Board Review:
Arrhythmias
Katie Bever
August 20, 2013
Overview of Arrhythmias
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Diagnostic testing
Review of bradycardias
Review of tachycardias
Antiarrhythmic agents
Cardiac devices
Questions!
Diagnostic testing
• Resting ECG (if you’re lucky!)
• Continuous ambulatory ECG (24-48hrs)
• Event recorders: triggered by patient
o Looping recorder
o Postsymptom recorder
• Implantable loop recorder (up to 3 years battery life)
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Others to consider:
TTE to evaluate for structure heart disease
Ischemia evaluation if life-threatening arrhythmia
EP testing to provoke arrhythmia and potentially ablate
Overview of Bradycardia
• 2/2 disorders of impulse generation (impaired
automaticity) or impulse conduction (heart block)
• Reversible causes include Lyme disease, drugs,
hyperkalemia and thyroid disease
• Symptoms: syncope, LH, fatigue, dyspnea, exerciseintolerance, ventricular arrhythmias
• Evaluation includes documentation of bradycardia with
symptoms
• Management includes atropine/transcutaneous pacing if
unstable, treatment of reversible causes, PPM
Impaired automaticity
• Sinus brady not necessarily pathologic (i.e. athletes)
• Causes of pathologic sinus bradycardia
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Sick sinus syndrome/SA node dysfunction
Infarction or cardiac surgery
Infiltrative processes (amyloidosis, sarcoidosis)
Increased vagal tone (Valsalva, vomiting)
Medications (ie BB, CCB)
Genetic diseases
• Pacemaker is indicated for symptomatic sinus
bradycardia
Heart Block
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1st degree and 2nd degree Mobitz 1 block usually 2/2 disease within the
AV node
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2nd degree Mobitz 2 and 3rd degree block usually His bundle or below
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1st degree block associated with increased risk afib, pacemaker
implantation and all-cause mortality
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“Advanced” or “high-grade” 2nd degree heart block if 2+ nonconducted
P’s before each QRS
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Pacemaker indicated for advanced 2nd degree or 3rd degree AV block
(CHB)
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Reversible causes of CHB include medications and Lyme disease
Overview of tachycardia
• Narrow complex tachycardias
o Atrial fibrillation/atrial flutter
o Supraventricular tachycardias
• Wide complex tachycardias
o SVT with aberrancy
o Ventricular arrhythmias
Acute management of afib
• Immediate synchronized cardioversion if hypotension,
angina or heart failure
• If HD stable, goal HR 60-110/min with BB, CCB or
digoxin
• Consider elective cardioversion:
o If duration afib<48hrs, can proceed with DCCV
o If duration >48hrs or unknown: anticoagulate for 3+ weeks prior to DCCV, or
anticoagulate then TEE to rule out intracardiac thrombus prior to DCCV
o Anticoagulation must continue after cardioversion for 4 weeks
Long-term management of afib
• Increased risk of embolic stroke, heart failure and all-cause
mortality
• Anticoagulation based on risk factors (ie CHADS2, rheumatic MS,
or mechanical heart valve)
o
o
o
Warfarin > aspirin + plavix > aspirin alone
Direct thrombin inhibitors (ie dabigatran)
Rivaroxaban (oral factor Xa inhibitor)
• Rate control
• Rhythm control if symptoms despite adequate rate control
o
Consider “pill-in-the-pocket” approach with flecainide or propafenone for symptomatic
paroxysmal afib (remember to rate control as well!)
• Ablation, esp if aflutter
• AV nodal ablation
• Maze surgery
Supraventricular
tachycardias
• AVNRT – fast and slow pathways within AV
node
• AVRT – circuit includes AV node and bypass
tract
o
o
Anterograde conduction leads to preexcitation: short PR
interval, delta wave (WPW)
Retrograde conduction -> concealed bypass tract
• Atrial tachycardia – ectopic focus or area of
micro-reentry
• Management includes AV nodal blocking
agents, antiarrhythmics or catheter ablation
• EXCEPTION!: do not give AV nodal blockers
to pts with WPW syndrome and afib ->
procainamide or amio are preferred
Ventricular Arrhythmias
• Premature ventricular contractions
o
o
o
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Present in up to 75% of healthy persons
More common in persons with HTN or structural heart disease
Tx symptoms with B-blocker or CCB
Antiarrhythmics or ablation if refractory symptoms
• Ventricular tachycardia
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o
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Increased risk of SCD in patients with structural heart disease
Idiopathic VT carries better prognosis
B-blockers for patients with HF or ischemic heart disease
ICD for primary or secondary prevention
Antiarrhythmics may reduce frequency of shocks but not mortality
• Inherited arrhythmia syndromes
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o
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Long QT syndrome -> torsades
Short QT syndrome -> afib, VT/VF, SCD
Brugada syndrome -> VF, SCD
Catecholaminergic polymorphic VT -> polymorphic or bidirectional VT during
exercise/stress, SCD
o ARVC -> epsilon waves, monomorphic VT
Antiarrhythmic Medications
VaughanWilliams
Classification
Mechanism of Action
Examples
Effect
Use
Class IA
Na-channel blockade, some Kchannel blockade
Quinidine,
procainamide,
disopyramide
Slows conduction, prolongs
repolarization
Preexcited afib, SVT,
ventricular
arrhythmias
Class IB
Na-channel blockade
Lidocaine,
mexiletine,
phenytoin
Slows conduction in diseased
tissures, shortens
repolarization
Ventricular
arrhythmias
Class IC
Na-channel blockade
Flecainide,
propafenone
Markedly slows conduction,
slightly prolongs repol
Afib, aflutter, SVT,
ventricular
arrhythmias
Class II
Beta blockade
Metoprolol,
propranolol,
Suppresses automaticity and
slows AV nodal conduction
Rate control of
arrhythmias, SVT,
ventricular
arrhythmias
Class III
Potassium channel blockade
Sotalol, amio,
dofetilide,
dronedarone
Prolongs action potential
duration
Afib, aflutter,
ventricular
arrhythmias
Class IV
Calcium channel blockade
Verapamil,
diltiazem
Slows SA node automaticity
and AV nodal conduction
SVT, rate control of
atrial arrhythmias,
triggered arrhythmias
A1 receptor agonist
Adenosine
Slows or blocks SA node
automaticity and AV node
condunction
Termination of SVT
Increasing vagal activity
Digoxin
Slows AV nodal conduction
Rate control of
arrhythmias
Indications for PPM
• Symptomatic bradycardia (HR<40/min) or sinus pauses
• Symptomatic CHB or 2nd degree heart block (type 1 or 2)
• Asymptomatic CHB or advanced 2nd degree HB
• Afib with pauses >= 5 seconds
• Alternating bundle branch block
• After catheter AV nodal ablation
Overview of ICD
• Indicated for primary and secondary prevention
• Management perioperatively: shock function should be
turned off during procedures using electrocautery
• Management of device infection: removal of entire
system
Question 1
76yo F is evaluated in ED for dizziness, SOB, and palpitations that
began acutely 1 hr ago. She has a hx of HTN and HFPEF. Medications
are HCTZ, lisinopril, and aspirin.
On exam, she is afebrile, BP 80/60, pulse 155/min, and respiration rate
is 30/min. O2 sat is 80% with 40% oxygen by face mask. Cardiac
auscultation reveals irregularly irregular rhythm, tachycardia, and
some variability in S1 intensity. Crackles are heard bilaterally one-third
up in the lower lung fields.
ECG demonstrates afib with RVR.
Which one of the following is the most appropriate acute treatment?
(A) Adenosine
(B) Amiodarone
(C) Cardioversion
(D) Diltiazem
(E) Metoprolol
Answer: cardioversion
The patient is hemodynamically unstable and should undergo immediate
cardioversion. She has hypotension and pulmonary edema in s/o rapid
afib. In patients with HFPEF, the loss of atrial “kick” with afib can
sometimes lead to severe symptoms. The best treatment in this situation is
immediate cardioversion to convert the patient to normal sinus rhythm.
Although there is a risk of thromboembolic event since she is not
anticoagulated, she is currently in extremis and is at risk of imminent
demise if not agressively treated.
Adenosine is useful for diagnosing an SVT and can treat AV nodedependent tachycardiacs, but is not useful in the treatment of afib.
Amio can convert afib to NSR as well as provide rate control, but
immediate treatment is needed and amio may take several hours. Oral
amio may be a reasonable long-term option given the severity of her
symptoms.
Metoprolol and dilt would slow her heart rate; however, she is
hypotensive and these medications could make her BP lower. In addition,
she is in active heart failure.
Question 2
75yo M w/HTN is evaluated during his 1st outpatient visit after an acute
MI. He is now asymptomatic and reports no CP or symptoms of heart
failure since discharge. He had a lateral infarction, and a DES was placed
in the left cx artery. He had two episodes of symptomatic afib during
hospitalization associated with presyncope and a rhythm control approach
was chosen; his LVEF was normal. His medications at the time of discharge
were metoprolol, aspirin, dronedarone, clopidogrel, warfarin and
atorvastatin.
On exam, he is afebrile, BP is 130/78, pulse 68/min and regular, RR 12/min.
There is an S4 but the remainder of the cardiac exam is normal. Lungs are
clear and there is no peripheral edema.
Labs are normal except for a serum creatinine of 1.5.
Which of the following meds is most likely to have caused the increase in
serum creatinine level?
(A) Atorvastatin
(B) Clopidogrel
(C) Dronedarone
(D) Metoprolol
Answer: dronedarone
Dronedarone is the newest antiarrhythmic approved for
treatment of afib or flutter and has been shown to reduce
combined endpoint of hospitalizations and mortality. It is
chemically related to amiodarone, has an improved safety
profile, but causes an average decrease in creatinine
clearance of 18% compared with baseline; up to 5% of
patients will have a significant increase in creatinine level.
This is due to partial inhibition of tubular transport of
creatinine (no change in GFR).
Dronedarone has black box warning for patients with heart
failure; it is contraindicated in those with NYHA class IV or
class II-III with recent decompensation.
Question 3
56yo M is evaluated in the hospital for paroxysmal afib. The patient develops
increasing SOB during these episodes. 5 days ago, he was admitted for an acute MI
and cardiogenic shock and received a DES in the LAD. Medications are lisinopril,
digoxin, furosemide, aspirin, clopidogrel, eplerenone, simvastatin, and
unfractionated heparin.
On exam, the patient is afebrile, blood 92/65, pulse 75. O2 sat is 95% with 3L NC.
Cardiac exam reveals estimated CVP of 12cm H2O. Heart sounds are distant and
regular. There is a grade 2/6 holosystolic murmur at the cardiac apex. A summation
gallop is present. Crackles are ausculated bilaterally in the lower lung fields.
Transthoracic echocardiogram shows LVEF 32%.
Which of the following is the most appropriate treatment for this pt’s afib?
(A) Amiodarone
(B) Disopyramide
(C) Dronedarone
(D) Flecainide
(E) Sotalol
Answer: amiodarone
Amiodarone is the best option for managing symptomatic afib in the setting of
heart failure. Patients with heart failure and MI are at increased risk for
development of afib. Although amio has may extracardiac side effects, it is most
effective agent for preventing afib recurrences, and it is one of the few agents
proved safe in patients with heart failure, LVH, CAD, or previous MI. In addition,
amio has B-blocking properties that can help with rate control.
Disopyramide has negative inotropic effects, which can be detrimental to someone
with reduced LVEF and heart failure.
Dronedarone increases mortality in pts with NYHA class IV or class II-III HF with
recent decompensation.
Flecainide is contraindicated after MI because of increased risk polymorphic VT.
Like amio, sotalol is class III antiarrhythmic but because of more potent B-blocking
effects, it should not be used in acute heart failure.
Question 4
61yo M is evaluated during follow up exam. He has a 4 year hx
of afib and underwent afib ablation 6 mos ago. He has had no
symptoms of palpitations, fatigue, SOB, or presyncope since the
procedure. He has HTN and DM2. Medications are lisinopril,
atenolol, metformin, and warfarin.
BP is 124/82 and pulse 72/min. Cardiac exam discloses regular
rate and rhythm. The rest of the exam is normal.
ECG demonstrated NSR.
Which of the following is the most appropriate treatment?
(A)Continue warfarin
(B)Switch aspirin
(C)Switch to clopidogrel
(D)Switch to aspirin and clopidogrel
Answer: continue warfarin
For the first 2-3 months after afib ablation, all patients should
take warfarin. Thereafter, anticoagulation should proceed as if
ablation did not occur (i.e. based on CHADS2 score).
Switching to aspirin or clopidogrel does not provide the same
protective benefit, and it is not appropriate to discontinue all
anticoagulation.
If CHADS2 score is 0, aspirin alone is preferred.
If CHADS2 score is 1, aspirin or warfarin is acceptable.
If CHADS2 score is >1 and patient cannot take warfarin,
aspirin+clopidogrel is better than aspirin alone.
Question 5
38yo F is evaluated during a follow-up visit for 2 syncopal episodes
experienced in the past 2 years. The 1st episode occurred 18 months ago at
rest. The 2nd episode occurred 5 months ago while she was walking. The
patient describes an “uneasy” sensation preceding the events, but reports
no dyspnea, chest discomfort, palpitations, or loss of bowl or bladder
control. A looping event recorder worn for 30 days did not reveal
arrhythmia. She is employed as a school bus driver. She takes no meds.
On exam, she is afebrile, BP 120/60, pulse rate is 60/min and regular. The
remainder of the exam is normal.
Baseline ECG is normal.
Which of the following is the most appropriate testing option?
(A) Continuous ambulatory ECG monitor
(B) Implantable loop recorder
(C) Postsymptom event recorder
(D) No further testing
Answer: implantable loop recorder (ILR)
Significant concern for arrhythmia given previous syncopal
events and occupation. ILR is placed subcutaneously under local
anesthesia and is capable of storing up to 42 minutes of ECG
rhythm. Battery life is approx 3 years, likely long enough to
capture an event in this patient.
Continuous ambulatory ECG may detect asymptomatic
arrhythmias but only worn for 24-48hrs.
External event recorders are used for more infrequent symptoms
and record ECG tracings only when triggered by the patient.
No further testing would not be appropriate in this patient with
high-risk occupation and has experienced syncope at rest.
Question 6
60yo M w/paroxysmal afib is scheduled to undergo screening
colonoscopy. Warfarin must be discontinued in case a biopsy is
needed. When the patient is in afib, he is asymptomatic. He also has
HTN and DM2. He has never had a stroke, TIA or VTE. Medications
are metoprolol, metformin, and warfarin.
On exam, pulse is 65/min. Other vitals signs are normal. Cardiac
rhythm is irregularly irregular.
Labs reveal an INR of 2.3.
In addition to discontinuing warfarin, which of the following is the
most appropriate treatment?
(A)Switch to aspirin
(B)Switch to clopidogrel
(C)Switch to IV UFH
(D)Switch to therapeutic doses of LMWH
(E)No bridging agent is needed
Answer: no bridging is needed
For this patient with CHADS2 score of 2 (HTN and DM2), no
periprocedural bridging is needed. Periprocedural management of AC
in s/o afib depends on patient’s risk of developing VTE and having an
adverse bleeding event. The CHADS2 score is one commonly used risk
stratification tool for the perioperative period:
Low risk: CHADS2 0-2 -> no bridging or bridge with low-dose LMWH is
appropriate
Moderate risk: CHADS2 3-4, hx of TIA/CVA, or mechanical aortic
valve -> bridging with therapeutic LMWH or UFH is reasonable
High risk: CHADS2 5-6, recent TIA/CVA, mechanic MV or rheumatic
valvular disease -> bridging with therapeutic LMWH or UFH should
be provided.
Question 7
54yo M is evaluated in the ED for 2hr history of palpitations. He
reports no syncope, presyncope, chest pain, SOB and has had no
previous episodes of palpitations. Medical hx is significant for
nonischemic cardiomyopathy; EF was most recently measured at 38%.
Medications are carvedilol and candesartan.
On exam, he is afebrile, BP 125/86, pulse rate is 110/min. Cardiac
evaluation reveals a regular rate and rhythm, although the intensity of
S1 is variable. Cannon a waves are seen in the jugular venous
pulsation.
The ECG is shown.
Which of the following is the most appropriate treatment?
(A)Immediate cardioversion
(B)IV adenosine
(C)IV amiodarone
(D)IV verapamil
Answer: amiodarone
The ECG demonstrates a regular, monomorphic wide-complex tachycardia in a
LBBB pattern. The differential diagnosis is SVT with aberrancy, antidromic AVRT,
and ventricular tachycardia. In a patient with wide-complex tachycardia with hx of
CAD or CMY, VT should be the assumed diagnosis. The presence of AV
dissociation in this ECG confirms the diagnosis of VT. In addition, the patient has
variable S1 as well as cannon a waves, which are caused by atrial contraction
against a closed tricuspid valve, confirming AV dissociation. Hemodynamic
stability does not rule out VT.
First line therapy for hemodynamically stable VT is IV antiarrhythmic agent such as
amiodarone. Procainamide and sotalol are also acceptable, and lidocaine is secondline.
Adenosine may be given for stable wide-complex rhythm to determine whether
SVT or VT, but in this instance, the ECG and exam demonstrate VT.
Verapamil or B-blockers are not indicated in patients with stable CT because they
can lease to severe hemodynamic deterioration, Vfib, and cardiac arrest.
Patient should be offered an ICD for long-term sudden death prevention.
Distinguishing SVT from VT
1. VT more likely when interval between R and S is
>100ms
2. Irregular RR interval is suggestive of SVT
3. AV dissociation with RR<PP interval is hallmark of VT
4. Typical RBBB or LBBB QRS morphology more likely
SVT
Question 8
62yo F is awaiting a procedure in the presurgical area. She has a
single-chamber ICD and is about to undergo a hemicolectomy
for colon cancer. Medical history is pertinent for ischemic
cardiomyopathy, chronic afib, complete heart bock, and
pacemaker dependence. Medications are aspirin, carvedilol,
lisinopril, digoxin, warfarin (withheld), and rosuvastatin.
Perioperative anticoagulation is provided with UFH.
Which of the following is the most appropriate perioperative
management of the patient’s ICD?
(A)Insert a temporary pacemaker
(B)Place a magnet over the ICD
(C)Turn shock therapy off and change to asynchronous mode
(D)No programming changes needed to ICD
Answer: turn shock therapy off and change to asynchronous
mode
When a patient with ICD undergoes surgery, the use of
electrocautery affects what the device “thinks” is happening
with cardiac activity. It will treat the patient as if vfib is
occurring, by inhibiting pacing and delivering a high-energy
shock. Therefore, for a patient with ICD who is pacemaker
dependent, the best management is to reprogram the device to
turn off shock therapy and change to an asynchronous mode
such as VOOO, which means that ventricular pacing will
continue regardless of any native electrical activity or
electrocautery.
Placing a magnet over an ICD disables the shock function but
does not affect the pacemaker settings.
Question 1
60yo M is evaluated for chest pain of 4 months’ duration. He describes the pain as
sharp, located in the left chest, with no radiation or associated symptoms, that
occurs with walking 1-2 blocks and resolves with rest. Occasionally, the pain
improves with continued walking or occurs during the evening hours. He has
hypertension. Family history does not include CV disease in any 1st degree
relatives. His only medication is amlodipine.
On physical exam, he is afebrile, blood pressure 130/80mmHg, pulse rate is 72/min,
and respiration rate is 12/min. BMI 28. No carotid bruits are present, and normal S1
and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are
normal.
ECG is normal.
Which of the following is the next mose appropriate diagnostic test to perform next?
(A) Adenosine nuclear perfusion stress test
(B) Coronary angiography
(C) Echocardiography
(D) Exercise treadmill test
Answer: exercise treadmill
test
Most appropriate test to establish the diagnosis of CAD in this patient
is an exercise treadmill test. The description of CP has both typical and
atypical features. Based on pt’s age and sex, the pretest likelihood that
his symptoms represent angina are increased, giving him an
intermediate probability of CAD. The patient is able to exercise and has
a normal baseline ECG. In this setting, an ETT is the most appropriate
non-invasive test.
Other choices:
A: pharm stress test such as adenosine nuclear perfusion stress test is useful when a patient
cannot exercise (ie arthritis, deconditioning, advanced lung disease) and in the s/o abnormal
ECG
B: coronary angiography has a small but inherent risk of vascular complications and is therefore
usually not the first choice. Indications for cath: lifestyle-limiting angina despite optimal
medical therapy, high-risk criteria on stress testing, or resuscitation from sudden cardiac death.
C: echo is useful to evaluate left ventricular systolic function (EF), assess for WMA, and exclude
significant valvular heart disease. Normal echo would not exclude underlying CAD.
Choice of stress testing
Question 33
68yo F is evaluated for palpitations. Her symptoms occur daily during both rest and
exertion. She describes the papitations as intermittent “hard” beats that “take her
breath away.” Her symptoms are made worse by caffeine consumption. She reports
no dizziness or syncope. Medical history is significant for hypertension and
hyperlipidemia. Medications are ACE inhibitor and statin.
On physical exam, she is afebrile, BP 138/80mmHg, pulse rate 83/min, and
respiration rate is 18/min. On cardiac examination, the rhythm is regular. There are
no murmurs or extra sounds. The lungs are clear. The remainder of the general
physical exam is normal.
The ECG shows NSR with minor ST-segment abnormalities.
What is the most appropriate testing option to utilize next in this patient?
(A) Electrophysiologic study
(B) 24-hour continuous ambulatory electrocardiographic monitor
(C) Implantable loop recorder
(D) Postsymptom event recorder
Answer: 24-hr continuous
ambulatory ECG
monitoring
When evaluating palpitations,
it is important to capture the
rhythm using ECG, continuous ambulatory ECG monitoring, an
event recorder, or implantable loop recorder, depending on
frequency of symptoms. The pt describes symptoms c/w
premature ventricular contractions (PVCs). A PVC is followed
by a compensatory pause, often described by pts as a “skipped
beat.” PVCs often associated with caffeine, EtOH, nicotine. If no
structural heart dz or fam hx SCD, PVCs are likely benign and
reassurance is sufficient.
Other answers:
(A) EP testing is indicated for pts with rhythm d/o or other sx such as syncope who are at
risk for sustained ventricular tacharrhythmia or SCD.
(C) and (D) Event recorders are useful for symptoms that do not occur daily. Loop
recorders record several seconds of the rhythm prior to device triggering. Postsymptom
recorder is held to the chest when sx occur, and is useful only when symptoms last long
enough for pt to activate the device.
Question 40
41yo M is evaluated for progressive SOB over several months. Medical hx is significant for
Hodgkin lymphoma, dx’d when he was a teenager. At that time he received doxorubicin,
bleomycin, vinblastine, and dacarbazine with mantle radiation. He is currently in remission
and takes no meds.
On exam, he is afebrile, BP 128/70, pulse rate 74/min and regular. Estim CVP is 6cm H2O. An
inspiratory decline in CVP is noted. The S1 is regular, with resp variation of S2. A II/VI midpeaking systolic murmur is heard. Lungs are clear.
Given pt’s symptoms, TTE is ordered and shows normal biventricular size and systolic
function. Diastolic indices show impaired left ventricular relaxation with normal left
ventricular filling pressure. Pulmonary systolic pressure is 25-30mmHg. The IVC is of normal
diameter, with full inspiratory collapse. Mild thickening of the aortic valve and mitral valve is
observed. ECG shows NSR with 1st degree AVB and is otherwise unremarkable.
Which of the following is the most appropriate diagnostic test to perform next?
(A) Cardiac CT
(B) Exercise ECG stress testing
(C) Right heart catheterization
(D) Transesophageal echocardiography
Answer: exercise ECG
stress testing
Because of his hx of Hodgkin lymphoma treated with chemo and radiation
regimens, there are multiple potential contributing factors to dyspnea
present, including systolic and diastolic dysfunction, restrictive CMY,
radiation valve disease, and CAD.
CAD 2/2 radiation exposure is classically proximal, most commonly LAD.
Risk of MI in survivors of HL is up to 7-fold greater than the general
population, and persists beyond 20yrs after completing tx. Other common
late CV complications include valve d/o, diastolic dysfunction, restrictive
CMY, and pericardial constriction.
Other answers:
(A) Cardiac CT is helpful in evaluating pericardial constriction by visualizing pericardial thickness. Pt’s exam is
not c/w this (no Kussmaul sign, no RHF, normal CVP and echo).
(C) RHC is helpful in diagnosing pericardial constriction in pts w/compatible exam findings. Findings on RHC
c/w constriction include equalization of diastolic pressures in PA and cardiac chambers, early diastolic “dipand-plateau” pattern on tracings and steep y descent.
(D) TEE would provide little incremental diagnostic benefit to diagnose late-onset valvular disease, given that
the valves were visualized with TTE. The II/VI midpeaking systolic murmur is c/w aortic sclerosis.
Question 92
68yo F is evaluated for 3-week history of intermittent exertional chest pain.
She walks several days per week. She has DM2 and HTN. Her father had
an MI at age 54yrs. Medications are ASA, metformin, glyburide, and
lisinopril.
On exam, she is afebrile, BP 128/90, pulse rate is 83/min, and respiration
rate is 18/min. BMI is 35. Cardiac sounds are distant but otherwise
unremarkable, without extra sounds or murmur.
An ECG is shown.
Which of the following is the most appropriate diagnostic test to perform
next?
(A) Cardiovascular MRI with gadolinium enhancement
(B) Exercise ECG stress test
(C) Exercise stress echocardiography
(D) Pharmacologic perfusion imaging study
Answer: exercise stress
echocardiography