SAN DIEGO—The first challenge with patients who potentially have coronary artery disease (CAD) is to “appropriately risk stratify them,” began physician assistant Daniel Thomas Thibodeau, MHP, PA-C, DFAAPA, in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.
He emphasized the importance of relying on tried and true guidelines, such as those that have been published by the American Heart Association/American College of Cardiology, to determine a patient’s risk. He explained that providers need to consider patient age; family history; whether the patient has comorbidities such as hypertension, diabetes mellitus, dyslipidemia, or obesity; whether the patient smokes; and race/ethnicity. “A 65-year-old black male who has hypertension, diabetes, a family history of CAD, and who is a pack-a-day smoker has a high-risk profile for heart disease,” Thibodeau illustrated.
“Then you place that [risk profile] in the context of why the patient is sitting in front of you,” Thibodeau continued at the conference, held by Global Academy for Medical Education. Does the patient have an acute, chronic, or subacute condition? Is the patient presenting with a cardiac complaint of chest pain or pressure?
Match the test to the patient
Then perhaps the biggest challenge, Thibodeau continued, is determining which stress test to order. To choose from the vast array of stress tests available, providers must consider, “What’s the likelihood of getting a positive test? That’s what you’re looking for. You’re looking for disease. What test do I want to order to provoke this patient enough to show that he/she has disease?” Thibodeau explained.
To narrow the testing options, Thibodeau said you begin by answering some basic questions. For example, can the patient exercise? If the patient is young and has some symptoms but her risk is low, then a simple treadmill test will probably suffice. If the patient is older with some orthopedic issues and can’t walk well, then a pharmacologic stress test will probably be necessary, Thibodeau explained. “Or perhaps you have a patient who cannot exercise and has severe chronic obstructive pulmonary disease and you require a dobutamine stress echocardiography to look at cardiac function and areas of wall motion abnormalities.”
Thibodeau remarked of his situation, “PAs do all the stress tests in the hospital, and oftentimes you’re sent an order [for a test] that the patient simply can’t do,” underscoring the need to order a test that is appropriate for the patient’s abilities.
Continue to: With treatment don't forget the fundamentals