This patient should undergo dobutamine stress echocardiography. She has a history of coronary artery disease (CAD) with new atypical, but exertional, symptoms suggestive of cardiac ischemia. Because she has baseline electrocardiogram abnormalities (left ventricular hypertrophy with repolarization abnormalities) that will make interpretation of ST-segment changes difficult, she should undergo stress testing with imaging, with either stress echocardiography with dobutamine or myocardial perfusion imaging with a vasodilator.

With stress echocardiography, regional myocardial function is assessed in real time. Stress images are obtained at peak or immediately after stress, before cardiac function returns to baseline. Wall motion abnormalities indicate either infarction (seen on stress and rest images) or ischemia (seen on stress images only). For patients who cannot exercise, such as this patient, pharmacologic stressors such as dobutamine in combination with imaging can be used in place of exercise and imaging.

Because of her COPD with active wheezing on examination, pharmacologic testing with vasodilators should be avoided. Pharmacologic vasodilators, such as dipyridamole, adenosine, and regadenoson, can cause bronchospasm and are therefore contraindicated in a patient who is actively wheezing. These agents can be used with caution in a patient with a history of bronchospastic airways disease, but the presence of active wheezing in this patient precludes the use of a vasodilator. Therefore, stress testing with dobutamine is the correct choice.

This patient has no symptoms to indicate an acute coronary syndrome that would prompt cardiac catheterization as the initial diagnostic test. Evaluation of the extent and severity of disease would be the first step in deciding management in this patient. If she has a small perfusion defect, she could be treated medically with more intensive antianginal therapies.