Stopping the beta-blocker is not likely to have much effect because the patient has mild COPD with no reversibility with salbutamol.Įxercise test and chest X-ray are normal, and his dyspnea is not progressive. In this patient, the most common causes of dyspnea (atypical angina, arrhythmias, heart failure, asthma, COPD, anemia, thyroid disorder, and kidney disease) have been excluded. The most common causes of chronic dyspnea in this age group are pulmonary and cardiac causes. An exercise regime aiming to gradually increase his walking to 30 minutes per day 5 days a week at a moderate pace. Provocative testing for reversible airway disease. Additional investigations such as a 24-hour ambulatory electrocardiography monitoring (holter) and high-resolution computed tomography scan of the chest. Stop beta-blocker because this may be exacerbating his COPD. What intervention is likely to be the most beneficial to the patient? Diffusing capacity of the lungs for carbon monoxide is normal, and there is no response to salbutamol. Lung function tests show mild chronic obstructive pulmonary disease (COPD) (FEV1 88% predicted). He felt short of breath in early stage 2 of the normal Bruce protocol, but there were no arrhythmia or electrocardiographic changes of ischemia. He has an appropriate chronotropic response to exercise. An exercise stress echocardiogram shows structurally normal heart and a left ventricular ejection fraction of 55% with mild diastolic dysfunction and normal pulmonary artery pressure. His hemoglobin is 147 g/dL, B-type natriuretic peptide and thyroid function tests are normal, and he has stage II chronic kidney disease. His chest is clear, he has no murmurs, and there is no clinical indication of failure. His body mass index is 29 kg/m 2, his blood pressure is 128/70 mmHg, and his heart rate is 65 bpm sinus rhythm. On examination, you notice that he looks frailer, and he admits to being more sedentary since his heart attack. He is on dual antiplatelet treatment (aspirin 81 mg daily and clopidogrel 75 mg daily), atorvastatin 80 mg daily, ramipril 2.5 mg daily, and metoprolol CD 47.5 mg daily. These have been well-managed since his NSTEMI. His risk factors for heart disease include that he is an ex-smoker for some years with a 20-year pack history of smoking, hypertension, and dyslipidemia. He has no orthopnea, paroxysmal nocturnal dyspnea, ankle swelling, or angina. The dyspnea is not getting any worse over time, but he is worried that his shortness of breath means that he has something wrong and is too worried to exercise.

He finds he gets short of breath when he walks on any incline but is fine on the flat.

At the time of his NSTEMI, he had an 80% left anterior descending artery lesion that was stented and minor disease elsewhere. A 72-year-old man has ongoing dyspnea on exertion since his non-ST-segment elevation myocardial infarction (NSTEMI) 1 year ago.

Orthopnea paroxysmal nocturnal dyspnea