Case Studies
These patient profiles represent hypothetical patients. Images do not depict actual patients.
Patient Presentation – Sam
Sam is a 55-year-old man with a family history of CAD who is overweight and taking medication for hypertension. He denies experiencing chest pain or dyspnea. He was a heavy smoker but says he's down to 2 cigarettes a day.
Examination
Vital signs
- Height: 5'7"
- Weight: 213 lb
- Blood pressure: 140/95 mm Hg
- Heart rate: 85 bpm
- Total cholesterol: 240 mg/dL
- High-density lipoprotein (HDL): 40 mg/dL
Electrocardiogram (ECG)
- ST segment abnormalities
Asymptomatic, High Risk
The Appropriate Use Criteria (AUC) rating of stress radionuclide imaging (RNI) for asymptomatic patients with a high risk of a cardiac event is: MAY BE APPROPRIATE.2
SPECT TEST RESULTS: NORMAL
Because of his family history of CAD and hypertension, Sam was referred for a single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) test. Results showed no inducible ischemia or perfusion abnormality.
Due to his high risk of a CAD event, Sam was prescribed statin therapy and lifestyle modifications were recommended.
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Patient Presentation — Nora
Nora is a 65-year-old woman who says she gets chest tightness when walking upstairs but has no symptoms at rest. She is taking medication for diabetes and hypertension. She has a history of mitral valve prolapse and esophageal stricture. Last year, she had a hip replacement.
Examination
Vital signs
- Height: 5'4"
- Weight: 191 lb
- Blood pressure: 146/98 mm Hg
- Heart rate: 60 bpm
- Total cholesterol: 300 mg/dL
- HDL: 35 mg/dL
ECG
- Right bundle-branch block (RBBB), ST-T wave abnormalities at rest, and ST changes on stress
Symptomatic, High Risk
The AUC rating of stress RNI for symptomatic patients with a high pretest probability risk of CAD is: APPROPRIATE.2
PET Test Results: Abnormal
Nora was referred for a positron emission tomography (PET) test, which showed a reversible defect in the anterior and apical walls in the left anterior descending artery. A coronary angiogram showed total occlusion of the left anterior descending artery.
Nora was scheduled for coronary revascularization.
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Patient Presentation – Mike
Mike is a 50-year-old man scheduled to undergo abdominal aortic aneurysm surgery. He is not experiencing any chest pain. He is sedentary and gets winded climbing 2 flights of stairs. He's a former smoker with diabetes.
Examination
Vital signs
- Height: 5'11"
- Weight: 204 lb
- Blood pressure: 135/80 mm Hg
- Heart rate: 85 bpm
- Total cholesterol: 205 mg/dL
- HDL: 36 mg/dL
Heart
- Regular rate and rhythm, no murmur
ECG
- Some baseline abnormalities
Poor Functional Capacity Prior to Vascular Surgery
The AUC rating of echocardiogram (echo) for a patient with poor functional capacity prior to vascular surgery is: APPROPRIATE.2
ECHO Results: Abnormal
Mike was referred for a stress echo test. Results showed an ejection fraction of 30% and right ventricular systolic pressure of 63 mm Hg. Minor mitral regurgitation was detected, so Mike was sent for stress RNI prior to his surgery.
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Patient Presentation – Shirley
Shirley is a 47-year-old woman who has slight stress-related chest pain. For the past 2 years, she has been taking medication for hypertension. She is moderately physically active.
Examination
Vital signs
- Height: 5'9"
- Weight: 182 lb
- Blood pressure: 180/95 mm Hg
- Heart rate: 92 bpm
- Total cholesterol: 200 mg/dL
- HDL: 40 mg/dL
ECG
- ST segment abnormality
Symptomatic, Low Risk
The AUC rating of stress RNI for symptomatic patients with a low risk of CAD is: RARELY APPROPRIATE.2
No Further Testing
Because Shirley is at low risk for CAD, and a nuclear stress test would not have been appropriate for her, lifestyle modifications were recommended.
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ASCVD = atherosclerotic cardiovascular disease.