Mr. W is a 56-year-old man who comes to your office with chest pain.

Mr. W has a history of well-controlled hypertension and diabetes. He has been having symptoms for the last 4 months. He feels squeezing, substernal pressure while climbing stairs to the elevated train he rides to work. The pressure resolves after about 5 minutes of rest. He also occasionally feels the sensation during stressful periods at work. It is occasionally associated with mild nausea and jaw pain. Medications are metformin, aspirin, and enalapril.

Mr. W is a middle-aged man with chronic, nonpleuritic chest pain and risk factors for coronary artery disease (CAD). His symptoms are consistent with stable angina. The pivotal points in this case are the chronicity, exertional nature, and substernal location of the pain. Given the seriousness and prevalence of CAD, it must lead the differential diagnosis. Gastroesophageal reflux disease (GERD) and musculoskeletal disorders are common causes of chest pain that can mimic angina (exacerbated by activity, sensation of pressure) and thus should be considered. The chronicity of his symptoms argues against many other worrisome diagnoses (eg, pulmonary embolism [PE], pneumothorax, pericarditis, or aortic dissection). Pain from a mediastinal abnormality is possible.

Physical exam is entirely unremarkable except for mild, stable, peripheral neuropathy presumably related to diabetes. The patient’s ECG is remarkable only for evidence of left ventricular hypertrophy with strain.

A tentative diagnosis of stable angina from CAD is made. Laboratory data are notable for normal blood counts and chemistries. There is hypercholesterolemia (LDL, 136 mg/dL; HDL, 42 mg/dL). Mr. W is referred for an exercise tolerance test. Because of his abnormal resting ECG, an exercise myocardial perfusion SPECT was performed. Although chest pain developed during the test, his results were normal without evidence of myocardial ischemia.

The results of the patient’s exercise test are surprising. Stable angina remains high in the differential despite the normal stress test but alternative diagnoses must be considered. The intermittent nature of the pain and the lack of constitutional symptoms both make a mediastinal lesion unlikely. The absence of a recent injury, change in activity or reproducible pain on physical exam moves musculoskeletal pain down on the differential. GERD is a common cause of chest pain and should be considered.

Prior to the stress test, Mr. W’s probability of having CAD was at least 92% (see Table 9-2). It is important to understand why the exercise test was done in this case. The diagnosis of coronary disease was essentially made by the history and physical. The exercise test was meant to guide therapy. Considering a pretest probability of 92%, and a LR– of about 0.15 for the exercise test, the posttest probability is 60%. This is still well above the test threshold for a potentially fatal disease like CAD.
Despite the results of the stress test, stable angina was considered more likely than GERD. Mr. W was given aspirin and a beta-blocker and underwent an angiogram the week after the visit. He was found to have a 90% stenosis of the mid left anterior descending artery and underwent PCI with stent placement.

 

 

Point in time is 1st visit.

 

S: 56 y/o man complains of chronic non-pleuritic chest pain for the past 4 months, seeks treatment now for squeezing, substernal pressure with occasional nausea and jaw pain, brought on by stairs and stress. Pressure resolves after 5 minutes of rest. Pt has a history of well-controlled HTN and diabetes and takes metformin, aspirin, and enalapril. Pt has several risk factors for CAD.

 

O: Physical exam: unremarkable except mild, stable, peripheral neuropathy

ECG: evidence of left ventricular hypertrophy with strain

Lab data: LDL, 136 mg/dL; HDL, 42 mg/dL

Exercise myocardial perfusion SPEC: normal but with chest pain

Pretest probability of CAD: 92%

Posttest probability of CAD: 60%

LR for exercise test: 0.15

 

A: stable angina/ CAD

GERD

 

P: aspirin and beta-blocker

Angiogram 1 week post-visit

 

Monica Benjamin, Physician Assistant Student

 

With the exception of the normal exercise test, the symptoms point to stable angina. As in Mr. W’s case, stable angina is characterized by substernal chest pressure upon exertion (stairs for Mr. W). Stable angina occurs when the heart does not receive enough oxygen, which is usually the result of coronary artery stenoses. Stable angina is highly associated with Coronary Artery Disease, which Mr. W has many risk factors for. Some risk factors for CAD are being male, being over the age of 55 for men and 65 for women, smoking, diabetes, hypertension, family history of cardiovascular disease younger than 55 for men and 65 for women, and an elevated lipid profile. Based on what we know, he is at risk based on age, sex, diabetes, hypertension, and an elevated lipid profile. Furthermore, smoking and family history has not been ruled out.

 

Another possible diagnosis is Gastroesophageal Reflux Disease (GERD), which often presents similarly to stable angina. GERD is primarily characterized by substernal burning or discomfort, which is the same area stable angina is felt. Other symptoms include regurgitation, dysphagia, and chest pain and are exacerbated at night and after consumption of large quantities of food.

 

Mr. W also had an exercise test performed, a typical diagnostic tool performed on patients with suspected stable angina. This test not only contributes to a diagnosis of CAD, but also provides information needed to choose a treatment option. These tests work by inducing ischemia in the heart, usually through exercise and monitoring the results with an ECG, echocardiogram, or nuclear imaging.