For patients complaining of Dyspnea, consider Coronary Ischemia if intermittent symptoms, usually exertional, last 1-5 minutes. Frank M.I. lasts longer. Index of Suspicion based on the following 3 components of History:1. Presence of Associated Chest Symptoms
- “Pain” (usually), but maybe “Pressure,” “Tightness,” “Discomfort”
- If not in “Chest,” maybe left shoulder, jaw, upper arm, right chest or epigastrium.
- Nausea or vomiting
- Diaphoresis (“do cold, wet, drops of sweat break out on your forehead?”)
- Lightheadedness or dizziness
- Age: Men >40; Post-menopausal Women
- Tobacco (any cigarettes in past month; regular smoking in past 1-2 years)
- Strong Family History of CAD
- Same-day cocaine or amphetamine use
- History of typical anginal exertional chest pain, even if that’s not the pain your patient is seeking care for today.
Don’t worry about soft risks like obesity or sedentary life-style.Stress-Testing for Suspected Angina
- If the baseline EKG is normal, order a basic exercise treadmill test (ETT).
- If there are baseline S-T segment or T-wave abnormalities, must order a stress echocardiogram or an ETT with radionuclide scan (e.g. thallium).
- If the patient can’t exercise (e.g. bum knee, too frail, etc.), order a pharmacologic stress test using dobutamine, dipyridamole (Persantine), adenosine, etc.
- Baseline left bundle branch block necessitates a pharmacologic stress radionuclide scan.
Abnormal stress-echo or radionuclide scan means treatable ischemia if the study reverses to normal at rest. If equally abnormal at rest & during stress, it reveals an untreatable old M.I.
See posting Chest Pain – 1.