A 74-year-old physically active man exercises daily, takes a statin for hyperlipidemia, and has no other risk factors aside from a mildly elevated hemoglobin A1c. His most recent lipid profile, in January 2015, was:
- Total-c: 144 mg/dL
- LDL-c: 84 mg/dL
- HDL-c: 48 mg/dL
- Triglycerides: 59 mg/dL
His coronary artery calcium scores were 109.5 in the year 2000 and 400.4 in 2008.
Stress tests in 2002 and 2006 were normal with good exercise tolerance, but the ECG portion of both stress tests was abnormal. The nuclear perfusion scans were normal both times. His cardiologist at the time told him to continue his medical therapy, which included aspirin 81 mg and atorvastatin 10 mg.
In 2014, a new cardiologist repeats the stress test and again finds discordant results: The echo is normal, but the ECG is abnormal. An exercise nuclear perfusion scan is ordered. Again the perfusion is normal, but the ECG is abnormal. The new cardiologist increases the atorvastatin to 40 mg. The patient continues to exercise and remains asymptomatic.
The patient is sent for a CT angiogram, but the test is not done because the patient has a calcium score of 756, which is felt to be too high to exclude CAD by CT angiography.
Questions:
1. Do you agree that nuclear perfusion imaging and treadmill echo are more specific than treadmill ECG alone without imaging? Does an abnormal exercise ECG with normal imaging raise a concern?
2. Should an increasing calcium score in an asymptomatic individual raise concerns?
3. Would this patient have met the enrollment criteria for the COURAGE trial? Should the data from COURAGE help guide decision making for this patient?
4. What would you do next to care for this patient?
