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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 the 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 smoked
two 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 EKG and here take a look at it for a
few minutes and see what you think
so this ECG has some abnormal s T and T
waves but it's really nonspecific 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 and on because it's
nonspecific 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
it does show us some abnormalities in
the s TN T waves Anna said there could
be 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 a thirst grossest or we could do
an ECG exercise test that's probably the
best test to start with an ECG exercise
test um if the patient didn't want to 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
workup turned out to be negative and you
were looking for peptic ulcer disease or
like the last case a Coley a
cholecystitis or a cholelithiasis that
is stones in the gallbladder and of
course we're going to 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
engine a 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 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 milligrams and he might at
some point depending on how positive his
exercise test
he might down-the-road get coronary
angiography and a possible standing of a
blocked coronary artery how would we
decide that we would look to see how
nasty his exercise test looked 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
myocardial not getting blood flow but
suppose the medical therapy worked his
angina goes away or his chest as comfort
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
the nurses watch the patient carefully
to make sure that when he exercises it's
safe
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