In the scenario of chest pain, the initial evaluation will be a resting electrocardiogram (ECG) in order to exclude a heart attack.
If the ECG is normal, then the next step will be to do a stress test. The preferred stress then in our center is that of an exercise stress echocardiogram (ESE) if the patient is able to walk on the treadmill. This test will be able to inform us whether there is a presence of a previous heart attack and whether there are any blockages of the heart arteries. If the patient is elderly or unable to walk, then a dobutamine stress echocardiogram is done instead. This method is essentially the same as a ESE except that instead of walking on a treadmill, an infusion of medication is given.
An alternative to the stress test is a CT coronary angiogram (CTA). This is a X-ray based method which allows direct visualization of the heart arteries to see if there is any narrowing or blockages or cholesterol deposits. Which method would be preferable will be decided upon after careful consultation with your doctor.
When the stress tests or CTA indicates the presence of blockages, an invasive coronary angiogram or cardiac catheterization is usually offered. This is the most direct and accurate way of visualizing the coronary arteries and if the blockages are confirmed, an angioplasty and stenting can be done immediately or if the disease is really bad, the patient may be offered a coronary bypass surgery.