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Is an angiogram necessary for chest pain?

Q: My 60 years old father exercises every day for 45 minutes like brisk walking in hilly areas. Recently he got chest pain while walking . However, the pain subsided after taking a few minutes of rest. He has high blood pressure and diabetes and takes Amlodipine and Gilpizide. He had an ECG done and the doctor advised against walks in hilly areas. But he could do brisk walking on a flat area for 45 minutes and had no pain. After 2 months he again went for further check up but no symptoms of pain were found on regular walking. ECO showed the heart size, chambers and valves to be normal with EF 69%. However the ECG was abnormal and TMT test was positive. His TMT states: HR/BP response normal, poor exercise tolerance, patient had angina during exercise. Significant ST depression in V3-V6 during peak exercise. ST depression -1.9 mm with horizontal slope in V4 at during peak exercise. My father can do regular work and walks but has pain only while walking up-hill that also not too severe; hence he is not following the doctors' advise. The doctor advised an angiogram immediately to look for blocks. Also he has been prescribed Clopidogrel, Asprin, Sorbitrate 10 mg Tid and Atenolol 25. Is there any serious problem with his heart? Does he need an angiogram, angiography or bypass? His weight is 70 kg and height is 168 cm.

A:The gentleman in question has presented with angina of effort, which has gradually abated with medication on a background of Diabetes and Hypertension. It is likely that he has coronary artery disease with significant blocks in one or more of his large arteries. Important new information from clinical trials recently conducted shows that medical treatment is as effective in this group of patients as angioplasty in preventing heart attacks or death. Angioplasty will improve symptoms and increase exercise capacity. There is no need to rush for angiography unless his symptoms significantly worsen; he however should be on the best medical management and have a combination of drugs to lower LDL cholesterol aggressively, optimal blood pressure control, sugar control monitored by HbA1C levels below 7, and a combination of anti anginal medication.

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