Recurrent Atypical Chest Pain and Mild Shortness of Breath in a 62-Year-Old Woman

Case Presentation

A 62-year-old Hispanic woman with atypical chest pain and mild shortness of breath presents to a cardiologist as a new patient. She is noted to have recurring, fleeting, dull, and nonradiating pain over the central chest, lasting 5-10 minutes per episode. The episodes appear to be brought about by high-stress environments, and the patient reports being under increased stress due to family illness and concerns about COVID.

The patient has a family history of heart disease; her father died of myocardial infarction (MI) at age 53 years. Her medical history is significant for high cholesterol and hypertension. The hypertension is well-controlled with an angiotensin receptor blocker. She is on no other medications and denies past or current tobacco, alcohol, or recreational drug use.

The patient's vital signs at presentation are normal, as follows:

• Blood pressure: 128/78 mm Hg

• Heart rate: 74 beats/min

• Respiratory rate: 18 breaths/min

• Temperature: 98.4°F

• Oxygen saturation: 99% on room air

The physical examination is unremarkable. Laboratory studies reveal the following:

• A1c: 5.8%

• Thyroid-stimulating hormone (with creatinine values: within normal range)

• Total cholesterol: 209 mg/dL

• High-density lipoprotein cholesterol (HDL-C): 52 mg/dL

• Low-density lipoprotein cholesterol (LDL-C): 128 mg/dL

• Triglycerides: 145 mg/dL

• Non–HDL-C: 157 mg/dL

Management

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain (2021 AHA/ACC Guideline) recommends a comprehensive approach to assessing patients with chest pain, including obtaining a detailed history of symptoms and considering suspected ischemia with nonobstructive coronary artery disease (INOCA) as an alternative diagnosis to obstructive coronary artery disease (CAD). The 2021 AHA/ACC Guideline emphasizes that chest pain can present as an anginal equivalent (ie, shortness of breath, fatigue) and stresses the importance of identifying ischemic causes of pain. In addition, the guideline encourages a shared decision-making approach between clinicians and patients and provides new algorithms that more strongly incorporate atherosclerotic imaging modalities (eg, coronary artery calcium [CAC], cardiac CT angiography [CCTA]) and a structured risk assessment.

In the 2021 AHA/ACC Guideline's structured risk assessment for chest pain, clinicians use evidence-based diagnostic protocols, including calculating pretest probability, to estimate a patient's risk for CAD and determine the next best course of action. This evidence-based approach risk stratifies patients into low-, intermediate-, and high-risk groups, in turn reducing unnecessary testing and cost compared with an unstructured assessment. For example, the guideline recommends CAC testing or treadmill electrocardiography for symptomatic patients at low risk for heart disease and favors CCTA for patients at intermediate and high risk and functional testing for patients at higher risk.

Moreover, the comprehensive AHA/ACC Guideline moves the needle strongly toward anatomical imaging over functional testing, recommending CAC in low-risk patients and CCTA in intermediate-risk patients. Thus, the 2021 AHA/ACC Guideline suggests CCTA as a first-line test over functional imaging, with a higher level of recommendation in stable CAD. For intermediate- to high-risk patients with stable chest pain and no known CAD, the guideline recommends CCTA (class of recommendation, 1; level of evidence, A) or stress imaging (stress echocardiography, PET, single-photon emission CT, myocardial perfusion imaging [MPI], cardiac magnetic resonance; class of recommendation, 1, level of evidence, B-R).

As calculated by the ACC/AHA Pooled Cohort Atherosclerotic Cardiovascular Disease Risk Equation, the patient's initial estimated risk for future MI was 6%, placing her at intermediate risk. Given this patient's hypercholesterolemia, hypertension, postmenopausal status, and family history of heart disease, CCTA is favored over other testing algorithms. Not only does CCTA afford direct visualization of the coronary arteries, with a negative predictive value of 99% to exclude obstructive coronary disease, studies have demonstrated that CCTA is significantly more accurate than MPI in identifying obstructive disease. Moreover, the SCOT-HEART trial showed that anatomical testing (CCTA) lowers the rate of death or nonfatal MI by 41% compared with stress testing at 5 years (hazard ratio, 0.59; 95% CI, 0.41-0.84; P = .004).

Another compelling reason to choose CCTA over MPI was reported from the recent ISCHEMIA trial, wherein risk stratification using functional imaging (predominantly MPI) failed to identify patients in whom the risk for MI or death could be predicted, while also failing to predict those in whom revascularization would lower their risk for MI or death. Anatomical extent and burden of CAD on CCTA (P < .001) was highly predictive of mortality and MI, whereas severity of ischemia was not (P = .33).

The patient underwent CAC and CCTA. Although CCTA showed only mild nonobstructive disease, her CAC score was 112, and a Multi-Ethnic Study of Atherosclerosis calculation with CAC estimated her 10-year risk for atherosclerotic cardiovascular disease (ASCVD) to be 11%, elevating her from intermediate to high risk. Following the recommendations set forth in the 2018 AHA/ACC Multisociety Guideline on the Management of Blood Cholesterol and the 2019 ACC/AHA Guideline on the Prevention of Cardiovascular Disease, the cardiologist appropriately prescribed low-dose aspirin (81 mg/d) and moderate-dose statin therapy (atorvastatin 20 mg/d) to decrease the patient's risk for ASCVD.

Conclusion

This case vignette demonstrates the most compelling reason that many clinicians are switching from functional testing to anatomical (CT-based) testing to assess cardiac risk. The ability of anatomical testing to visualize and quantitate atherosclerosis leads to increased use of effective preventive therapy, such as statins, low-dose aspirin, and angiotensin-converting enzyme inhibitors, as well as improved adherence to these therapies, as demonstrated in multiple randomized studies. A negative functional test, however, does not inform the clinician of any subclinical atherosclerosis — a potent target for risk reduction. The utility of CCTA to detect subclinical atherosclerosis is further emphasized in the 2021 AHA/ACC Guideline, which states, "CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD." Furthermore, the new guideline favors CCTA and CAC owing to improved patient compliance associated with the presence of atherosclerosis — that is, patients are more likely to adhere to medication and behavioral modifications when presented with anatomical proof.

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