An 82-Year-Old Man With Worsening Exercise Tolerance
July 25, 2013
An 82-year-old man presents to the office with worsening exercise intolerance. His past history is remarkable for pulmonary emboli, for which he takes chronic warfarin, hypertension, and a left bundle branch noted four years earlier. At that time he underwent an echo which showed normal ejection fraction and no abnormalities, and a PET scan which showed calcified coronaries but no ischemia. He is an internist who continues to see patients in the office several days per week, and has been quite active, working out in a gym on elliptical, stationary bicycle, and weight machines for 90 minutes, four times per week for many years. However, about three months ago, he noted he was unable to exercise as he had been, due to increasing dyspnea on exertion, with no dyspnea at rest and no symptoms of chest pain, syncope, dizziness, or lower extremity edema. His medications include lisinopril, pravastatin, warfarin, and pantoprazole. Repeat echo was unremarkable, and chest CT showed no evidence of pulmonary emboli.
Stress test results are shown below:
Myocardial perfusion imaging showed a small reversible inferobasal defect.