient’s inflammatory arthritis presentation should be worked up first.
Key Learning Point
Coronary artery disease is the leading cause of death in rheumatoid arthritis patients. NSAIDs increase the risk for cardiovascular events. Avoid using NSAIDs in patients presenting with possible CAD, and in any patients with a recent history of myocardial infarction.
Dr. Raj Dasgupta