This patient should undergo exercise electrocardiography (ECG). Although she has several risk factors for coronary artery disease (CAD), including hyperlipidemia and a family history of premature CAD, her symptoms are not typical for angina, which requires the presence of pain precipitated by exercise or emotion, a substernal location of the pain, and relief with rest or nitroglycerin. Because she has only two of the three diagnostic criteria for angina, she is classified as having atypical angina. Women in her age group with atypical angina have an intermediate pretest probability of CAD (approximately 22%). For patients with an intermediate pretest probability of disease and a normal resting ECG, exercise ECG testing is recommended as the initial test of choice.

Conventional coronary angiography identifies the location and severity of blockages and allows vascular access for percutaneous intervention. Because of the invasive nature of coronary angiography and the inherent risks of vascular complications, it should be reserved for patients with acute coronary syndrome requiring immediate intervention, lifestyle-limiting angina despite medical therapy, or high-risk criteria on noninvasive stress testing. This patient's pretest probability of CAD is intermediate, which is not high enough to warrant immediate coronary angiography as the initial diagnostic test.

The sensitivity and specificity of noninvasive stress testing for the evaluation of chest pain are lower in women than in men. However, the routine use of exercise testing with either nuclear perfusion imaging or echocardiography to assess left ventricular regional wall motion or perfusion imaging is not recommended for women or men in the absence of baseline ECG abnormalities. Although the addition of noninvasive imaging increases diagnostic sensitivity for coronary artery disease, use of exercise nuclear perfusion testing as the initial test has not been found to reduce cardiovascular events compared with exercise ECG testing alone.

Pharmacologic stress testing with imaging is indicated for patients who are unable to exercise. In addition, patients with left bundle branch block undergoing nuclear stress testing should be administered a pharmacologic stressor even if they are able to exercise because of the potential for a false-positive test owing to a septal perfusion abnormality that may occur with exercise. Pharmacologic stress testing is not indicated because this patient is physically able to exercise and does not have a left bundle branch block.