When Stable Becomes Unstable

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Stephen D. Wiviott), who responds to the information, sharing his or her reasoning with the reader (regular type). A Discussion by the authors follows. A 61-year-old man presents to his primary care physician with several weeks of substernal chest pain. He reports that the discomfort occurs consistently with exertion, subsides after he rests for 15 minutes, and is often associated with dyspnea and diaphoresis. He denies any episodes of chest pain at rest, paroxysmal nocturnal dyspnea, palpitations, presyncope or syncope, or lower-extremity edema. His medical history is notable for hypertension, dyslipidemia, and non– insulin-dependent diabetes mellitus. Over the past year, he has made significant lifestyle modifications, including reductions in high-fat foods and enrollment in an exercise program. He reports consistent adherence to his prescribed medications, which include lisinopril 20 mg daily, metformin 1000 mg twice daily, metoprolol succinate 25 mg daily, and simvastatin 40 mg daily. He has no allergies and no significant history of tobacco, alcohol, or illicit drug use. He is employed as a financial planner and lives with his wife and 2 children. There is no family history of premature coronary artery disease (CAD) or sudden cardiac death. His temperature is 98.1°F; blood pressure is 148/96 mm Hg in the left arm and 144/94 mm Hg in the right arm, pulse is 84 beats/min and regular, and respiratory rate is 14 breaths per minute with an oxygen saturation of 96% on room air. He is an obese (body mass index 33 kg/m2) white male who appears to be his stated age. There is no thyromegaly or adenopathy, and the jugular venous pressure is 6 cm H2O. Cardiac examination reveals a discrete, nondisplaced point of maximal impulse in the …