The most appropriate diagnostic test for this patient is exercise stress testing. He has an intermediate pretest probability of coronary artery disease (CAD) based on his age, sex, and symptoms. He should undergo stress testing to determine if his symptoms are related to obstructive CAD. Exercise electrocardiographic (ECG) testing is the standard stress test for CAD diagnosis in patients with a normal baseline ECG. If abnormalities limiting ST-segment analysis are present (left bundle branch block [LBBB], left ventricular hypertrophy, paced rhythm, Wolff-Parkinson-White pattern), results may be indeterminate. This patient has none of these conditions, and therefore exercise stress testing is a reasonable option. In patients who can exercise, exercise stress is preferred to pharmacologic stress because of the functional and prognostic information exercise stress provides. Persons who can exercise have a better prognosis than those who are unable to exercise and require pharmacologic stress testing.

Among patients with resting ECG abnormalities that limit ST-segment analysis, the addition of imaging aids diagnostic accuracy and provides improvement in localizing the site and extent of ischemia. In patients with LBBB, exercise stress may result in abnormal septal motion due to conduction delay with falsely positive septal abnormalities; this abnormality is lessened with use of vasodilator (such as adenosine) stress imaging. This patient does not have ECG abnormalities that warrant adenosine myocardial imaging study and the added expense and radiation exposure that this procedure would require.

Cardiac magnetic resonance (CMR) imaging can be used to evaluate aortic pathology, pericardial diseases, and myocardial diseases, as well as to evaluate the extent of myocardial fibrosis. CMR imaging may be useful in determining the extent of myocardial infarction and potential viability. This patient is asymptomatic; therefore, CMR imaging is not indicated.

CT angiography allows determination of the presence and extent of coronary artery disease. If this intermediate-risk patient was unable to exercise or the ECG was uninterpretable, CT angiography could be performed. If, however, obstructive disease was found, the patient would then need to undergo coronary angiography to perform a percutaneous intervention, thus performing two procedures that require contrast agents and radiation exposure.

For patients unable to exercise because of physical limitations or physical deconditioning, pharmacologic stressors, such as dobutamine, can be used. These agents, which are recommended if the patient cannot achieve at least five metabolic equivalents, increase myocardial contractility and oxygen demand. This patient can exercise, and dobutamine stress echocardiography is not indicated.