Chest pain best next step??!!?

[adagio]

48 yo female comes to office with chest pain that has been occurring over the last several weeks. the pain is NOT reliably related to exercise. She is comfortable now. The location of the pain is retrosternal. She has no past medical history, and the EKG is normal.

What is the most appropriate next step in management?

1- CK-MB
2-Troponin
3- EChocardiogram
4- Exercise tolerance testing
5-Angiography
6-CT angiography
7-Cardiac MRI
8-Holter Mointoring



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The book says the choice is Exercise stress testing, but shouldnt we get a troponin to see whether she was have a NSTEMI and infarcting during her last episodes before we stress?

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[Jccripe]

If the pain is unreliably related to exercise, this is a big hint that the pain is due to prinzmetal angina/ vasospasm. Thus, cardiac enzymes will all be normal. Stress to rule out stable/ unstable angina.

 

[adagio]

what if the sentence was pain was related to exercise, what would the next step be? Tropo or Stress testing?

 

[Jccripe]

what if the sentence was pain was related to exercise, what would the next step be? Tropo or Stress testing?

Def. trop and enzymes. Stressing someone with stable/ unstable angina can cause an MI or expand an existing MI.

 

[adagio]

Def. trop and enzymes. Stressing someone with stable/ unstable angina can cause an MI or expand an existing MI.

but the story is that the lady is not having pain now, and as far as i understand, the pain is what precludes the Stressing, and her ekg is normal, so what would it be best step? stress or enzymes?

 

[Fuzuli]

If the pain is unreliably related to exercise, this is a big hint that the pain is due to prinzmetal angina/ vasospasm. Thus, cardiac enzymes will all be normal. Stress to rule out stable/ unstable angina.

A 48 year old woman who has only one of the classical symptoms of angina has a very low pretest probability of CAD. Performing a stress test is inappropriate for this patient.

48 yo female comes to office with chest pain that has been occurring over the last several weeks. the pain is NOT reliably related to exercise. She is comfortable now. The location of the pain is retrosternal. She has no past medical history, and the EKG is normal.

What is the most appropriate next step in management?

1- CK-MB
2-Troponin
3- EChocardiogram
4- Exercise tolerance testing
5-Angiography
6-CT angiography
7-Cardiac MRI
8-Holter Mointoring

None of the above The likelihood of the patient having CAD is very low, so I would look for non-cardiac causes of chest pain. For example, make the pain related with large meals and fatty foods and add "trial of PPI" to the answer choices.

 

[adagio]

hi fuzuli, this is a question on MTB 2, and Fischer chose Stress testing!!!!! and this is why i am asking

 

[Fuzuli]

hi fuzuli, this is a question on MTB 2, and Fischer chose Stress testing!!!!! and this is why i am asking

Can you paste the whole question here? Maybe there's something else that increases the risk of the patient. If this is the whole question, that MTB is incorrect:

An issue with exercise testing is its predictive value. On the basis of Bayes' theorem ( Chapter 9 ), ST segment shifts on exercise testing in patients with a low probability of angina will most often be false-positives, whereas the same changes in patients with a higher clinical probability of the disease will almost always represent true-positives. It can be argued that a positive test result only confirms a diagnosis when the probability of CHD is high, whereas a negative test result is not discriminatory enough for diagnosis, and that a negative test result is only confirmatory when the probability is low, whereas a positive test result has little effect on the probability ( Fig. 70-3 ). As a result, the strongest indication for diagnostic exercise testing is in patients with an intermediate (10% and 90%) pretest probability of CHD (see Table 70-1 ).

("Angina Pectoris", Cecil Textbook of Medicine, 23rd edition)

 

[adagio]

I assure you this is the FULL question, nothing else in it...

 

[nlax30]

Keep in mind you are choosing the "best" answer from the choices provided. So in this case, among those choices, I'd pick stress testing as well.

 

[MedLover25]

If the pain is unreliably related to exercise, this is a big hint that the pain is due to prinzmetal angina/ vasospasm. Thus, cardiac enzymes will all be normal. Stress to rule out stable/ unstable angina.

What? Prinzmetal's, first off, is "something taught in med school" and they give us those nifty buzz words to help us "recognize it" on a test....in the real world....NO ONE makes the diagnosis that way.

Also, enzymes CAN be abnormal, because vasospasm CAN cause damage.

Prinzmetal's can also be confused with esophageal spasm (both treated with CCBs anyways).

The point of the question is "a person has had a history of chest pain" (maybe with some exercise, maybe without it)....and since you're not all-knowing....better do a stress test and get an idea of what's going on