A 60-year-old man with exertional chest pain relieved by rest and mild dyspnea on exertion. What is the most appropriate next diagnostic test?

• A. Cardiac catheterization
• B. Nuclear exercise stress test
• C. Helical (spiral) CT
• D. Transthoracic Echocardiogram

Answer: (B)

Evaluating suspected stable angina in a patient who can exercise is best done with functional noninvasive testing to see if exertion triggers ischemia and to gauge risk.

A nuclear exercise stress test fits here because it reproduces the activity that brings symptoms and uses a radioactive tracer to visualize myocardial perfusion during stress. If regions show reduced perfusion during exercise, it indicates flow-limiting coronary disease and helps localize and quantify ischemia, guiding management and prognosis. It provides both functional (ischemia under stress) and anatomic (perfusion) information without being invasive.

Cardiac catheterization is more invasive and is typically reserved after noninvasive testing suggests significant ischemia or for planning revascularization. Helical CT focuses on coronary anatomy rather than ischemia, and a resting transthoracic echo alone does not assess inducible ischemia (and would miss stress-induced perfusion defects unless paired with a stress protocol).