TM - Ref. Response

Re: Sarah Johnson - Persistent Chest Pain Dear Dr. Emily White, GP Thank you for referring the above patient to me. It was a pleasure to review Sarah Johnson in my cardiology clinic. Ms. Johnson has a known history of essential hypertension, diagnosed five years ago, currently managed with Amlodipine 5mg daily. She also has a family history of coronary artery disease, with her father experiencing a myocardial infarction at age 55. She denies any prior cardiac interventions or hospitalisations for cardiac issues. A recent echocardiogram, performed on 25 October 2024, revealed normal left ventricular systolic function with an ejection fraction of 60%. There was no evidence of significant valvular heart disease or regional wall motion abnormalities. A chest X-ray on 20 October 2024 showed clear lung fields and normal cardiac silhouette. Ambulatory blood pressure monitoring over 24 hours on 28 October 2024 indicated an average blood pressure of 135/85 mmHg, with occasional spikes up to 150/95 mmHg, particularly during periods of stress. She has not undergone any previous Holter monitoring or stress testing. Ms. Johnson presents with a 3-month history of intermittent central chest pain, described as a dull ache, radiating occasionally to her left arm. The pain is usually brought on by exertion, such as climbing stairs, and relieved by rest. She reports no associated shortness of breath, palpitations, dizziness, or syncope. She denies any nocturnal chest pain. On examination, Ms. Johnson was well-appearing and in no acute distress. Her weight was 70 kg, and height 165 cm, yielding a BMI of 25.7 kg/m². Blood pressure was 130/80 mmHg, pulse 72 bpm regular, respiratory rate 16 breaths/min, and oxygen saturation 99% on room air. Cardiac auscultation revealed normal S1 and S2 heart sounds with no murmurs, rubs, or gallops. Lungs were clear to auscultation bilaterally. Peripheral pulses were 2+ and symmetrical. No peripheral oedema was noted. ECG performed today shows normal sinus rhythm, rate 70 bpm, with no significant ST-T wave changes or evidence of ischaemia. There are no pathological Q waves or axis deviation. My clinical impression is that Ms. Johnson's symptoms are highly suggestive of stable angina pectoris. Given her risk factors and the exertional nature of her chest pain, further investigation is warranted to assess for coronary artery disease. The plan of care includes initiating a trial of sublingual glyceryl trinitrate for symptomatic relief and a prescription for Aspirin 75mg daily. I have also requested a dobutamine stress echocardiogram to further evaluate for inducible ischaemia. I will arrange a follow-up appointment in 4 weeks to review the results of the stress echo and assess her symptomatic response to the new medications. I have advised Ms. Johnson on the importance of lifestyle modifications, including a low-fat diet, regular exercise, and smoking cessation. I will keep you informed of her progress. Should you have any further questions regarding the above patient, please do not hesitate to contact 020 7946 0000. Sincerely, Dr. Jonathan Lee Consultant Cardiologist