chest pain, when to cath, when not to do a stress test.paul
TRANSCRIPT
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TO STRESS OR NOT TOSTRESS ?
Karam Paul MS, MD, MBA, FACC
Community Heart and Vascular
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Cardiac stress testing - learningobjectives
►Know why to undertae a
stress test►Know who should have one►Know how it is !er"or#ed►$nderstand the li#itations►$nderstand which to choose►Know what to do with theresult
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Cardiac stress testing
%hy do a stresstest?
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&i#s o" stress testing
►Elicit abnor#alities not !resentat rest
►Esti#ate "unctional ca!acity
►Esti#ate !rognosis
►'ielihood o" coronary artery
disease ►E(tent o" coronary arterydisease
►E)ect o" treat#ent
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Cardiac stress testing
%ho should haveone?
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*iagnostic test
►+ayes, Theore#
►Consider the !re-test ris,
►Sensitivity . s!eci/city o" the test
►0ost-test !robability o" C&*
►*iagnostic !ower o" EST is #a(i#alwhen the !re-test !robability isinter#ediate1
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Ris assess#ent
►0re-e(isting coronaryartery disease
►*iabetes
►2y!ertension
►S#oing history
►3a#ily history ►Renal disease
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Consider other ris "actors
0re-e(isting coronaryartery disease►*iabetes
►2y!ertension ►2y!erli!ide#ia►S#oing history►3a#ily history
►Renal disease
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Consider other ris "actors
►0re-e(isting coronaryartery disease
►*iabetes►2y!ertension
►2y!erli!ide#ia►S#oing history►3a#ily history►Renal disease
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4alvular heart disease
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Rhyth# disorders
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Contraindications
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Cardiac Stress Testing
2ow is it done?
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E(ercise !rotocol
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0ositive5
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6easure#ents
►EC7
►E(ercise ca!acity86ETS 9 #etabolic
e:uivalent;
►Sy#!to#s
►+lood !ressure
►2eart rate res!onse .recovery
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EC7
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► The nor#al and ra!id u!slo!ing STseg#ent res!onses are nor#alres!onses to e(ercise1► 6inor ST de!ression can occur
occasionally at sub#a(i#alworloads in !atients with coronarydisease1► The slow u!slo!ing ST seg#ent!attern o"ten de#onstrates anische#ic res!onse in !atients withnown coronary disease or those with
a high !retest clinical ris o" coronarydisease1► *ownslo!ing ST seg#entde!ression re!resents a severeische#ic res!onse1► ST seg#ent elevation in an in"arct
territory 8> wave lead; indicates asevere wall #otion abnor#ality andin #ost cases is not considered anische#ic res!onse1
(From Chaitman BR: Exercise electrocardiographicstress testing. @n Beller GA [ed]: Chronic IschemicHeart isease. @n Bra!n"ald E [series ed]: Atlas o#
Heart iseases. $ol %. Chronic Ischemic Heartisease. &hiladelphia' C!rrent edicine' )**%' pp
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T wave changes
► @nAuenced byB +ody !osition Res!iration
2y!erventilation *rug R( 6yocardial ische#ia Necrosis
► 0seudonor#alisationB $sually non-diagnostic Consider ancillaryi#aging
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6ETs
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2eart rate res!onse
►0ea 2R DF o" #a(i#al !redicted"or age
►2R recovery
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2eart rate res!onse
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0rognostic value o" stresstesting
0ara#eters associated with adverse!rognosis or #ulti-vessel disease
► Duration of symptom-limiting eercise !" M#$s► Failure to increase sBP %&'(mmHg, or a sustaineddecreased % &(mmHg, or )elo* rest le+els, duringprogressi+e eercise► S$ segment depression %'mm, do*nsloping S$ segment,starting at !" M#$s, in+ol+ing %" leads, persisting %" mininto reco+ery► #ercise-induced S$ segment ele+ation aV ecluded.► Angina pectoris at lo* eercise *or/loads► eproduci)le sustained 01( sec. or symptomatic
+entricular tac2ycardia
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'i#itations o" tread#ill stresstest
► Non-diagnostic EC7 changes► 3alse !ositivesH"alse negatives
► %o#en 9 "alse !ositives► Elderly 9 #ore sensitiveHless s!eci/c► *iabetics 9 autono#ic dys"unction► 2y!ertension► @nability to e(ercise
► *rugs 9 digo(inI anti-anginals
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Non-coronary causes o" STseg#ent de!ression
► &ne#ia► Cardio#yo!athy► *igo(in► 7lucose load
► 2y!erventilation► 2y!oale#ia► @ntraventricular conductiondisturbance► 6itral valve !rola!se► 0re-e(citation syndro#e
► Severe aortic stenosis► Severe hy!ertension► Severe hy!o(ia► Severe volu#e overload 8aortic or#itral regurgitation;► Sudden e(cessive e(ercise
► Su!raventricular tachycardiaJs
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'i#itations o" tread#ill stresstest
Sensitivity DF
S!eci/city LLF
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&ncillary techni:ues to enhancecontent
Echocardiogra!hy Radionuclidei#aging
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Stress echocardiogra!hy
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Stress echocardiogra!hy
Co#!ares !re . !ostB Regional
contractility Overall systolic"unction 4olu#es
0ressure gradients 3illing !ressures 0ul#onary!ressures 4alvular "unction
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*obuta#ine stress echo
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Stress echo - li#itations
3actors which e)ect i#age:ualityB
+ody habitus 'ung disease +reast i#!lants
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Nor#al stress echocardiogra#
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Case <
►M year old ban !roject#anager
►E(ertional chest !ain .dys!nea ►E(-s#oer
►TC 1L##olH' ►Stress EC7 9 G## STseg#ent de!ression in leads
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Stress echocardiogra#
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Coronary angiogra#
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Case G
►G year old "e#ale
►Chest !ain . dys!nea
►Tread#ill e(ercise test 9 non-diagnostic sub-#a(i#al 2y!ertension
No EC7 changes
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Case G
►E(ercised L #inutes8P1M 6ETS;
►No chest !ain
►EC7 changes
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Case G
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Case G
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Case =
►GM year old "e#aleengineer
►E(ertional dys!nea
►0al!itations
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Case =
@nducible dys!nea►EC7 !artial right bundle
branch bloc no ische#ic changes
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Case =
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Case =
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Case =
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Case M
►M= year old #ale -airline catering
►Chest !ain
►*ys!nea
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Case M
►@nducible dys!nea ►Non-s!eci/c T wave
changes ►No ST seg#ent shi"t ►7lobal deterioration in
le"t ventricular "unction
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Case M
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Case M
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Case M
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Nuclear S0ECT i#aging
►Radio-tracer injection ►@soto!esB Thalliu#-GQ< Technetiu# PP# 8sesta#ibi;
►6yocardial u!tae ►0hoton e#ission ca!tured byga##a ca#era ►Rest . redistribution !hases
►0har#acologic !rotocolsavailable ►*igital !resentation
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Nuclear S0ECT i#aging
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Nuclear S0ECT i#aging
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Nuclear S0ECT i#aging
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Nuclear S0ECT i#aging
Reversible in"erior wall de"ect
6ilder reversible in"erior wall de"ect
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
►Ti#e-consu#ing
►&rti"acts ►+alanced ische#ia ►Radiation
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
Nor#al a!ical thinning1
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
&1 +reast attenuation +1 &nterior ische#ia
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
►Ris o" iatrogenic #alignancy
►'inear no-threshold #odel ►ConsiderB age
gender bacground
'i#itations o" nuclear S0ECT
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'i#itations o" nuclear S0ECTi#aging
Einstein &1 1 et al1 Circulation GQQLI
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6R@ cardiac stress test
$se"ul "orB►0atients unable toe(ercise
►EC7 uninter!retable►$nsuitable "or *SE
&nd1
►No radiation
+ut►Not currently available
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>uestion
►M year old diabetic #an
►&nterior chest disco#"ort withe(ertion
►E(ercised "or G #ins =Q secs8M1 6ETs; ►PF #a(i#al !redicted heartrate
►6ild chest !ain
►+0 increased "ro# baseline to
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%hich is true?
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&nswer
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Re#e#ber
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Re#e#ber
0ara#eters associated with adverse !rognosisor #ulti-vessel disease
► Duration of symptom-limiting eercise !" M#$s► Failure to increase sBP %&'(mmHg, or a sustained decreased %&(mmHg, or )elo* rest le+els, during progressi+e eercise► S$ segment depression %'mm, do*nsloping S$ segment, starting at!" M#$s, in+ol+ing %" leads, persisting %" min into reco+ery► #ercise-induced S$ segment ele+ation aV ecluded.
► Angina pectoris at lo* eercise *or/loads► eproduci)le sustained 01( sec. or symptomatic +entriculartac2ycardia
%hen ordering a stress test
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%hen ordering a stress testconsider
►0re-test ris o" disease
►Sensitivity . s!eci/city o" thetest
►4alue o" su!!le#entary data
►&N* $ST ONE 6ORE T@011
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6R@ cardiac stress test
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Cardiac stress testing
So1which one to choose?
%hat to do with the
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%hat to do with theresult?
►Re#e#ber +ayes,theore#
►Consider the !re-test
ris
►+e aware o" thesensitivity . s!eci/city
o" the test
►&!!ly the !ost test!robability
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C C l i
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CT Calciu# score
►Correlates with !resence . e(tent o" C&* ►Strong negative !redictive value
►Cannot !redict "unctional signi/cance
►2igher scores can !redict events
►Reco##ended "or asy#!to#atic withinter#ediate ris
CT C l i
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CT Calciu# score
Calci/cation o" the le"tanterior descending
coronary artery 8largearrow; and le"tcircu#Ae( coronaryartery 8s#all arrow;1
CT C l i
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CT Calciu# score
Score description Q nil< 9 PP #ild
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CT Calciu# score
► @ndicated 9 asy#!to#atic withinter#ediate ris
► Not "or low risH!o!ulation screening ► 2igh ris 9 use current guidelines
► *o not reduce R( i" inter#ediate ris .
Q, score
CT i h
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CT coronary angiogra!hy
►G-di#ensional . =-di#ensionalreconstructions
►Relies on slow regularheart rate
►2igh negative!redictive value 8ruleout, ability;
CT coronary angiogra!hy -
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CT coronary angiogra!hy li#itations
►'ower !ositive!redictive value 8over-esti#ation tendency;
►7rading o" stenosisli#ited
►*oes not evaluate"unctional signi/cance
►Radiation e(!osure
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CT coronary angiogra!hy
►Role not yet clearly de/ned
►0otential "or those with
inter#ediate lielihood o"diseaseB%here stress testing not!ossible
Stress teste:uivocalHuninter!retable &cute chest !ainHno EC7changesHnor#al eny#es
►Role in ano#alous anato#y
CT i h
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CT coronary angiogra!hy