Skill Checkup: A 71-Year-Old Man With History of Type 2 Diabetes and Related Hypertension Experiences Retrosternal Pressure

Carolyn Newberry, MD, PNS


December 21, 2022

A 2018 statement from the American College of Cardiology recommends assessment of symptomatic patients without known coronary artery disease (CAD) using noninvasive CTA. Functional stress testing generally includes exercise testing or single-photon emission CT-based myocardial perfusion imaging and historically was the index test. However, several large trials have shown CTA to be superior to functional testing in terms of identifying significant CV risk and guiding risk reduction therapy. Earlier in 2022, results of the DISCHARGE trial demonstrated that CTA was as predictive as ICA for risk for subsequent major cardiovascular events (MACE), without the procedure-related complications associated with ICA. Results of CTA can be used to guide medical therapy on the basis of absence or presence and extent of atherosclerosis.

Noninvasive coronary artery calcium scoring is a simple test typically used to assess atherosclerotic risk in asymptomatic individuals as part of CV risk assessment. It may have some utility as an initial test for symptomatic patients at low-to-intermediate risk with suspected CAD to rule out clinically significant atherosclerosis or to improve accuracy of functional testing. However, this patient's T2D, hypertension, and obesity put him at substantial preexisting CV risk, warranting the more accurate CTA.

This patient has multiple comorbidities that may contribute to his acute symptoms. He would benefit from complete metabolic testing and blood work to assess the status of his hyperglycemia, renal and hepatic function, and lipids. These assessments are standard for patients being managed for T2D. While they may guide diabetes or obesity treatment decisions, they do not assess cardiac symptoms.


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