AT THE CLINIC ; CLASSICAL ANGINA, SHOULD WE STRESS?

It was an interesting week at the clinic. One of the patients I saw this week was a 70 year old Chinese gentleman, who has a 30 year history of diabetes and 3 year history of hypertension. He was very lucid and gave a classical history of effort angina for the last two weeks. Do you think that I need do a stress ECG to evaluate the chest pains? Would a stress ECG have added any extra information to help in my diagnosis? I reasoned to myself and then discussed this with the patient and relative ( the son who accompanied him was a very well educated manager ). I felt that with those major coronary risk factors and a history of classical angina, I only need do a resting ECG and if they wish ( since he is symptomatic ), I would proceed on to coronary arteriography and possibly angioplasty. I felt that that was safe and probably the best thing to do in managing him. The resting ECG was within normal limits.
It has always been a mood point as to whether all chest pains need a further non-invasive testing before embarking on the invasive coronary arteriography. I am well aware of the loophole that will allow some cardiologist to angiogram all chest pains, if the guidelines allow it. There is obviously tremendous financial rewards to doing angiograms for all chest pains. I think the guidelines will require that a comprehensive history be obtain including an assessment of the coronary risk over the next 10years ( using the Framingham score ) and then decide on further investigations. Obviously, the low risk group should only get a stress ECG and medical therapy, if the stress ECG is minimally positive or positive at only very high workload. The intermediate and high risk coronary risk groups ( those more that 10% risk by Framingham ) may require stress ECG and possibly invasive angiogram. I feel that the high risk group, with classical symptoms, may allow us to avoid the need for the stress ECG and invasive angiogram at the stage is warranted.
The patient received his angiogram and it showed severe two vessel CAD ( as one would expect in hypertensive, diabetic at 70years ), for which angioplasty was successfully done. He is now well and resting at home.
So so all chest pains need a stress ECG, although it is relatively cheap and low risk? Well, there are always exceptions to all rules. I suppose that is where a clinician must make a judgement call, and earn our consult fees.