q 99 - doctor7

[ArchivalUser]

A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about three blocks and goes away with rest. He has developed a habit of taking rest when the chest pain comes and he did not think it needed medical attention until his friend told him yesterday that it might be a symptom of heart disease. He is concerned and requests your recommendation. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain. His past medical history is significant for pacemaker insertion for a symptomatic second degree heart block, Hypertension, and Smoking . His medications include lisinopril, atenolol and hydrochlorthiazide. Physical examination is benign. An EKG is obtained which reveals pacemaker rhythm with secondary ST-T changes. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization
answer given is d..i thought e...plz give me ur answers

[ArchivalUser]

C) Dobutamine Stress Echocardiogram

[ArchivalUser]

C is my choice

[ArchivalUser]

D. Persantin is the preferred option for stress when Exercise Stress Test is not useful or can not be done.
Patients with pacemaker rhythms, LBBB and severe LVH, will have baseline EKG changes that may make EKG component of the Stress test difficult. However, in these conditions, Tachycardic stress ( Exercise Stress test) may also produce false positive defects on nuclear imaging. So, the solution is to use a different type of stress such as vasodilator stress ( Persantin). Moreover, this patient was also on beta blocker which makes it difficult to achieve target heart rate during the Exercise Stress.
Dobutamine stress test is reserved for patients with bronchospasm or heartblocks ( in conditions where persantin is contraindicated) . Dobutamine stress test is also not a good test when a patient si on beta blockers and for LBBB and paced rhythms.
If stress test revealed ischemia, cardiac catheterization should be performed.


Stress test explanation are in dr.red slides

[ArchivalUser]

my answer is Cardiac Catheterization
what do u do in this pat if stress test is negative?