Q99) A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about three blocks and goes away with rest. He has developed a habit of taking rest when the chest pain comes and he did not think it needed medical attention until his friend told him yesterday that it might be a symptom of heart disease. He is concerned and requests your recommendation. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain. His past medical history is significant for pacemaker insertion for a symptomatic second degree heart block, Hypertension, and Smoking . His medications include lisinopril, atenolol and hydrochlorthiazide. Physical examination is benign. An EKG is obtained which reveals pacemaker rhythm with secondary ST-T changes. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization
B
Answer = E
The patient has multiple risk factors such as previous arrhytmia, Hypertension and smoking, 65 years old. and EKG changes. He needs to go for cardiac angiogram to check disease extension and decide management.
D
cause atenolol
E
on basline ekg already show the st-t changes then why should we do the stress test again to see the st-t changes
should do catheterization to rull out prognosis and guide the therapy
answer should be exercise thallium or exercise echo.
when u cannot read the ecg due to baseline abnormalities like lbbb or pacemaker use then it is exercise thallium or exercise echo.
c is the answer. thinking patient cannot exercise for maximal heart rate ,it should be dobutamine echo.
pacemaker use causing baseline abnormality,so 2 best methods of detecting ischemia without EKG are either nuclear isotope uptake thallium or sestamibi,or echocardiographic detection of wall motion abnormalities.
so I dont think answer is d,,, it could be persantine in combination with thallium
ccccccccccc
c
cant read ekg=stress echo
ddd, before angiography you need de dx, pt w/ bb, pacemaker no asthmatic or copd dypridamole is ok, in case of asthma use dobutamine.
B wrong – because of baseline EKG changes due to pacemaker.
A wrong – doesn’t reveal Ischemia
Principles -
If we can’t read EKG accurately and Pt can do treadmill exercise – we do
Treadmill/Stress Echo
OR Treadmill/Stress Thallium (AKA Nuclear Stress Test AKA Thallium Stress)
If we can’t read EKG and Pt CAN’T do exercise -
Dobutamine Echo
OR Persantin(Dipyridamole)Thallium Test AKA Persantin Stress Test
E Wrong – because we need to do some sort of stress test to reveal ischemia before an invasive catheterization.
In this case, both C and D can be done for this patient. Which is suitable and why ??
Actually, when the patient is on Beta blockers, Dobutamine cannot reach its maximal effect – ie the max HR cannot be reached. Therefore, Dobutamine echo is not the right answer.
E CORRECT ANS – On the other hand, Persantine mimics exercise by dilating the arteries. It does not raise HR, so B Blockers have no effect on Persantin.
Therefore, Persantin-Thallium Stress Test is the best test for this patient.
I meant D is the Correct answer