Dr. Katie A. Young discusses the different tests available for assessing patients with chest pain, including the importance of resting ECG, the use of CT angiogram to evaluate coronary anatomy, potential complications of an invasive coronary angiogram, and other tests and considerations for assessing chest pain.
Determining if chest pain is cardiac in nature is the first step in assessment, using patient history and hallmark features.
Resting electrocardiogram (ECG) plays a crucial role in evaluating patients with chest pain, providing reassurance or indicating the need for further testing.
Deep dives
Determining Cardiac Chest Pain
When assessing a patient with chest pain, the first step is to determine if it is cardiac chest pain. This is done by taking a thorough patient history and identifying hallmark features such as pain being sub-sternal, provoked by exertion or emotional stress, and relieved by rest or nitroglycerin. It's important to consider atypical symptoms in certain populations like women, diabetics, and the elderly. Descriptors such as possibly cardiac and non-cardiac are used to classify the type of chest pain.
The Role of Resting ECG
Resting electrocardiogram (ECG) plays a crucial role in evaluating patients with chest pain. A normal ECG provides reassurance that the heart function is normal, and it can also help identify active ischemic changes or even ST elevation myocardial infarction. Abnormal ECG results may indicate the need for further testing. A resting ECG is recommended for patients with possibly cardiac or cardiac chest pain.
Choosing the Right Stress Test
Selecting the appropriate stress test depends on the patient's pretest probability of coronary artery disease. An exercise ECG is considered if the patient can exercise adequately, has a normal ECG, and no history of coronary revascularization. Pharmacologic stress tests are recommended when the patient is unable to exercise or has certain conditions like left bundle branch block or a ventricular pacemaker. Further imaging tests such as nuclear perfusion imaging or stress echo may be added to assess localization of ischemia, heart function, and valve disease. Coronary CTA provides anatomical evaluation and is suitable for younger patients with suspected less plaque burden. Invasive coronary angiography remains the gold standard for definitive diagnosis of plaque severity.
We now have a variety of tests to assess patients who present with chest pain. These tests include such basic assessment tools such as a resting ECG to the most invasive of cardiac tests, a coronary angiogram. But there are multiple tests in between these two extremes. Each have their specific benefits and limitations. Which test or tests should we order for patients with chest pain? What are the potential risks of these tests to the patient? In this podcast, we’ll discuss these questions and more with cardiologist Katie A. Young, M.D., from the Department of Cardiovascular Disease from the Mayo Clinic. The topic for today’s podcast is “Chest Pain: What’s the Best Test?”
Connect with the Mayo Clinic’s School of Continuous Professional Development online at https://ce.mayo.edu/ or on Twitter @MayoMedEd.
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