Scenario: A 69-year-old man came to the emergency department with developing dyspnea and syncope after gardening. His cardiovascular risk factors included older age (>65 years), male sex, hypertension, hypercholesterolemia, obesity, and a 35-pack-year smoking history. He had a nondiagnostic resting 12-lead electrocardiogram (ECG) at triage, no arrhythmic events on 5-lead telemetry, and a nondiagnostic change in serial high-sensitivity troponin levels (0 hour: 9 ng/dL, 3 hour: 11 ng/dL; normal: <14 ng/dL), which collectively ruled out acute coronary syndrome. He was discharged home with an appointment 3 days later for cardiology follow-up with an exercise nuclear stress test. Before that test, his 12-lead ECG was normal (no ST-segment or T-wave changes). After 13 minutes of exercise, he achieved 9.3 metabolic equivalents with a diagnostic cardiac workload but had to stop exercising because of 7/10 chest pain. The nurse noted he was pale and assisted him to the stretcher, with the...

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