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I want viva answer of prilimary diagnosis and proving how

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stable angina AND diagnosis

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2024 ESC chronic coronary syndromes guideline diagnosis exercise ECG stable angina

Primary diagnosis

Chronic coronary syndrome (stable exertional angina) due to suspected obstructive coronary artery disease, Canadian Cardiovascular Society (CCS) class III.

Viva answer: How do you prove it?

This patient has typical angina pectoris because the chest pain has all three classical features:
  1. Constricting retrosternal chest pain
  2. Precipitated by exertion: walking about 200 m or climbing one flight of stairs
  3. Relieved by rest within 3-5 minutes
It radiates to the left shoulder, which further supports myocardial ischemia.
His symptoms have been present for about 1.5 years, with no pain at rest and a predictable exertional pattern. Therefore, it is stable angina, now termed a chronic coronary syndrome, rather than acute coronary syndrome.

Why CCS class III?

He develops angina after walking only 200 m or climbing one flight of stairs. This represents a marked limitation of ordinary physical activity, consistent with CCS class III angina.

Evidence supporting coronary artery disease

He has multiple atherosclerotic risk factors:
  • Male, 55 years
  • Hypertension
  • Dyslipidemia: total cholesterol 6.5 mmol/L, LDL-C 3.5 mmol/L, triglycerides 2.7 mmol/L
  • Past smoking history
  • Central obesity: waist circumference 96 cm
  • Family history of premature myocardial infarction: father died at age 59

Test evidence

The resting ECG is normal, which does not exclude stable coronary artery disease.
The exercise ECG was stopped at 75 W because of chest discomfort and showed 2 mm ST-segment depression in V4, V5, and V6.
This is a positive exercise stress test because exercise-induced horizontal or downsloping ST depression of at least 1 mm is diagnostic of inducible myocardial ischemia when the resting ECG is interpretable. His 2 mm depression in contiguous lateral precordial leads, associated with typical chest pain, strongly supports exercise-induced subendocardial ischemia.
The likely ischemic territory is anterolateral/lateral myocardium.

One-line examination answer

“This is chronic coronary syndrome presenting as typical stable exertional angina, CCS class III, with a positive exercise ECG for inducible myocardial ischemia, most likely due to obstructive coronary artery disease.”

How to confirm anatomically

A positive exercise test supports ischemia but does not show the coronary anatomy. Confirmation can be by:
  • Coronary CT angiography in suitable patients, or
  • Invasive coronary angiography, especially because he has class III symptoms, early positive stress testing, and significant ST depression.
Modern ESC guidance uses clinical likelihood plus non-invasive anatomical or functional imaging for suspected chronic coronary syndrome; invasive angiography is appropriate when symptoms are severe or risk is high. 2024 ESC chronic coronary guidance notes that exercise ECG alone is less accurate than imaging-based tests, although it remains useful for exercise capacity, symptom reproduction, and ECG ischemia assessment.
Important viva point: Say “positive for exercise-induced myocardial ischemia”, not “the treadmill test proves coronary blockage.” The blockage must be demonstrated by CT coronary angiography or invasive coronary angiography.
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