A 63-year-old man presents to the Emergency Department after a fall, and he is found to have a broken hip. He undergoes surgical correction and recovers in the hospital. Before being discharged, he mentions to you that prior to the accident, he had not been able to exercise like before. For the past few months, he has experienced occasional chest pain with exertion that forces him to stop and rest. The pain goes away within 5 minutes of resting.
What should be performed before the patient is discharged from the hospital?
A. Pharmacologic stress testPharmacologic stress test. Although this is an unusual situation in that this history was not elicited before the patient underwent surgery, the point of the question is to assess the reader’s knowledge on how to evaluate coronary artery disease. When a patient presents with symptoms of angina, it is important to make the diagnosis with a stress test. (B) An exercise stress test with ECG is the most common and preferred method for most patients; for patients that cannot undergo an exercise stress test like this patient with a broken hip, a pharmacologic stress test should be ordered. There are a variety of agents that may be used in this test (regadenoson, dobutamine, adenosine, dipyridamole), and the point is to stress the heart to the degree it would be stressed during exercise and assess for ischemic changes (ST depressions or elevations on ECG).
(C) An echocardiogram might be helpful to assess cardiac function and any valvular abnormalities, but it alone would not help in making the diagnosis of coronary artery disease unless it was done as part of a stress echo (looking for signs of ischemia that manifest as wall motion abnormalities). (D) Coronary angiography is an invasive procedure and may be performed after the stress test if the results are high risk or inconclusive.