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Non-Invasive evaluation of
CAD Thomas Oliver
North Cascade Cardiology
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Outline
• Brief overview of indications for non-invasive evaluation of CAD
• Review of modalities available
• Exercise stress testing
• Stress echo
• Nuclear stress testing
• Coronary CTA
• PET stress test
• MRI
• Summary of each modality
• How to choose the best test for each patient
• Case examples
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Scope of problem
• ~4% of all office visits are for chest pain
• 9,800,000 (4.4%) people in US with stable
angina
• 500,000 new cases of stable angina/year
• ~9 million nuclear cardiac stress tests were
performed in US/year
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Who needs Stress Testing?
• Patients with symptoms
• Initial evaluation for suspected CAD
• Known CAD with change in status
• Surveillance screening of patients who presented with atypical or no symptoms – up to every 2 years
• Other – LV dysfunction, arythmias, valvular disease
• Post MI
• Prognostic assessment
• Do not test asymptomatic patients
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Stress Testing: Who?
• Adults with intermediate (10-90%) pre-test probability of CAD
Age Sex Typical Atypical Non-anginal Asymp
30-39
Male Intermediate Intermediate Low Very low
Female Intermediate Very Low Very low Very low
40-49
Male High Intermediate Intermediate Low
Female Intermediate Low Very low Very low
50-59
Male High Intermediate Intermediate Low
Female Intermediate Intermediate Low Very low
60-69
Male High Intermediate Intermediate Low
Female High Intermediate Intermediate Low
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What info can a stress test
provide
• Diagnosis of CAD
• Are the patients symptoms from CAD – Specificity of the stress test
• Does the patient have CAD - Sensitivity of stress test
• Prognosis
• Is the patient going to die
• What is the risk that the patient will have an MI
• Has patient already had an MI
• Other
• Valve function, LV function, other cardiovascular structures
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Types of non-invasive test
• Exercise stress testing
• Stress echo
• Nuclear stress testing
• PET stress test
• Coronary CTA
• MRI
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Exercise stress testing
• Treadmill
• Bike
• Standardized protocol
• Bruce protocol – 3 minute stages of
incremental difficulty
• Look for changes in ST segment on EKG
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Exercise stress testing - example
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ETT – Diagnostic Data
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ETT – Diagnostic Data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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ETT - Prognostic data
• Early positive-stage I: Mortality >5%/year
• Strongly positive > 2.5 mm ST depression
• Fall in SBP >10 mm Hg
• Early onset ventricular arrhythmia's
• Prolonged Ischaemic changes in recovery > 2mm lasting > 6 minutes
• Duke treadmill score < -10
• Duration of exercise in minutes on the Bruce protocol - (5 x maximal mm ST deviation) - (4 x treadmill angina index)
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Advantages to exercise stress
testing
• Cheap
• Readily available in many locations
• Gives an idea of functional capacity
• Reasonable prognostic data in intermediate
probability patients
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Disadvantages to exercise stress
testing• Non-diagnostic in patients:
• On digoxin
• Left ventricular Hypertrophy
• Pre-excitation (WPW)
• Paced rhythm
• LBBB or QRS>120 ms
• > 1 mm resting ST depression
• Women –very poor sensitivity/specificity
• Overall, mediocre sensitivity/specificity
• Must be able to exercise
• Does not localize ischemia
• Does not visualize infarction
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Nuclear stress testing
• Treadmill /Bicycle
• Pharmacologic
• Indicated for LBBB, Paced, Unable to exercise
• Dipyridamole (Persantine®)
• Adenosine (Adenoscan®)
• Dobutamine
• A2 Receptor specific (Lexiscan)
• Thallium/Tectnecium or both injected at rest and with stress
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Nuclear stress testing
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Cath – before and after
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Nuclear diagnostic data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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Nuclear prognostic data
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Nuclear testing - Advantages
• Widely available
• Well tested – huge amounts of data
• Can be performed in patients whom ekg’s are
non-diagnostic
• Can be performed in patient who cannot
exercise
• Excellent prognostic data
• Good sensitivity
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Nuclear testing - disadvantages
• Radiation exposure ~11 mSeV
• Time consuming
• Expensive
• Cannot see small endocardial defects well
• Artifacts
• Diaphramatic artifact
• Breast artifact – 11% of women and 2% men
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PET imaging
• Pharmacological perfusion imaging
• Adenosine
• Persantine
• Lexiscan
• Infarct/Viability imaging
• Higher energy level isotopes and less
artifacts lead to better images than standard
nuclear stress test
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PET image
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PET - data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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PET - Advantages
• Excellent sensitivity and specificity
• Good prognostic data
• Infarct imaging/viability
• Fast – good turn around time for patients
• Lower artifacts then standard nuclear imaging
• Particularly good in obese or female patients
• Can be used when false positive nuclear study
is suspected
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Pet - Disadvantages
• Need to make isotope on site
• Availability
• Only modality not available in Whatcom County
• Limited availability nationally
• Vasodilator only
• Patient prep is difficult
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Stress echo
• Exercise stress echo
• Dobutamine stress echo
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Stress echo example
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Stress echo example - Cath
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Stress echo diagnostic data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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Stress echo prognosis
• Rates of cardiac death or nonfatal MI after a
normal stress echo.
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Stress echo prognosis
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Stress echo advantages
• Excellent specificity, reasonable sensitivity
• Better data for women
• Significant amount of non-coronary data
• Valve function
• LV thickness/size
• Global LV function
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Stress echo - Disadvantages
• Worse sensitivity than other modalities in men
• Poor imaging windows can interfere with
images• Obesity
• COPD
• Difficult to diagnose wall motion when• LBBB
• Paced
• Post-CABG
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Coronary CTA
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Normal CTA
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Abnormal CTA
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CABG example
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Coronary calcium
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CT diagnostic data
Publication #Pt
s
Sens
Per
segment
Spec
per
segment
PPV per
segment
NPV per
segment
Per pt
NPV
Leber, et al
(J Am Coll Cardiol 2005
59 88% 97% % % %
Leschka et al
(European Heart Journal 2005)
67 94% 97% 87% 99% 100%
Raff, et al
(J Am Coll Cardiol 2005
70 86% 95% 66% 98% 93%
Ropers 84 93% 97% 100%
Fine 66 95% 96% 97% 92%
Mollet et al
(Circulation 2005)
52 99% 95% 76% 99% 100%
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Coronary CTA – New data
• 64 detector 0.5-mm slice CTA vs Cath for detecting a 50% stenosis
• Nine centers enrolled patients who calcium scores of <600
• Sensitivity of 85% and specificity of 90%.
• A positive predictive value of 91%.
• A negative predictive value of 83%.
• Conclusions: “The negative and positive predictive values indicate that multidetector CT angiography cannot replace conventional coronary angiography at present.”
NEJM
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CTA – diagnostic data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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CTA – prognostic data
VERY LIMITED DATA
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Advantages of CTA
• Evaluation of native CAD
• Excellent negative predictive value
• Good for those with false positive stress test
• Shows anatomy very well
• In some cases better than catheterization (remodeling)
• Graft patency post-CABG
• Anomalous coronaries
• Other
• LV function
• Ascending aorta
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Disadvantages of CTA
• Cardiac motion – requires EKG gating
• Problem for those with high heart rates or Afib
• Radiation dose 10-15 mSv
• Breath hold 15 seconds
• Coronary calcium
• >60 y/o caucasian males
• Lack of insurance/Government reimbursement
• Prospective data lags way behind technology
• Small studies only looking at prognosis
• Cannot image those with prior stents
• Requires 80-100 ml contrast
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Cardiac MRI
• MRI stress testing
• Dobutamine stress MRI
• Adenosine/Lexiscan stress perfusion
• Coronary anatomy
• Infarct imaging
• Other
• Valves
• LV function
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Dobutamine MRI
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MRI Coronary anatomy
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Stress-
Perfusion
Rest-
Perfusion
BaselineLV contrast
uptake
RV contrast
uptake
Myocardial
contrast uptake
Myocardial perfusion
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Myocardial perfusion
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Myocardial Perfusion Case
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Myocardial Infarction
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Myocardial Infarction
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Other Info
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MRI – diagnostic data
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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MRI – prognostic data
• 2 Larger trials
looking at this
• DETERMINE
Trial
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Advantages of cardiac MRI
• Good sensitivity/specificity for detecting CAD
• Can see infarction
• Provides significant non-CAD data
• Excellent (albeit small numbers) prognostic
data
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Disadvantages of MRI
• Many contra-indications• Metal in your head/eye
• Claustrophobia - 4% of patients
• Pacemakers /ICD’s**
• Renal insufficiency
• Nephrogenic Systemic Fibrosis
• Costs
• Availability – Very few place have the technology• Not quite doing stress perfusion here
• Patient tolerability • Adenosine in a MRI
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What is the best test?
• No study has performed all available non-
invasive tests in the same group of patients to
compare their diagnostic accuracy.
• There are few studies that compare results of
even two noninvasive tests in the same
patients.
• IE: There is no overall proven “best stress
test”
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What is the best test for my pt?
• What modalities are available in your area?
• What test are contraindicated or won’t work?
• What data is the most important?
• Prognosis – is my pt going to die
• Diagnosis - (sensitivity/specificity)
• Do they have cad (yes/no)
• Are the patients symptoms from CAD
• Anatomy
• What other data would be nice to have?
• LV function, infarct/viability, valve function
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Summary - ETT
• Cheap
• Readily available
• Non-diagnostic in many patients
• On digoxin, LVH, WPW, Paced, LBBB
• Must be able to exercise
• Overall, mediocre sensitivity/specificity – particularly bad in
women
• Does not localize ischemia
• Does not visualize infarction
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Summary - nuclear
• Widely available
• Well tested
• Very few contraindications
• Good sensitivity
• Excellent prognostic data
• Time consuming
• Expensive
• Artifacts – particularly in women
• Diaphramatic artifact
• Breast artifact – 11% of women and 2% men
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Summary - PET
• Excellent sensitivity and specificity
• Good prognostic data
• Lower artifacts then standard nuclear imaging
• Particularly good in obese or female patients
• Infarct imaging/viability
• Poor availability
• Only modality not available in Whatcom County
• Limited availability nationally
• Vasodilator only
• Patient prep is difficult
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Summary - CTA
• Good negative predictive value
• For those with false positive stress test
• Anomalous coronaries
• Graft patency post-CABG
• Not good for patients with prior stents
• Requires 80-100 ml contrast
• Cardiac motion – require regular heart rate
• Coronary calcium
• Old caucasian males
• Lack of insurance/Government reimbursement
• Prospective data lags way behind technology
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Summary - MRI
• Good sensitivity/specificity for detecting CAD
• Can see infarction
• Provides significant non-CAD data
• Excellent prognostic data
• Many contra-indications
• Expensive
• Poor availability
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Summary
ModalityAll
Sensitivity
All
Specificity
Women
Sensitivity
Women
specificity
ETT 68% 77% 61% 70%
Nuclear 88% 77% 78% 64%
Echo 76% 88% 86% 79%
PET 91% 82%
CT 85% 90%
MRI 89% 87%
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Case examples #1
65 y/o male with h/o CABG, HTN, dyslipidemia. Presents with recurrent angina with exertion 4 months after RCA PCI.
A) Cath – stent everything that has changed
B) Stress echo
C) Nuclear stress test
D) Coronary CTA
E) MRI – stress perfusion
F) Exercise treadmill
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Case examples #1
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Cath
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Case examples #2
55 y/o female with long smoking history, hyperlipidemia, and a
FH of CAD. Previously presented with small NSTEMI and had
very small diagonal stented. Now with recurrent exertional
angina.
A) Cath
B) Nuc stress
C) Stress echo
D) Stress MRI
E) Exercise stress test
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Case example #2
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Case examples #2
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Case examples #3
• 68 y/o male with +family history and atypical angina. He
underwent a nuclear stress test with small inferior defect.
• What do you do now?
A) medical management
B) CTA
C) Nothing
D) Cath
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Case examples #3