getting the most out of exercise tests ernest v. gervino, sc.d., facsm assistant professor of...

Getting the Most Out of Exercise Tests

Ernest V. Gervino, Sc.D., FACSMErnest V. Gervino, Sc.D., FACSM

Assistant Professor of MedicineAssistant Professor of Medicine

Harvard Medical SchoolHarvard Medical School

Chief, Clinical Physiology LaboratoryChief, Clinical Physiology Laboratory

Beth Israel Deaconess Medical CenterBeth Israel Deaconess Medical Center

Utility of Stress Testing Detection of IschemiaDetection of Ischemia

Sx; ST Sx; ST ; BP response; BP response Prognosis of Coronary DiseasePrognosis of Coronary Disease

MET capacity; Magnitude of STMET capacity; Magnitude of ST Extent of myocardial involvementExtent of myocardial involvement

Efficacy of RxEfficacy of Rx Risk StratificationRisk Stratification Exercise RxExercise Rx Arrhythmia detection/assessmentArrhythmia detection/assessment

Gervino et al. Textbook of Cardiothoracic Anesthesiology ; pp 203-232; 2001

Stress Testing: Asymptomatic Pts

No definite indicationsNo definite indications Possible indicationsPossible indications

Special OccupationsSpecial OccupationsPilotsPilotsPolice OfficersPolice OfficersBus DriversBus Drivers

Patients > 40 years of agePatients > 40 years of age2 or more cardiac risk factors2 or more cardiac risk factorsSedentary patients beginning exerciseSedentary patients beginning exercise

ICSI; 2007 Feb 20

Interpreting Stress ECG

Darrow, MD. Am. Fam. Phy. 59(2), 1999

Interpreting Stress ECG

Gervino et.al. Textbook of Cardiothoracic Anesthesiology p 212; 2001

Key Parameters of Test Results: ST Segments and Beyond

Exercise durationExercise duration Onset/Resolution of SxOnset/Resolution of Sx Onset/Resolution of ST Onset/Resolution of ST Magnitude of ST Magnitude of ST Impaired HR response (“chronotropic incompetence”)Impaired HR response (“chronotropic incompetence”) SBP with SBP with workloads workloads High-grade arrhythmias; e.g., prolonged VT; High-grade arrhythmias; e.g., prolonged VT;

paroxysmal atrial fibrillation/flutter; high grade AV paroxysmal atrial fibrillation/flutter; high grade AV blockblock

ICSI, guidelines 2007

Findings Associated with Poor Prognosis Low WorkloadLow Workload

< 6.5 METS< 6.5 METS < 6 minutes of Bruce protocol< 6 minutes of Bruce protocol

Low Peak Heart RateLow Peak Heart Rate HR < 120 bpm (not on Beta blocker)HR < 120 bpm (not on Beta blocker)

Decrease or blunted systolic BP responseDecrease or blunted systolic BP response Remains under 130 mmHgRemains under 130 mmHg

ST Segment Depression > 2 mmST Segment Depression > 2 mm Multiple LeadsMultiple Leads Prolonged recovery > 6 minutesProlonged recovery > 6 minutes

ST Segment Elevation non-Q wave leadsST Segment Elevation non-Q wave leads Increase in complex ventricular ectopyIncrease in complex ventricular ectopy Exercise-induced anginaExercise-induced angina

ICSI 2007, Feb 20

Duke Prognostic Treadmill Score

Determining Score:Determining Score:Duke Score = Ex time (min) - (5 X ST Duke Score = Ex time (min) - (5 X ST dep in mm) – (4 X angina score dep in mm) – (4 X angina score

on on treadmill)treadmill) Angina Score:Angina Score:

No angina = 0No angina = 0Non-limiting angina = 1Non-limiting angina = 1Limiting angina = 2Limiting angina = 2

Prognostic Value of Duke TM Score

Score > 5Score > 5Low Risk: 4 yr survival 99%Low Risk: 4 yr survival 99%

Score of -10 to +4Score of -10 to +4Intermediate Risk: 4 yr survival 95%Intermediate Risk: 4 yr survival 95%

Score > -10Score > -10High Risk: 4 yr survival 79%High Risk: 4 yr survival 79%

ICSI; 2007 Feb 20

Principles Regarding Stress Tests

Order only if results will likely alter your Order only if results will likely alter your management, e.g., NOTmanagement, e.g., NOT 25 y/o with vague sx most likely normal25 y/o with vague sx most likely normal 85 y/o typical angina while walking85 y/o typical angina while walking

Goal to identify patients at high risk of Goal to identify patients at high risk of major cardiac morbidity or mortality major cardiac morbidity or mortality Esp. Left main, 3VD or SCD riskEsp. Left main, 3VD or SCD risk

Assessment of Myocardium at RiskAnatomy vs. Physiology

Presence of an anatomic lesion(s) at Presence of an anatomic lesion(s) at coronary angiography may not reflect the coronary angiography may not reflect the amount of myocardium at riskamount of myocardium at risk

Amount of myocardium at risk may be Amount of myocardium at risk may be minimal and a physiologic study (with or minimal and a physiologic study (with or without imaging) may be more usefulwithout imaging) may be more useful

Treadmill

Cycle Ergometer

Pharmacologic Stress Test

Pacing Stress Test

Independent Reasons for Terminating Exercise Stress Test

Patient’s requestPatient’s request ST segment depression > 3 mmST segment depression > 3 mm ST segment elevation > 2 mm in a non-Q wave leadST segment elevation > 2 mm in a non-Q wave lead Progressive angina (or equivalent) of 8/10Progressive angina (or equivalent) of 8/10 Drop in SBP with increasing workloadsDrop in SBP with increasing workloads VEA or AEA with hemodynamic compromiseVEA or AEA with hemodynamic compromise Patient appears pale or clammyPatient appears pale or clammy SBP/DBP response to exercise > 230/110 mmHgSBP/DBP response to exercise > 230/110 mmHg Development of 2Development of 2ndnd or 3 or 3rdrd degree heart block degree heart block Fatigue/exhaustion (RPE Fatigue/exhaustion (RPE >> 17 Borg Scale) 17 Borg Scale)

Gibbons et al., Circulation, 106: 1883-1889; 2002

Major Contraindications

Acute MI < 3 daysAcute MI < 3 days Unstable angina pectorisUnstable angina pectoris Acute myocarditis or pericarditisAcute myocarditis or pericarditis Uncontrolled ventricular or atrial arrhythmiasUncontrolled ventricular or atrial arrhythmias Symptomatic 2Symptomatic 2ndnd or 3 or 3rdrd degree AV heart block degree AV heart block Acute illness Acute illness Acute aortic dissectionAcute aortic dissection Acute PE / pulmonary infarctionAcute PE / pulmonary infarction Inability to give informed consentInability to give informed consent

Based on: Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002

ACC/AHA Classifications

Class I:Class I: Evidence and/or general agreement that Evidence and/or general agreement that procedure is useful and effectiveprocedure is useful and effective

Class II:Class II: Conflicting evidence and/or divergence of Conflicting evidence and/or divergence of opinion in usefulness/efficacyopinion in usefulness/efficacy

Class IIa:Class IIa: Weight of evidence/opinion in favor of Weight of evidence/opinion in favor of usefulness/efficacyusefulness/efficacy

Class IIb:Class IIb: Usefulness/efficacy less well established Usefulness/efficacy less well established by evidence/opinionby evidence/opinion

Class III:Class III: Evidence or general agreement that Evidence or general agreement that procedure/treatment is not useful or effective and in some procedure/treatment is not useful or effective and in some cases may be harmfulcases may be harmful


ETT Recommendations

Class I:Class I: Pts initial evaluation of suspected or known CADPts initial evaluation of suspected or known CAD

RBBB, < 1 mm ST depression at restRBBB, < 1 mm ST depression at rest Pts with suspected or known CAD with significant Pts with suspected or known CAD with significant

change in clinical statuschange in clinical status Low risk crescendo anginaLow risk crescendo angina

Free of active ischemic or CHF sx for 8-12 hoursFree of active ischemic or CHF sx for 8-12 hours Intermediate risk crescendo anginaIntermediate risk crescendo angina

Free of active ischemic or CHF sx for 48-72 hoursFree of active ischemic or CHF sx for 48-72 hours


ETT Recommendations (Cont.)

Class IIa: Intermediate risk of crescendo anginaClass IIa: Intermediate risk of crescendo angina Negative initial cardiac markersNegative initial cardiac markers Serial EKG without significant changeSerial EKG without significant change Negative cardiac markers 6-12 hours from onset of sxNegative cardiac markers 6-12 hours from onset of sx No other evidence of ischemia during observationNo other evidence of ischemia during observation

Class IIb: Following EKG abnormalitiesClass IIb: Following EKG abnormalities WPWWPW V-paced rhythmV-paced rhythm >> 1 mm resting ST depression 1 mm resting ST depression LBBB or IVCD with QRS > 120 msLBBB or IVCD with QRS > 120 ms Pt with stable course with periodic monitoring to guide treatmentPt with stable course with periodic monitoring to guide treatment


ETT Recommendations (Cont.)

Class III:Class III: Severe comorbidity likely to limit life Severe comorbidity likely to limit life

expectancy or candidacy for expectancy or candidacy for revascularizationrevascularization

High risk for unstable anginaHigh risk for unstable angina


Terminating Stress Tests Patient’s requestPatient’s request ST segment depression ST segment depression >> 3 mm 3 mm ST segment elevation ST segment elevation >> 2 mm in a non-Q wave lead 2 mm in a non-Q wave lead Progressive angina (or equivalent) of Progressive angina (or equivalent) of >> 8/10 8/10 Drop in SBP with increasing workloadsDrop in SBP with increasing workloads Arrhythmia with hemodynamic compromiseArrhythmia with hemodynamic compromise Palor or clamminessPalor or clamminess SBP/DBP response to exercise SBP/DBP response to exercise >> 230/110 mmHg 230/110 mmHg Development of 2Development of 2ndnd or 3 or 3rdrd degree AV heart block degree AV heart block Fatigue/exhaustion (RPE* Fatigue/exhaustion (RPE* >> 17 Borg Scale) 17 Borg Scale)

Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002

*Rating of Perceived Exhaustion where 20 is tops

Reported Average Sensitivity & Specificity of Stress Tests

Test modalityTest modality SensitivitySensitivity SpecificitySpecificity

Non-Imaging ETTNon-Imaging ETT 65% 65% 85% 85%

Nuclear ETTNuclear ETT QuantitativeQuantitative 87% 87% 87% 87% QualitativeQualitative 87% 87% 77% 77% DipyridamoleDipyridamole 90% 90% 90% 90% RVGRVG 87% 87% 75% 75%

Echo ETTEcho ETT 80% 80% 87% 87%

Determining Pre-Test Probability for “Myocardial Ischemic Syndrome” vs. Obstructive CAD

Symptoms:Symptoms: Angina, Atypical Angina, Non-Angina, NoneAngina, Atypical Angina, Non-Angina, None

Risk factors:Risk factors: HTN, HTN, Lipids, Smoking, Lipids, Smoking, Activity, Activity, + Fam. Hx, DM, Obesity, + Fam. Hx, DM, Obesity, Age, PVD Age, PVD

Activity pattern:Activity pattern: Bed rest, Inactive, Active, ExerciseBed rest, Inactive, Active, Exercise

Reason for test:Reason for test: CP, known CAD, MI, Arrhythmia, Pre-Op testingCP, known CAD, MI, Arrhythmia, Pre-Op testing

Adapted from Han et al., Ann Emerg. Med . 2007

Symptoms of Non-Obstructive “Myocardial Ischemic Syndrome” Occurs with exertionOccurs with exertion Usually located in the anterior chest wall Usually located in the anterior chest wall

(but not always)(but not always) Increases in intensity with increased Increases in intensity with increased

myocardial demandmyocardial demand Relieved with rest within 5 minutesRelieved with rest within 5 minutes Symptom is similar on repeated bouts of Symptom is similar on repeated bouts of

exertionexertionGervino et.al. Textbook of Cardiothoracic Anesthesiology

203-232; 2001

Post-Test Probability of CAD Based on Pre-Test Symptoms - Women

0.0 0.5 1.0 1.5 2.0 2.5 3.0

0

10

20

30

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Women 60 - 69

None Non-Angina Atypical Angina Typical Angina

0.0 0.5 1.0 1.5 2.0 2.5 3.0

0102030405060708090

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Women 50 - 59


0.0 0.5 1.0 1.5 2.0 2.5 3.0

010

2030

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Women 40 - 49


0.0 0.5 1.0 1.5 2.0 2.5 3.0

0

10

20

30

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Women 30 - 39


Diamond and Forrester. N. Engl. J. Med. 1350-7, 1979

Post-Test Probability of CAD Based on Pre-Test Symptoms - Men

0.0 0.5 1.0 1.5 2.0 2.5 3.0

010

2030

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Men 40 - 49


0.0 0.5 1.0 1.5 2.0 2.5 3.0

0102030405060708090

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Men 50 - 59


0.0 0.5 1.0 1.5 2.0 2.5 3.0

0

10

20

30

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Men 60 - 69


Diamond and Forrester. N. Engl. J. Med. 1350-7, 1979

0.0 0.5 1.0 1.5 2.0 2.5 3.0

0

10

20

30

40

50

60

70

80

90

100

% P

rob

ab

ilty

CA

D

ST Depression mm

Men 30 - 39


Major Indications for Imaging ETT

LVH by ECGLVH by ECG LBBB (consider vasodilator)LBBB (consider vasodilator) Digoxin Rx Digoxin Rx Abnormal ST-T on resting ECGAbnormal ST-T on resting ECG Localization of region(s) of ischemiaLocalization of region(s) of ischemia Increased sensitivity in selected populationsIncreased sensitivity in selected populations

Hendel et.al. J Nucl Card, 13 (6); E152-E156;2006

ECG Requiring Imaging ETT

LVH with ST-T LVH with ST-T changes and LAAchanges and LAA

Advantages of Imaging Studies

Stress Echo:Stress Echo: specificityspecificity VersatilityVersatility

Eval cardiac Eval cardiac anatomy & functionanatomy & function

ConvenienceConvenience test durationtest duration

costcost

Nuclear Perfusion:Nuclear Perfusion: technical success ratetechnical success rate sensitivity for 1VDsensitivity for 1VD accuracy for multiple accuracy for multiple

wall motion wall motion abnormalitiesabnormalities

published datapublished data

Limitations of Imaging Studies

ObesityObesity Breast AttenuationBreast Attenuation Excess infra-diaphragmatic uptakeExcess infra-diaphragmatic uptake Cost Cost (may require prior 3(may require prior 3rdrd party approval!) party approval!)

Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002

Indications for Pharmacologic Stress Testing Advanced peripheral vascular diseaseAdvanced peripheral vascular disease

Inability to ambulateInability to ambulate

Evaluation of “stunned” or “hibernating” Evaluation of “stunned” or “hibernating” myocardium with dobutaminemyocardium with dobutamine

Gervino et.al. Textbook of Cardiothoracic Anesthesiology pp 203-232; 2001

Contraindications to Dipyridamole/Adenosine Stress Testing Unprotected 2Unprotected 2ndnd or 3 or 3rdrd degree heart block degree heart block Unstable anginaUnstable angina Asthma with active wheezingAsthma with active wheezing Use of theophylline Use of theophylline (last 24 hours)(last 24 hours), caffeine, , caffeine,

xanthines, colas, chocolate xanthines, colas, chocolate (last 6-12 hours)(last 6-12 hours)

LVEF < 15%LVEF < 15% Severe/critical outflow obstructionSevere/critical outflow obstruction Resting hypotension (SBP Resting hypotension (SBP << 100 mmHg) 100 mmHg)

Hendel et.al. J Nucl Cardiol 2006: 13; E152.

Contraindications to Dobutamine Stress Testing High grade tachyarrhythmiaHigh grade tachyarrhythmia Resting hypertension Resting hypertension (BP (BP >> 190/110 mmHg) 190/110 mmHg)

Critical valvular heart diseaseCritical valvular heart disease Unstable anginaUnstable angina History of severe anxiety/panic attacksHistory of severe anxiety/panic attacks

Cheitlin et al., Circulation, 3-88; 2003

E C G N o r m a l E C G A bn o r m a l

C o m p le t e le f t bun dle - br a n c h blo c k P r e - e x c it a t io n sy n dr o m e L e f t v e n t r ic ula r h y p e r t r o p h y ( L VH )

D igo x in t h e r a p y > 1 m m o f r e st in g ST - se gm e n t de p r e ssio n E le c t r o n ic a lly p a c e d v e n t r ic ula r r h y t h m

P e r sa n t in e - M I B I

R e a c t iv e A ir wa yD ise a se wit h

A ctive Wh eezin g

L B B BO be sit y

A r r h y t h m ia

D o but a m in e - M I B I

A ble t o A m bula t e U n a ble t o A m bula t e A ble t o A m bula t eU n a ble t o A m bula t e

E T T N o n - im a gin g E T T - M I B I

S tre s s Te s t Ev a lu a t io n o fM y o ca rdia l I s ch e m ic S y n dro m e

Summary for Evaluation of Myocardial Ischemic Syndrome

Tria g e ba s e d o n M y o ca rdia lI s ch e m ic S y n dro m e Pro ba bility

- Aty p ic a l- D M ( n o n - an g in a l an d a ty p ic a l)

Ho m e ( + /- ) O u tp a tien t E T T C ar d io lo g y C o n s u lt

Hig h P r o b ab ility o fM y o c ar d ia l I s c h em ic S y n d r o m e

M o d er a te P r o b ab ility o fM y o c ar d ia l I s c h em ic S y n d r o m e

L o w P r o b ab ility o fM y o c ar d ia l I s c h em ic S y n d r o m e

I n p atien t C ar d iac S tr es s T es t

E q u iv o c alN o r m al P o s it iv e

Ho m eHo m e ( + /- ) C ar d io lo g y

C o n s u lta t io nC ar d io lo g y C o n s u lt

S tr es s T es t d ir ec tly f r o mE m er g en c y R o o m

Conclusion:

Study should add incremental informationStudy should add incremental information Functional test preferredFunctional test preferred Pre-test probability conditions post-test Pre-test probability conditions post-test

likelihood of ischemic syndrome (Bayesian likelihood of ischemic syndrome (Bayesian analysis)analysis)

Magnitude, onset/resolution of changes (sx Magnitude, onset/resolution of changes (sx and/or ST segments) help determine and/or ST segments) help determine severity of ischemiaseverity of ischemia

Selected References Gibbons RJ, Antman EM, Albert JS, et al. ACC/AHA 2002 guideline update for Gibbons RJ, Antman EM, Albert JS, et al. ACC/AHA 2002 guideline update for

exercise testing. J. Am. Coll. Cardiol. 2002;40;1531-1540.exercise testing. J. Am. Coll. Cardiol. 2002;40;1531-1540.

Eagle KA, Gibbons RJ, Antman EM, Gregoratos G, et al. ACC/AHA 2002 Eagle KA, Gibbons RJ, Antman EM, Gregoratos G, et al. ACC/AHA 2002 guideline update on perioperative cardiovascular evaluation for noncardiac guideline update on perioperative cardiovascular evaluation for noncardiac surgery. J. Am. Coll. Cardiol. 2002; surgery. J. Am. Coll. Cardiol. 2002; www.acc.orgwww.acc.org, 1-38., 1-38.

Maslow A, Gervino EV, Lowenstein E. Maslow A, Gervino EV, Lowenstein E. Textbook of Cardiothoracic Textbook of Cardiothoracic AnesthesiologyAnesthesiology. Ed: DM Thys. Ch. 9: Stress testing. pp 203-232. McGraw Hill , . Ed: DM Thys. Ch. 9: Stress testing. pp 203-232. McGraw Hill , NY, 2001.NY, 2001.

Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, et al. Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, et al. ACC/AHA Clinical Competence Statement on Stress Testing. Circulation ACC/AHA Clinical Competence Statement on Stress Testing. Circulation 2000;102:1726-1738.2000;102:1726-1738.

Miller T, McBride J, Basset J, Haranath S, Evenson AM. Cardiac stress test Miller T, McBride J, Basset J, Haranath S, Evenson AM. Cardiac stress test supplement. Institute for Clinical System Improvement; 2007, Feb 20. supplement. Institute for Clinical System Improvement; 2007, Feb 20. www.icsi.org

getting the most out of exercise tests ernest v. gervino, sc.d., facsm assistant professor of...

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