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STRESS ECG AND STRESS ECHOCARDIOGRAPHY
Giuseppe Biondi ZoccaiGiuseppe Biondi Zoccai
Division of Cardiology, University of Turin, Turin, ItalyDivision of Cardiology, University of Turin, Turin, Italy
Meta-analysis and Evidence-based medicine Training in Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, ItalyCardiology (METCARDIO), Ospedaletti, Italy
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LEARNING GOALS
• Scope of the problem• Stress ECG• Stress echocardiography• Reconciling the evidence
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LEARNING GOALS
• Scope of the problem• Stress ECG• Stress echocardiography• Reconciling the evidence
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FINDING AN APPROPRIATE DIAGNOSTIC LEVEL
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FINDING AN APPROPRIATE PROGNOSTIC LEVEL
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DIAGNOSTIC AND PROGNOSTIC WORK-UP OF SUSPECTED
CORONARY HEART DISEASE• Clinical history• Physical examination• Resting ECG• Resting echocardiography• Stress ECG• Stress echocardiography• Stress nuclear scan• Coronary CT• Coronary angiography• ….
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EFFECTIVE RADIATION DOSES
Picano, Am J Med 2003
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CORONARY STEAL PHENOMENON
Picano, Circ 1998
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CORONARY STEAL PHENOMENON
Picano, Circ 1998
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THREE STATES OF THE SODIUM CHANNEL AND THE NORMAL SODIUM CURRENT (INa)
Ca++
out
in
out
in
Na+/Ca++
Exchanger
Ca++
Ca++
Ca++
Ca++
Na+
Na+
Na+
Na+Na+
Na+
Na+
RestingClosedRestingClosed
Na+
ActivatedActivated InactivatedInactivated
Na+
Na+
Na+ Ca++
Ca++
0
Late
Peak
SodiumCurrent
[Na]140 mM ~ 10mM
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ISCHEMIA INDUCED EFFECTS ON LATE INa AND INTRACELLULAR CALCIUM
Ca++
Na+/Ca++
Exchanger
Ca++Ca++
Na+
Na+Na+
Na+
Na+Na+
Na+Na+Na+
Na+
Na+
Ca++Ca++Ca++
Ca++
Ca++Ca++ Ca++
Ca++
Ca++
Ca++ Ca++
Excess Calcium:• Electrical instabilityElectrical instability• Contractile Contractile
dysfunctiondysfunction• ECG changesECG changes
Excess Calcium:• Electrical instabilityElectrical instability• Contractile Contractile
dysfunctiondysfunction• ECG changesECG changes
0
Late
Peak
out
in
out
in
Na+
Na+
Na+
Na+ Ca++
Ca++
ImpairedInactivation
ImpairedInactivation
Ca++Ca++
SodiumCurrent
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THE ISCHEMIC CASCADE
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LEARNING GOALS
• Scope of the problem• Stress ECG• Stress echocardiography• Reconciling the evidence
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TREADMILL STRESS TEST
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KEY ACCESSORY
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EQUIPMENT FOR STRESS TESTING• Treadmill or bicycle or steps• ECG machine• Blood pressure cuff• Computer is a ‘nice to have’• ACLS certification• Defibrillation/intubation cart• Exit strategy• Good help* (it takes two to
test)
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PROTOCOLS
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TYPICAL BRUCE OR RAMP STRESS
WORK WORK
TIME TIME TIME TIME
WORK WORK
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WHY USE A BIKE ERGOMETER?
1. Accurate measurement of POWER. 2. Ramping protocols allow for assessment of physiologic function across all
work levels. 3. Independent of patient’s weight. 4. Less danger of fall and injury to patient. 5. Easier to take accurate B/P at high work rates. 6. Patient can stop at anytime. 7. Holding handle bars does not effect test (Holding treadmill handrails can
significantly effect results). 8. Fits into smaller space and is portable.9. Patients with knee or hip problems tend to perform better and report being
more comfortable on the bike.
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WHY USE A BIKE ERGOMETER?
10. Bike ramp protocols are designed to last 6-10 minutes, resulting in less fatigue (yet peak work is maximized).
11. HR, Work, and VO2 (Cardiac Output) are linearly related. Bike ramp protocols produce linear increases in Work, thereby mimicking the expected physiologic response in health and disease.
12. Determination of the Anaerobic Threshold (AT) by the most popular methods (V-slope and VE/VO2 nadir) were developed and proven through the use of bike ramp protocols. To use another method means to lose AT detection accuracy.
13. Bike ramp protocols are used by many of the leading clinical and research cardiopulmonary exercise testing labs (UCLA, Duke, Mayo, Stanford, Bowman-Gray, Johns Hopkins, UAB, Temple to name a few). Recently, treadmills capable of performing ramp protocols have been developed.
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MY VIEW: TREADMILL IS BEST
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INDICATIONS TO STRESS TEST
• Diagnosis of coronary artery disease• Risk-stratification of coronary artery disease• Risk-stratification in cardiac valve disease• Appraisal of rate response• Appraisal of pressure response to stress• Appraisal of functional capacity
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INFORMATION OBTAINED FROM EXERCISE STRESS BUT NOT AVAILABLE WITH PHARMACOLOGICAL TEST
• Exercise duration/tolerance• Reproducibility of symptoms with activity• Heart rate response to exercise• Blood Pressure response • Detection of stress induced arrhythmias• Assess control of angina with medical therapy• Prognosis
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KEY ASPECTS• Exercise duration and work-load (minutes, METs, Watts)• Maximum blood pressure• Maximum heart rate (given that predicted for age)
• Rate-pressure product• Baseline ECG
• ST-segment changes• T-wave changes• Q waves• Duke treadmill score• Heart rate recovery
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ABNORMAL RESPONSE TO STRESS TESTING
1) Heart rate fails to rise above 120 or unable to attain target heart rate of 85% of max
2) Blood pressure shows a drop in systolic3) Patient physically unable to complete test4) Marked hypertension, >260/1155) Chest Pain and/or unusual shortness of
breath
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NORMAL RESPONSE OF ECG TO STRESS TESTING
ECG Changes1) QRS complex decreases in size2) J point depresses, resulting in up sloping of ST
segment3) ST segment returns to baseline by 80
milliseconds4) PR segment may down slope – thus baseline is
defined as PQ junction5) R amplitude may decrease at rates that go
above 1306) T wave decreases
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ABNORMAL RESPONSE OF ECG TO STRESS TESTING
ECG Changes– Horizontal or down sloping ST segments – ST segment depressed or elevated – ST segment does not return to baseline by 80
milliseconds– U or T wave inversion – Dysrhythmias – rate dependent blocks above
first degree, WPW appears, Atrial fib/flutter, multiform and/or increasing PVC’s, V-tach occurs
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ECG CHANGES
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ECG CHANGES
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RISK
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CRITERIA DIAGNOSTIC FOR ISCHEMIA
• Horizontal or down sloping ST segment with depression of 1 or greater mm.
• Horizontal, up or down sloping ST segment with elevation of 1 or greater mm.
• Up sloping ST depression greater than 1.5 mm at J+80 msec.
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CRITERIA DIAGNOSTIC FOR ISCHEMIA
• Horizontal or down sloping ST segment with depression of 1 or greater mm.
• Horizontal, up or down sloping ST segment with elevation of 1 or greater mm.
• Up sloping ST depression greater than 1.5 mm at J+80 msec.
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CRITERIA SUGGESTIVE FOR ISCHEMIA
• Horizontal or down sloping ST segment with depression greater than 0.5mm but <1 mm.
• Up sloping ST depression between 0.7 and 1.5mm at J+80 msec.
• Chest pain or fall in Blood pressure or persistent HTN in recovery or new S3 or murmur at peak exercise.
(<1 mm)
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SYMPTOM-SIGN LIMITED TESTING ENDPOINTS – WHEN TO STOP!
Dyspnea, fatigue, chest pain
Systolic blood pressure drop
ECG--ST changes, arrhythmias
Physician Assessment
Borg Scale (17 or greater)
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PREDICTED MAXIMUM HEART RATE
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WHAT IS A MET?
Metabolic Equivalent Term
1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2 /Kg/min
Actually differs with thyroid status, post exercise, obesity, disease states
But by convention just divide ml O2/Kg/min by 3.5
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MAJOR DETERMINANTS OF MYOCARDIAL OXYGEN CONSUMPTION
Picano, Circ 1998
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PROGNOSTIC ROLE OF METs
Myers et al, New Engl J Med 2002
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PREDICTING CARDIAC DEATH
Marcus et al, Chest 1995
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DUKE TREADMILL SCORE
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BAYES THEOREM
If P(B) ≠ ), then
P(A/B) = “ P(B/A)P(A) “P(B/A)P(A) + P(B/not A)P (not A)
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CONTINUOUS OF RISK
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TYPICAL REPORTTreadmill stress test stopped at the end of the 3rd standard Bruce stage for fatigue (max BP 200/100 mm Hg, max HR 140 bpm, RPP 28,000).No symptoms. No arrhythmias. No abnormalities in the baseline ECG. In the 2nd stage development of ST depression, which becomes diagnostic in the 3rd stage (max 1.5 mm in V5 at the peak), with quick recovery after the stress.Duke treadmill score: 1 (<-11 high risk; >4 low risk).Heart rate recovery: 10 (valore di riferimento >12).Positive stress test for myocardial ischemia at mid-to-high work-load.
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GUIDELINES
Gibbons et al, Circ 2002
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GUIDELINES: RECOMMENDATIONS
Gibbons et al, Circ 2002
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GUIDELINES: RECOMMENDATIONS
Gibbons et al, Circ 2002
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STRESS EKG IS NOT A SLAM DUNK
• 5/10,000 result in serious cardiovascular event
• 1/10,000 result in death• Results are based on Bayes Theorem• Requires proper selection, preparation, and
execution• Not the GOLD standard
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LEARNING GOALS
• Scope of the problem• Stress ECG• Stress echocardiography• Reconciling the evidence
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STRESS ECHOCARDIOGRAPHY
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BASIC PRINCIPLE OF STRESS ECHO
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BASIC PRINCIPLE OF STRESS ECHO
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WALL MOTION RESPONSES
Sicari et al, Eur Heart J 2009
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CARDIAC SEGMENTS
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WALL SEGMENTS AND CORONARY DISTRIBUTION
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CURRENT STRESS PROTOCOLS
ECG ECHONUCLEAR
Exercise: Tread Post-Tread TreadBicycle Bicycle
Pharmacologic: Catecholamines: Dobutamine Dobutamine Vasodilators: Dipyridamole Dipyridamole
DipyridamoleAdenosine Adenosine
Vasospastic: Ergonovine Ergonovine Adjuncts: Atropine
Handgrip
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INDICATIONS TO STRESS ECHOCARDIOGRAPHY
• Diagnosis of coronary artery disease• Risk-stratification of coronary artery disease• Risk-stratification in cardiac valve disease• Appraisal of myocardial viability• Patients unable to ambulate
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PREPARATION
• Avoid smoking• Avoid food/beverages• Take all medications unless
instructed otherwise• Wear comfortable clothes and shoes
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KEY PHARMACOLOGICAL TESTS
Picano, Circ 1998
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DOBUTAMINE PROTOCOL
Sicari et al, Eur Heart J 2009
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DIPYRIDAMOLE PROTOCOL
Sicari et al, Eur Heart J 2009
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FURTHER APPLICATIONS
Sicari et al, Eur Heart J 2009
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LEARNING GOALS
• Scope of the problem• Stress ECG• Stress echocardiography• Reconciling the evidence
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PATIENTS APPROPRIATE FOR ROUTINE ECG STRESS TEST WITHOUT IMAGING
• Patient can exercise for 6 or more minutes• Normal baseline ECG• No history of diabetes• No history of coronary revascularization• No history of myocardial infarction
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ABSOLUTE CONTRAINDICATIONS• Within 24 hours of troponin positive ACS• Within 7 days for high dose DSE after STEMI• Left ventricular failure with symptoms at rest (in tertiary centres
viability may be assessed using low dose dobutamine stress).• Recent history (within the last week) of life threatening arrhythmias.• Severe dynamic or fixed left ventricular outflow tract obstruction
although low dose DSE may be useful.• BP >220/120• Recent pulmonary embolism or infarction.• Thrombophlebitis or active deep vein thrombosis.• Known hypokalaemia (particularly for Dobutamine stress)• Active endocarditis, myocarditis, or pericarditis.
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POSSIBLE CONTRAINDICATIONS TO STRESS TESTING BASED ON RESTING ECG
• ST-segment changes 1 mm or greater, either depression or elevation
• Ventricular strain patterns or hypertrophy• T-wave inversions• Left bundle branch block• Right bundle branch block, if significant• Prolonged QT interval
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ABSOLUTE CONTRAINDICATIONS TO DOBUTAMINE STRESS ECHO
• Suspected or known severe bronchospasm• 2nd or 3rd degree AV block without pacemaker• Sick sinus syndrome without pacemaker• BP <90mmHg systolic• Xanthines taken in the last 12 hours, or dipyridamole use in
the last 24 hours
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FIRST THINGS FIRST: DIAGNOSTIC PERFORMACE OF DIFFERENT TESTS
Grouping # of Studies
Total # Patients
Sens Spec Predictive Accuracy
Standard ET 147 24,047 68% 77% 73% ET Scores 24 11,788 80% Score Strategy 2 >1000 85% 92% 88%
Thallium Scint 59 6,038 85% 85% 85% SPECT 16+14 5,272 88% 72% 80% Adenosine SPECT 10+4 2,137 89% 80% 85% Exercise ECHO 58 5,000 84% 75% 80% Dobutamine ECHO 5 <1000 88% 84% 86% Dobutamine Scint 20 1014 88% 74% 81% Electron Beam Tomography (EBCT)
16 3,683 60% 70% 65%
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CHOOSING YOUR TEST
Heijenbrok-Kal et al, Am Heart J 2007
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CHOOSING YOUR TEST
Froelicher et al, Chest 1999
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CARDIAC STRESS IMAGING
Picano, Am J Med 2003
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ADVANTAGES OF STRESS ECHOCARDIOGRAPHY COMPARED TO NUCLEAR STRESS TESTING
• Higher Specificity• Visualization of cardiac valves• Evaluate for presence of pericardial effusion• Ability to measure RV Systolic Pressure• More accurate assessment of LV ejection fraction• Doppler interrogation to determine Diastolic Function • Lower Cost• Lack of Radiation Exposure
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TAKE HOME MESSAGES• Stress testing, by either stress ECG, stress nuclear scan,
dipyrididamol/dobutamine nuclear scan, stress echocardiography, dipyrididamol/dobutamine echocardiography, is crucial in the diagnostic work-up of patients with suspected coronary heart disease
• These tests are also useful in the prognostic work-up of patients with established coronary heart disease
• Given financial and logistic constraints, stress ECG should be performed in most suitable subjects as 1st line test, followed/substituted by imaging tests in all the other cases
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Thank you for your attention
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