This 44-year-old man comes into the office complaining of indigestion
that occurs only when he climbs stairs or carries heavy packages in from a car.
The discomfort occurs over his sternum -- over his breast bone -
and goes away a few minutes after he rests and stops exertion.
His history is as follows: he recently recovered from a viral upper respiratory infection -
a cold, he smokes 2 packs of cigarettes and has been doing that for 24 years,
he has a history of hypertension that's been plus/minus controlled,
and he's been told he has abnormal cholesterol values, and we order an electrocardiogram.
So, the important aspect here is exercise brings on chest discomfort
and he has coronary heart disease risk factors. So, let's look at his ECG.
And here, take a look at it for a few minutes and see what you think.
So, this ECG has some abnormal ST and T waves but it's really non-specific.
It's not like the last one where we saw the nice squared-off ST segment depression
so this could be consistent with ischemia though because it's non-specific
but maybe he has a low blood potassium. There could be many causes of this.
He could also be hypoxic because he may have lung disease from all of his years of smoking cigarettes.
So, the ECG doesn't show us a myocardial infarct
but does show us some abnormalities in the ST and T waves.
And as said, there could me many causes: ischemia, drugs can sometimes do this,
hypoxia as I mentioned, sometimes infections, there could be central nervous system disease,
a stroke, many, many others. So, it's not a specific ECG.
So, we're thinking from the story that he has angina pectoris
because he gets chest discomfort when he climbs the stairs that's consistent with angina,
consistent with myocardial ischemia, lack of blood flow in the heart muscle.
So, what are the diagnostic tests that we could do? Well, we could do abdominal ultrasound
but I don't think we're gonna do that.
We could do a CT coronary calcium scan that would tell us if there's atherosclerosis
or we could do an ECG exercise test.
That's probably the best test to start with, an ECG exercise test.
If the patient didn't wanna do that, you could do coronary calcium
and see if there was a lot of atherosclerosis there.
The abdominal ultrasound might be done if the coronary work up turn out to be negative
and you were looking for peptic ulcer disease or like the last case,
a cholecystitis or a cholelithiasis that is stones in the gall bladder.
And of course, we're gonna look at his cholesterol lipids to confirm that he's at risk for atherosclerosis.
So, let's say we decide that this man does indeed have angina pectoris.
Let's say he has a stress test that's positive.
So the first step wouldn't be to rush to the cath lab and put in a stent but it would be to do a medical therapy.
First, we would give him a statin to lower his cholesterol values.
Then, we would control his blood pressure with antihypertensive drugs, probably a beta blocker
and possibly either an angiotensin receptor blocker or an angiotensin converting enzyme blocker.
We would give him a platelet activation blocker, probably low dose aspirin, perhaps 81 mg.
And he might at some point depending on how positive his exercise test,
he might down the road get coronary angiography and a possible stenting of a blocked coronary artery.
How would we decide that? We would look to see how nasty his exercise test look.
If at a very low level of exercise he had marked ST depression and severe long-lasting angina,
that would push us in a direction of angioplasty
because we would be worried that there was a lot of myocardium not getting blood flow.
But suppose the medical therapy worked. His angina goes away or his chest discomfort goes away.
He leads a normal life, he gets his cholesterol level down, and he's perfectly happy.
The long-term results are just as good with medical therapy as with angioplasty
so we wouldn't rush him to angioplasty.
And of course, we'd want to work with him for smoking cessation.
If he continues to smoke, his likelihood of having a heart attack
or living a long-time is markedly reduced
and usually we refer such a patient to a cardiac rehabilitation program
where there's education-graded exercise and where they exercise,
physiologists and nurses watch the patient carefully to make sure that when he exercises, it's safe.