Ans. D. Pharmacological stress testing using adenosine and myocardial perfusion scintigraphy.
Explanation: Based on age, gender and symptoms, the above mentioned patient can be classified under the intermediate risk group according to Framingham risk stratification, and the chest pain can be described as atypical angina. According to ACC/AHA guidelines, in intermediate risk group, if there are no signs of ischemia on resting ECG, the next appropriate step is a stress-rest myocardial scintigraphy (MPS), to look for inducible ischemia. Invasive coronary angiography is most suitable for high risk group and exercise stress testing (TMT) is indicated in low risk group. MPS can be done using exercise stress testing or pharmacological stressing. Note should be made that the above patient’s ECG and ECHO show findings of left bundle branch block (LBBB). According to ACNC imaging guidelines, the stress testing related to chronotropic effects of the heart like exercise stress testing or pharmacological stress using dobutamine, should not be done for performing MPS to avoid misinterpretation of MPS scans.
References:
- Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/ SCMR/SNM 2009 Appropriate Use criteria for Cardiac Radionuclide Imaging. J Am Coll Cardiol 2009; doi: 10.1016/j.jacc.2009.02.013.
- Morise AP, Haddad WJ, Beckner D. Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease. Am J Med1997;102:350-6.