Ischemic Heart Disease

Of note, the LVEF at rest was measured at 67%, falling to 57% with exercise. Of further note, two blood pressure values at rest are noted to be 164/104 and 167/90 mm Hg.

Additional information which would be of interest:
Additional medical history for this patient would be valuable. For example, is there any history of glucose intolerance? Is there a family history of hypertension, coronary artery disease, cerebrovascular disease, diabetes mellitus, gout, or hyperlipidemia? Does the patient have any drug allergies? Does the patient smoke (or is there a history of tobacco use)? Does the patient take any medications?

With respect to the findings of ischemia, does the patient ever experience shortness of breath? Chest pain? Difficulty lying flat in bed due to shortness of breath? Palpitations or an irregular heart beat?

Has an echocardiogram ever been performed? Is there evidence of left atrial enlargement or of left ventricular hypertrophy?

What are the findings on his electrocardiogram? Is there evidence of left atrial enlargement or left ventricular hypertrophy?

The answers to these questions and the additional information would affect my suggestions for the approach to further testing and treatment.
In the absence of this additional information, I would suggest the following:

1. The results of the stress test suggests strongly that the patient has silent myocardial ischemia and may be at risk for sudden cardiac death especially in light of the marked exertional level of activity. A further effort to define the presence or absence of a significant coronary stenosis should be undertaken. Although coronary angiography is not necessarily needed immediately, I would suggest that a CT coronary angiogram be obtained and that the results of that procedure guide the decision as to proceed with cardiac catheterization. The fall in LV ejection fraction with exercise suggests that there is indeed a significant coronary obstruction which results in LV dysfunction at peak exertion.

2. A complete fasting lipid profile including HDL and LDL cholesterol, and triglycerides and high sensitivity C-reactive protein (hs-CRP) and fasting blood sugar should be obtained. Depending on the results of this testing, the patient's family history of hyperlipidemia, the family history of vascular disease, and the results of the testing suggested above, the patient may need/should be placed on high dose statin therapy (Lipitor 80 mg QD or Crestor 20 mg QD).

3. A more accurate assessment of the patient's blood pressure should be obtained. The two readings reported are clearly abnormal but the patient reports much lower values at home. The results of the EKG and echocardiogram will help to determine whether his blood pressure is higher than expected. A 24-hour blood pressure recording and multiple additional measurements at rest would be helpful. If blood pressure values in excess of 140/90 mm Hg are found frequently, aggressive blood pressure control should be initiated with anti-hypertensive agents, which may or may not include a beta-adrenergic blocking drug if ischemia is confirmed.

With regard to the specific questions raised by the patient:

1. Based on the data presented, I believe there is indeed evidence of myocardial ischemia and that medical therapy and/or intervention (angioplasty/stent insertion) will be required. Additional testing as suggested above will be needed to confirm or exclude a coronary artery obstruction.

2. Until the presence or absence of significant coronary artery disease is determined, I would suggest a reduction in physical activity.

3. I can't comment on the treatment of lipids as the materials submitted only include an LDL value. A complete lipid profile, along with CRP determination, and fasting blood sugar are needed to make further suggestions.