A 67-year-old man presents with progressive exertional angina for 4 months. ECG at rest is normal. During exercise treadmill testing, he develops 1.5mm horizontal ST depression in leads I, aVL, and V4-V6, starting at 5 minutes of Bruce protocol and persisting for 6 minutes into recovery. He has no contraindications to surgery. Which is the most appropriate next step?
- A Discharge with optimal medical therapy
- B Coronary CT angiography
- C Invasive coronary angiography ✓
- D Repeat stress test in 6 months
Correct answer: C. Invasive coronary angiography
Explanation
This patient has high-risk features on exercise testing: ST depression in multiple leads (5 leads), early onset (low workload), and prolonged recovery (>5 minutes into recovery). According to ACC/AHA guidelines, high-risk treadmill scores warrant invasive coronary angiography to define anatomy and guide revascularization. The Duke treadmill score would be high risk. Coronary CT angiography is not indicated as the next step when stress testing already shows high-risk features.
Reference: Braunwald's Heart Disease, 12th ed.
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Written and medically reviewed by the StethoPrep medical team.