Yesterday you admitted a 55-year-old man to the hospital for an episode of chest pain. The patient has past medical history of COPD, peripheral vascular disease with claudication, hypertension and hypercholesterolemia. On admission his BMI is 40, there is bilateral wheezing, and cardiac examination reveals a grade 1/6 early systolic murmur at the upper left sternal border without radiation. Blood pressure readings have consistently been 140/90 to 150/100. Cardiac enzymes are normal. A resting ECG shows left ventricular hypertrophy with secondary ST-T-wave changes (“LVH with strain”). You decide to do a cardiac stress test on this patient. Which cardiac stress test would be most appropriate for this patient?
A. Exercise EKG stress testThe choice of initial stress test modality depends on the patient’s resting ECG, ability to exercise, and the availability of expertise and technology. Exercise electrocardiographic test should be the initial stress test in patients with an interpretable ECG who are able to exercise. When certain resting ECG abnormalities are present (ST depression > 1 mm, left ventricular hypertrophy, bundle branch block, paced rhythm, or pre-excitation), either nuclear imaging or echocardiography is the preferred initial stress imaging. Pharmacologic stimulation of heart rate should be used in patients who are unable to exercise. For patients with concomitant valve disease, pericardial disease, or aortic disease, echocardiography has the advantage of providing information regarding these issues. The major limitation of echocardiography is in patients in whom satisfactory imaging may be technically difficult to acquire satisfactory images. This is often the case is patients with COPD or morbid obesity. In this patient a standard exercise ECG stress test is not appropriate because of the baseline ECG abnormalities. An exercise nuclear test would probably be impossible because of his claudication. Thus he should have a pharmacologic test. In the setting of COPD, adenosine is best avoided because it can aggravate bronchospasm. Because both obesity and COPD compromise echocardio-graphic detail, a stress echo is not the best choice.