Stratifying Symptomatic Patients Using the Exercise Test and Other Tools

Abstract

Risk stratification of patients with chest pain occurs daily by physicians in the primary care setting. When patients present in the office with recent or new-onset chest pain, the physician must determine the appropriate evaluation. Does this pain represent coronary artery disease or is the pain due to some other cause? When a patient with pre-existing risk factors for coronary artery disease presents with typical angina symptoms, the physician must recommend appropriate evaluation. Finally, how does one manage the patient in the emergency department with chest pain? All of these clinical situations presenting to the primary care physician require assessment through the performance of specific evaluations in the proper setting and time period. Some patients can be evaluated over hours or days. Other patients require immediate consultation with a cardiologist. This chapter first reviews the concept of risk stratification, definitions of coronary disease and looks at multiple stratification tools. Second, these tools are discussed as they are applied to stratifying patients with chest pain. The final section presents multiple case studies illustrating the use of these tools in the approach to the patient with chest pain. Risk stratification involves determining the likelihood of coronary artery disease being present (diagnosis) and the future risk of cardiac events for the patient (prognosis). This process may require careful objective testing while at other times subjective intuitive evaluation based on experience and statistical data occurs. When a 62-year-old man with multiple cardiac risk factors (positive family history of coronary artery disease, personal history of smoking, hypertension, type 2 diabetes mellitus and hyperlipidemia) presents with a pressure discomfort in the anterior chest precipitated by exertion and relieved with rest, one promptly places this patient at a high likelihood for coronary artery disease. This immediate determination from the history that coronary artery disease is probably present occurs before the patient is examined and with no objective test results. Other clinical presentations may require thorough evaluation and testing for subsequent risk stratification.