Download - To Stress or not to stress ?
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TO STRESS OR NOT TO STRESS ?
Karam Paul MS, MD, MBA, FACCCommunity Heart and Vascular
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Cardiac stress testing - learning objectives
►Know why to undertake a stress test ►Know who should have one ►Know how it is performed ►Understand the limitations ►Understand which to choose ►Know what to do with the result
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Cardiac stress testing
Why do a stress test?
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Aims of stress testing ►Elicit abnormalities not present at rest
►Estimate functional capacity
►Estimate prognosis
►Likelihood of coronary artery disease ►Extent of coronary artery disease
►Effect of treatment
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Cardiac stress testing
Who should have one?
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Diagnostic test
►Bayes’ Theorem
►Consider the ‘pre-test risk’
►Sensitivity & specificity of the test
►Post-test probability of CAD ►Diagnostic power of EST is maximal when the pre-test probability is intermediate.
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Risk assessment ►Pre-existing coronary artery disease
►Diabetes
►Hypertension
►Smoking history
►Family history ►Renal disease
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Consider other risk factors
Pre-existing coronary artery disease ►Diabetes ►Hypertension ►Hyperlipidemia ►Smoking history ►Family history ►Renal disease
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Consider other risk factors
►Pre-existing coronary artery disease
►Diabetes ►Hypertension ►Hyperlipidemia ►Smoking history ►Family history ►Renal disease
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Valvular heart disease
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Rhythm disorders
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Contraindications
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Cardiac Stress Testing
How is it done?
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Exercise protocol
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Positive!
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Measurements ►ECG
►Exercise capacity (METS – metabolic equivalent)
►Symptoms
►Blood pressure
►Heart rate response & recovery
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ECG
1mm planar ST depression
3 consecutive beats
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► The normal and rapid upsloping ST segment responses are normal responses to exercise. ► Minor ST depression can occur occasionally at submaximal workloads in patients with coronary disease. ► The slow upsloping ST segment pattern often demonstrates an ischemic response in patients with known coronary disease or those with a high pretest clinical risk of coronary disease. ► Downsloping ST segment depression represents a severe ischemic response. ► ST segment elevation in an infarct territory (Q wave lead) indicates a severe wall motion abnormality and, in most cases, is not considered an ischemic response.
(From Chaitman BR: Exercise electrocardiographic stress testing. In Beller GA [ed]: Chronic Ischemic Heart Disease. In Braunwald E [series ed]: Atlas of Heart Diseases. Vol 5. Chronic Ischemic Heart Disease. Philadelphia, Current Medicine, 1995, pp 2.1-2.30
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T wave changes
► Influenced by: Body position Respiration Hyperventilation Drug Rx Myocardial ischemia Necrosis
► Pseudonormalisation: Usually non-diagnostic Consider ancillary imaging
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METs
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Heart rate response
►Peak HR > 85% of maximal predicted for age
►HR recovery >12 bpm (erect)
►HR recovery >18 bpm (supine)
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Heart rate response
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Prognostic value of stress testing
Parameters associated with adverse prognosis or multi-vessel disease
► Duration of symptom-limiting exercise <5 METs ► Failure to increase sBP ≥120mmHg, or a sustained decreased ≥ 10mmHg, or below rest levels, during progressive exercise ► ST segment depression ≥2mm, downsloping ST segment, starting at <5 METs, involving ≥5 leads, persisting ≥5 min into recovery ► Exercise-induced ST segment elevation (aVR excluded) ► Angina pectoris at low exercise workloads ► Reproducible sustained (>30 sec) or symptomatic ventricular tachycardia
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Limitations of treadmill stress test
► Non-diagnostic ECG changes ► False positives/false negatives ► Women – false positives ► Elderly – more sensitive/less specific ► Diabetics – autonomic dysfunction ► Hypertension ► Inability to exercise ► Drugs – digoxin; anti-anginals
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Non-coronary causes of ST segment depression
► Anemia ► Cardiomyopathy ► Digoxin ► Glucose load ► Hyperventilation ► Hypokalemia ► Intraventricular conduction disturbance ► Mitral valve prolapse ► Pre-excitation syndrome ► Severe aortic stenosis ► Severe hypertension ► Severe hypoxia ► Severe volume overload (aortic or mitral regurgitation) ► Sudden excessive exercise ► Supraventricular tachycardia's
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Limitations of treadmill stress test
Sensitivity 68% Specificity 77%
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Ancillary techniques to enhance content
Echocardiography Radionuclide imaging
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Stress echocardiography
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Stress echocardiography Compares pre & post: Regional contractility Overall systolic function Volumes Pressure gradients Filling pressures Pulmonary pressures Valvular function
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Dobutamine stress echo
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Stress echo - limitations
Factors which effect image quality:
Body habitus Lung disease Breast implants
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Normal stress echocardiogram
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Case 1
►54 year old bank project manager ►Exertional chest pain & dyspnea ►Ex-smoker ►TC = 6.7mmol/L ►Stress ECG – 2mm ST segment depression in 5 leads
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Stress echocardiogram
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Coronary angiogram
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Case 2
►62 year old female
►Chest pain & dyspnea
►Treadmill exercise test – non-diagnostic sub-maximal Hypertension No ECG changes
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Case 2
►Exercised 7½ minutes (9.4 METS)
►No chest pain
►ECG changes
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Case 2
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Case 2
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Case 3
►24 year old female engineer ►Exertional dyspnea
►Palpitations
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Case 3
Inducible dyspnea ►ECG partial right bundle branch block no ischemic changes
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Case 3
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Case 3
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Case 3
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Case 4
►43 year old male - airline catering ►Chest pain
►Dyspnea
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Case 4
►Inducible dyspnea ►Non-specific T wave changes ►No ST segment shift ►Global deterioration in left ventricular function
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Case 4
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Case 4
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Case 4
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Nuclear SPECT imaging ►Radio-tracer injection ►Isotopes: Thallium-201 Technetium 99m (sestamibi)
►Myocardial uptake ►Photon emission captured by gamma camera ►Rest & redistribution phases ►Pharmacologic protocols available ►Digital presentation
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Nuclear SPECT imaging
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Nuclear SPECT imaging
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Nuclear SPECT imaging
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Nuclear SPECT imaging
Reversible inferior wall defect
Milder reversible inferior wall defect
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Limitations of nuclear SPECT imaging
►Time-consuming
►Artifacts ►Balanced ischemia ►Radiation
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Limitations of nuclear SPECT imaging
Normal apical thinning.
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Limitations of nuclear SPECT imaging
A. Breast attenuation B. Anterior ischemia
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Limitations of nuclear SPECT imaging
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Limitations of nuclear SPECT imaging
►Risk of iatrogenic malignancy
►Linear no-threshold model ►Consider: age gender background
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Limitations of nuclear SPECT imaging
Einstein, A. J. et al. Circulation 2007;116:1290-1305
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MRI cardiac stress test
Useful for: ►Patients unable to exercise ►ECG uninterpretable ►Unsuitable for DSE
And…. ►No radiation
But… ►Not currently available
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Question ►45 year old diabetic man
►Anterior chest discomfort with exertion ►Exercised for 2 mins 30 secs (4.6 METs) ►95% maximal predicted heart rate
►Mild chest pain
►BP increased from baseline to 180/80mmHg
►1mm ST depression in leads II, III, aVF, V4-6
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Which is true?
1. Pre-test risk is intermediate 2. Post-test probability for cardiac events is high 3. The ECG changes are non-diagnostic 4. The ECG changes are false-positive in the setting of hypertension 5. Chest pain is not a useful symptom in diabetics
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Answer
1. Pre-test risk is intermediate 2. Post-test probability for cardiac events is high 3. The ECG changes are non-diagnostic 4. The ECG changes are false-positive in the setting of hypertension 5. Chest pain is not a useful symptom in diabetics
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Remember…
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Remember…
Parameters associated with adverse prognosis or multi-vessel disease
► Duration of symptom-limiting exercise <5 METs ► Failure to increase sBP ≥120mmHg, or a sustained decreased ≥ 10mmHg, or below rest levels, during progressive exercise ► ST segment depression ≥2mm, downsloping ST segment, starting at <5 METs, involving ≥5 leads, persisting ≥5 min into recovery ► Exercise-induced ST segment elevation (aVR excluded) ► Angina pectoris at low exercise workloads ► Reproducible sustained (>30 sec) or symptomatic ventricular tachycardia
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When ordering a stress test consider…
►Pre-test risk of disease
►Sensitivity & specificity of the test
►Value of supplementary data
►AND JUST ONE MORE TIP……..
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MRI cardiac stress test
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Cardiac stress testing
So….which one to choose?
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What to do with the result?
►Remember Bayes’ theorem
►Consider the pre-test risk
►Be aware of the sensitivity & specificity of the test
►Apply the post test probability
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CT Calcium score
►Correlates with presence & extent of CAD ►Strong negative predictive value
►Cannot predict functional significance
►Higher scores can predict events
►Recommended for asymptomatic with intermediate risk
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CT Calcium score
Calcification of the left anterior descending coronary artery (large arrow) and left circumflex coronary artery (small arrow).
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CT Calcium score
Score description RR 0 nil 1 – 99 mild 1.9 100 – 399 moderate 4.3 400 – 999 severe 7.2 >1000 extensive 10.8
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CT Calcium score
► Indicated – asymptomatic with intermediate risk
► Not for low risk/population screening ► High risk – use current guidelines
► Do not reduce Rx if intermediate risk & ‘0’ score
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CT coronary angiography
►2-dimensional & 3-dimensional reconstructions
►Relies on slow, regular heart rate
►High negative predictive value (‘rule out’ ability)
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CT coronary angiography - limitations
►Lower positive predictive value (over-estimation tendency)
►Grading of stenosis limited
►Does not evaluate functional significance
►Radiation exposure
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CT coronary angiography
►Role not yet clearly defined
►Potential for those with intermediate likelihood of disease: Where stress testing not possible Stress test equivocal/uninterpretable Acute chest pain/no ECG changes/normal enzymes
►Role in anomalous anatomy
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CT coronary angiography