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Adenosine/Dipyridamole (cont.)  cContraindications Hypotension Uncontrolled Asthma/COPD 3rd degree AV block Use of oral Dipyridamole<R&*W  Dobutamine !Stimulator of cardiac beta receptors Causes increase in HR, BP and contractility Again causes a differential in blood flow to patent vessels versus stenotic vessels, but less so than adenosine because of reduced diastolic filling time with increased HR Response attenuated by beta blockersDobutamine (cont.)  {Contraindications: Recent MI Unstable Angina Uncontrolled HTN Tachyarrythmias Severe Aortic Stenosis Severe Aortic Aneurysm&ii,> Types of Stress Test ImagingLExercise Stress Testing (ECG) Stress Echocardiography Nuclear Stress TestingMnM Exercise Stress Testing )The most simple stress test Patient exercises on a treadmill with ECG, BP and HR monitoring Patient must be able to exercise to achieve goal HR of 85% of age-predicted maximum Test is considered positive if ST depression or elevation of >1 mm occurs or if anginal chest pain occurs during exercise# Exercise Stress Testing (cont.)QReport includes symptoms, exercise capacity, BP pattern, ECG changes and evaluation of risk of CAD Duke Treadmill score categorizes patients as low, intermediate or high risk of CAD based on exercise time, exercise capacity and presence/absence of angina Duke score has been validated among patients without known CAD in 5 year follow-upRZRExercise Stress Testing (cont.)Sensitivity of 50%, Specificity of 90% in comparison to coronary angiography Meta analysis revealed Sensitivity of 67% and specificity of 72% Exercise Stress Testing (cont.)Advantages: Low cost Low risk of complications Can be done by non-cardiologists Limitations: Difficult for patients with musculoskeletal disease, pulmonary disease, vascular disease  D Y D Y   Stress EchocardiographyBaseline 2-D Echo images obtained, along with baseline BP and ECG monitoring Patient then undergoes exercise protocol and repeat images are then obtained Exercise protocols superior than pharmacologic stress, especially for single vessel CADStress Echocardiography (cont.)Stress Echocardiography (cont.)Advantages Most specific of stress tests Ability to evaluate LV and valvular function Limitations Images affected by body habitus Less sensitive for single-vessel CAD L K G K G,D.(% Nuclear Stress Tests  Uses tracers Thallium and Technetium Thallium is a potassium analog and is renally excreted Technetium is lipid soluble and excreted through the GI tract Gamma camera used and computer then creates 3D reconstruction of resting and stress images which can be compared"Z Z L!Nuclear Stress Testing (cont.)Has both 1-day and 2-day protocols 2-day protocols provide superior images but 1-day protocols used more often because of logistics Exercise again preferred, but any of the mentioned pharamcologic agents can be used "Nuclear Stress Testing (cont.)#Nuclear Stress Tests (cont.)Advantages Evaluates LV function High Sensitivty Limitations Low specificity 1 day protocol provides poor images in obese patientsL & F & F& S$7'Approaching the patient with chest pain(((Goal is to effectively use stress test to help guide management, ie identify those patients with intermediate and possibly low risk of CAD Patients with high-risk of CAD may benefit from moving directly to cardiac catheterizationA8/Approaching the patient with chest pain (cont.)00(kNeed a method to determine pre-test probability of CAD Framingham Risk Score Based on Age, Sex and Symptoms&75759/Approaching the patient with chest pain (cont.)00(Framingham Score Categorizes patients as low, intermediate or high risk of death from CAD over the next 10 years Characteristics included in score are age, gender, total cholesterol, HDL cholesterol level, smoking status and systolic blood pressure 2:/Approaching the patient with chest pain (cont.)00( 45/ & ' ( ) * +,-./01236c  0` 3` ff>>\fg` J*T333` QYmx~3ft` \ғhEy`` cb^DDf`Y˵W` sg7xGr` K%ޯd{mG/` 33f>?" dd@,?nFd@    @ `  n?" dd@   @@``PR    @ ` `<p>> @P(    6ԃ #" `b `  >*   6Љ #" `` `  @* xT ~  "~\ {  "{  c BB CDEFd @ bb   H   T W6Vw}\gFQ6<1++11 1L b6xQrq 6\}N   - c    0 A Q g     S    6N KawF bFy0 a*ly7lE;uz  B | a F 0 ! 1 < B < & l L 0  @`"T   c |BC+DEFyd @ ==gL6cI}\eA& w6m!W<! &<W!r6W}F6\}>68QNlX^XH8+Sgg|@`"Jo 5 J   B! 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k*n_~٤ڛ>ireػ?CJW^h_(://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf<http://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpghttp://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpgbhttp://www.heartsite.com/html/isotope_stress.htmlbhttp://www.heartsite.com/html/isotope_stress.htmlD http://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpghttp://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpg/ 00DArialngsRomanTT/ܖ 0ܖDGaramondRomanTT/ܖ 0ܖ DTimes New RomanTT/ܖ 0ܖ0DWingdingsRomanTT/ܖ 0ܖ A .  @n?" dd@  @@`` <PB     $$&'()"+,/0123456789:;<=@BDEFGHIJKLMNOP SoR$\hF`>,I6R$gYB{ܘzE+62$gPƓhbJZhQCa2$o)seܽFD$R$Lj Types of Stress Test ImagingLExercise Stress Testing (ECG) Stress Echocardiography Nuclear Stress TestingMnM Exercise Stress Testing )The most simple stress test Patient exercises on a treadmill with ECG, BP and HR monitoring Patient must be able to exercise to achieve goal HR of 85% of age-predicted maximum Test is considered positive if ST depression or elevation of >1 mm occurs or if anginal chest pain occurs during exercise# Exercise Stress Testing (cont.)QReport includes symptoms, exercise capacity, BP pattern, ECG changes and evaluation of risk of CAD Duke Treadmill score categorizes patients as low, intermediate or high risk of CAD based on exercise time, exercise capacity and presence/absence of angina Duke score has been validated among patients without known CAD in 5 year follow-upRZRExercise Stress Testing (cont.)Sensitivity of 50%, Specificity of 90% in comparison to coronary angiography Meta analysis revealed Sensitivity of 67% and specificity of 72% Exercise Stress Testing (cont.)Advantages: Low cost Low risk of complications Can be done by non-cardiologists Limitations: Difficult for patients with musculoskeletal disease, pulmonary disease, vascular disease  D Y D Y   Stress EchocardiographyBaseline 2-D Echo images obtained, along with baseline BP and ECG monitoring Patient then undergoes exercise protocol and repeat images are then obtained Exercise protocols superior than pharmacologic stress, especially for single vessel CADStress Echocardiography (cont.)Stress Echocardiography (cont.)Advantages Most specific of stress tests Ability to evaluate LV and valvular function Limitations Images affected by body habitus Less sensitive for single-vessel CAD L K G K G,D.(% Nuclear Stress Tests  Uses tracers Thallium and Technetium Thallium is a potassium analog and is renally excreted Technetium is lipid soluble and excreted through the GI tract Gamma camera used and computer then creates 3D reconstruction of resting and stress images which can be compared"Z Z L!Nuclear Stress Testing (cont.)Has both 1-day and 2-day protocols 2-day protocols provide superior images but 1-day protocols used more often because of logistics Exercise again preferred, but any of the mentioned pharamcologic agents can be used "Nuclear Stress Testing (cont.)#Nuclear Stress Tests (cont.)Advantages Evaluates LV function High Sensitivty Limitations Low specificity 1 day protocol provides poor images in obese patientsL & F & F& S$7'Approaching the patient with chest pain(((Goal is to effectively use stress test to help guide management, ie identify those patients with intermediate and possibly low risk of CAD Patients with high-risk of CAD may benefit from moving directly to cardiac catheterizationA8/Approaching the patient with chest pain (cont.)00(kNeed a method to determine pre-test probability of CAD Framingham Risk Score Based on Age, Sex and Symptoms&75759/Approaching the patient with chest pain (cont.)00(Framingham Score Categorizes patients as low, intermediate or high risk of death from CAD over the next 10 years Characteristics included in score are age, gender, total cholesterol, HDL cholesterol level, smoking status and systolic blood pressure 2:/Approaching the patient with chest pain (cont.)00( 45Case 1*54 yo male w/ DM, HTN, Hyperlipidemia, CAD s/p CABG 9 months ago presents with substernal chest pain that is pressure-like, non-radiating, associated with SOB and worsened with exertion. ECG shows old TWI in anterior leads. Pt admitted to telemetry and is AMI negative x3. What is the next step?P! ;Case 258 yo male w/ uncontrolled HTN and hyperlipidemia, medical non-compliance who presents to your office with anginal chest pain that started this AM. Pt has noted a few similar episodes over the past 2 weeks. Initial VS are stable. ECG shown on the next page.>:B C!Case 366 yo female w/ h/o HTN, hyperlipdemia who comes to the ED with burning chest pain that began earlier today. Pain is somewhat worse with exertion. She is a non-smoker. In the ED, ECG is unremarkable and her VS are notable for BP of 158/84. Her most recent lipid panel showed Total Cholesterol of 240 and HDL of 43. She is admitted to telemetry and ruled out for MI. 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ObjectiveHow to cause stressAdenosine and DipyridamoleAdenosine/Dipyridamole (cont.) DobutamineDobutamine (cont.)Types of Stress Test ImagingExercise Stress Testing Exercise Stress Testing (cont.) Exercise Stress Testing (cont.) Exercise Stress Testing (cont.)Stress Echocardiography Stress Echocardiography (cont.) Stress Echocardiography (cont.) Slide 19Nuclear Stress TestsNuclear Stress Testing (cont.)Nuclear Stress Testing (cont.)Nuclear Stress Tests (cont.) Slide 24(Approaching the patient with chest pain0Approaching the patient with chest pain (cont.)0Approaching the patient with chest pain (cont.)0Approaching the patient with chest pain (cont.) Slide 29Case 1Case 2 Slide 32Case 3 References  Fonts UsedDesign Template Slide Titles" 8@ _PID_HLINKSA$Uhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfUhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfIhttp://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpg2http://www.heartsite.com/html/isotope_stress.htmlKhttp://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpgUTypes of Stress Test ImagingLExercise Stress Testing (ECG) Stress Echocardiography Nuclear Stress TestingMnM Exercise Stress Testing )The most simple stress test Patient exercises on a treadmill with ECG, BP and HR monitoring Patient must be able to exercise to achieve goal HR of 85% of age-predicted maximum Test is considered positive if ST depression or elevation of >1 mm occurs or if anginal chest pain occurs during exercise# Exercise Stress Testing (cont.)QReport includes symptoms, exercise capacity, BP pattern, ECG changes and evaluation of risk of CAD Duke Treadmill score categorizes patients as low, intermediate or high risk of CAD based on exercise time, exercise capacity and presence/absence of angina Duke score has been validated among patients without known CAD in 5 year follow-upRZRExercise Stress Testing (cont.)Sensitivity of 50%, Specificity of 90% in comparison to coronary angiography Meta analysis revealed Sensitivity of 67% and specificity of 72% Exercise Stress Testing (cont.)Advantages: Low cost Low risk of complications Can be done by non-cardiologists Limitations: Difficult for patients with musculoskeletal disease, pulmonary disease, vascular disease  D Y D Y   Stress EchocardiographyBaseline 2-D Echo images obtained, along with baseline BP and ECG monitoring Patient then undergoes exercise protocol and repeat images are then obtained Exercise protocols superior than pharmacologic stress, especially for single vessel CADStress Echocardiography (cont.)Stress Echocardiography (cont.)Advantages Most specific of stress tests Ability to evaluate LV and valvular function Limitations Images affected by body habitus Less sensitive for single-vessel CAD L K G K G,D.(% Nuclear Stress Tests  Uses tracers Thallium and Technetium Thallium is a potassium analog and is renally excreted Technetium is lipid soluble and excreted through the GI tract Gamma camera used and computer then creates 3D reconstruction of resting and stress images which can be compared"Z Z L!Nuclear Stress Testing (cont.)Has both 1-day and 2-day protocols 2-day protocols provide superior images but 1-day protocols used more often because of logistics Exercise again preferred, but any of the mentioned pharamcologic agents can be used "Nuclear Stress Testing (cont.)#Nuclear Stress Tests (cont.)Advantages Evaluates LV function High Sensitivty Limitations Low specificity 1 day protocol provides poor images in obese patientsL & F & F& S$7'Approaching the patient with chest pain(((Goal is to effectively use stress test to help guide management, ie identify those patients with intermediate and possibly low risk of CAD Patients with high-risk of CAD may benefit from moving directly to cardiac catheterizationA8/Approaching the patient with chest pain (cont.)00(kNeed a method to determine pre-test probability of CAD Framingham Risk Score Based on Age, Sex and Symptoms&75759/Approaching the patient with chest pain (cont.)00(Framingham Score Categorizes patients as low, intermediate or high risk of death from CAD over the next 10 years Characteristics included in score are age, gender, total cholesterol, HDL cholesterol level, smoking status and systolic blood pressure 2:/Approaching the patient with chest pain (cont.)00( 45Case 1*54 yo male w/ DM, HTN, Hyperlipidemia, CAD s/p CABG 9 months ago presents with substernal chest pain that is pressure-like, non-radiating, associated with SOB and worsened with exertion. ECG shows old TWI in anterior leads. Pt admitted to telemetry and is AMI negative x3. What is the next step?P! ;Case 258 yo male w/ uncontrolled HTN and hyperlipidemia, medical non-compliance who presents to your office with anginal chest pain that started this AM. Pt has noted a few similar episodes over the past 2 weeks. Initial VS are stable. ECG shown on the next page.>:B C!Case 366 yo female w/ h/o HTN, hyperlipdemia who comes to the ED with burning chest pain that began earlier today. Pain is somewhat worse with exertion. She is a non-smoker. In the ED, ECG is unremarkable and her VS are notable for BP of 158/84. Her most recent lipid panel showed Total Cholesterol of 240 and HDL of 43. She is admitted to telemetry and ruled out for MI. What is the next step?>  eD" References^ Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina) [publishederrata appear in J Am Coll Cardiol 1999;34:314 and 2001;38:296]. J Am Coll Cardiol 1999;33:2092-197. Carlisle R, Fitzpatrick KM, Oreskovich JM, et al. Cardiac Stress Testing for Diagnosis of Coronary Artery Disease in Adults with Acute Chest Pain. Hospital Physician 2008; 44:21-29 Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committeeon Exercise Testing). Circulation 1997;96:345 54. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing. Available at www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf. Kim C, Kwok YS, Heagerty P, Redberg R. Pharmacologic stress testing for coronary disease diagnosis: a meta-analysis. Am Heart J 2001;142:934 44.  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lhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdflhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf<http://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpghttp://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpgbhttp://www.heartsite.com/html/isotope_stress.htmlbhttp://www.heartsite.com/html/isotope_stress.htmlD http://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpghttp://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpg^www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf/ 00DArialngsRomanTT/ܖ 0ܖ"DGaramondRomanTT/ܖ 0ܖ DTimes New RomanTT/ܖ 0ܖ0DWingdingsRomanTT/ܖ 0ܖ A .  @n?" dd@  @@``  PU$G     $$&'()"+,/0123456789:;<=@BDEFGHIJKLMNOP STUVWXoR$\hF`>,I6R$gYB{ܘzE+62$gPƓhbJZhQCa2$o)seܽFD$R$Lj Types of Stress Test ImagingLExercise Stress Testing (ECG) Stress Echocardiography Nuclear Stress TestingMnM Exercise Stress Testing )The most simple stress test Patient exercises on a treadmill with ECG, BP and HR monitoring Patient must be able to exercise to achieve goal HR of 85% of age-predicted maximum Test is considered positive if ST depression or elevation of >1 mm occurs or if anginal chest pain occurs during exercise# Exercise Stress Testing (cont.)QReport includes symptoms, exercise capacity, BP pattern, ECG changes and evaluation of risk of CAD Duke Treadmill score categorizes patients as low, intermediate or high risk of CAD based on exercise time, exercise capacity and presence/absence of angina Duke score has been validated among patients without known CAD in 5 year follow-upRZRExercise Stress Testing (cont.)Sensitivity of 50%, Specificity of 90% in comparison to coronary angiography Meta analysis revealed Sensitivity of 67% and specificity of 72% Exercise Stress Testing (cont.)Advantages: Low cost Low risk of complications Can be done by non-cardiologists Limitations: Difficult for patients with musculoskeletal disease, pulmonary disease, vascular disease  D Y D Y   Stress EchocardiographyBaseline 2-D Echo images obtained, along with baseline BP and ECG monitoring Patient then undergoes exercise protocol and repeat images are then obtained Exercise protocols superior than pharmacologic stress, especially for single vessel CADStress Echocardiography (cont.)Stress Echocardiography (cont.)Advantages Most specific of stress tests Ability to evaluate LV and valvular function Limitations Images affected by body habitus Less sensitive for single-vessel CAD L K G K G,D.(% Nuclear Stress Tests  Uses tracers Thallium and Technetium Thallium is a potassium analog and is renally excreted Technetium is lipid soluble and excreted through the GI tract Gamma camera used and computer then creates 3D reconstruction of resting and stress images which can be compared"Z Z L!Nuclear Stress Testing (cont.)Has both 1-day and 2-day protocols 2-day protocols provide superior images but 1-day protocols used more often because of logistics Exercise again preferred, but any of the mentioned pharamcologic agents can be used "Nuclear Stress Testing (cont.)#Nuclear Stress Tests (cont.)Advantages Evaluates LV function High Sensitivty Limitations Low specificity 1 day protocol provides poor images in obese patientsL & F & F& S$7'Approaching the patient with chest pain(((Goal is to effectively use stress test to help guide management, ie identify those patients with intermediate and possibly low risk of CAD Patients with high-risk of CAD may benefit from moving directly to cardiac catheterizationA8/Approaching the patient with chest pain (cont.)00(kNeed a method to determine pre-test probability of CAD Framingham Risk Score Based on Age, Sex and Symptoms&75759/Approaching the patient with chest pain (cont.)00(Framingham Score Categorizes patients as low, intermediate or high risk of death from CAD over the next 10 years Characteristics included in score are age, gender, total cholesterol, HDL cholesterol level, smoking status and systolic blood pressure 2:/Approaching the patient with chest pain (cont.)00( 45Case 1*54 yo male w/ DM, HTN, Hyperlipidemia, CAD s/p CABG 9 months ago presents with substernal chest pain that is pressure-like, non-radiating, associated with SOB and worsened with exertion. ECG shows old TWI in anterior leads. Pt admitted to telemetry and is AMI negative x3. What is the next step?P! ;Case 258 yo male w/ uncontrolled HTN and hyperlipidemia, medical non-compliance who presents to your office with anginal chest pain that started this AM. Pt has noted a few similar episodes over the past 2 weeks. Initial VS are stable. ECG shown on the next page.>:B C!Case 366 yo female w/ h/o HTN, hyperlipdemia who comes to the ED with burning chest pain that began earlier today. Pain is somewhat worse with exertion. She is a non-smoker. In the ED, ECG is unremarkable and her VS are notable for BP of 158/84. Her most recent lipid panel showed Total Cholesterol of 240 and HDL of 43. She is admitted to telemetry and ruled out for MI. What is the next step?>  eD" References^ Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina) [publishederrata appear in J Am Coll Cardiol 1999;34:314 and 2001;38:296]. J Am Coll Cardiol 1999;33:2092-197. Carlisle R, Fitzpatrick KM, Oreskovich JM, et al. Cardiac Stress Testing for Diagnosis of Coronary Artery Disease in Adults with Acute Chest Pain. Hospital Physician 2008; 44:21-29 Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committeeon Exercise Testing). Circulation 1997;96:345 54. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guidelin      !"#$%&'()*+e update for exercise testing. Available at www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf. Kim C, Kwok YS, Heagerty P, Redberg R. Pharmacologic stress testing for coronary disease diagnosis: a meta-analysis. Am Heart J 2001;142:934 44.  " d2 " d2 " d2  $/  <YMs 0/ & ' ( ) * +,-./01236<=>?@AEFG H!$ ! 0 pL$(  Lr L S <  `}   r L S z `  H L 0޽h ? 380___PPT10.E6 " 0 P(  PX P C 4    P S H4 0    H P 0޽h ? 3380___PPT10.HaCrJD H &H1CH(   lhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdflhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf<http://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpghttp://www.gehealthcare.com/usen/security/cis/images/vividi_stress_l.jpgbhttp://www.heartsite.com/html/isotope_stress.htmlbhttp://www.heartsite.com/html/isotope_stress.htmlD http://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpghttp://www.medicaltraining.cc/sitebuilder/images/12_lead_stemi-439x203.jpg^www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdfhttp://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf/ 00DArialngsRomanTT/ܖ 0ܖ"DGaramondRomanTT/ܖ 0ܖ DTimes New RomanTT/ܖ 0ܖ0DWingdingsRomanTT/ܖ 0ܖ A .  @n?" dd@  @@``  PU$G     $$&'()"+,/0123456789:;<=@BDEFGHIJKLMNOP STUVWXoR$\hF`>,I6R$gYB{ܘzE+62$gPƓhbJZhQCa2$o)seܽFD$R$Lj Types of Stress Test ImagingLExercise Stress Testing (ECG) Stress Echocardiography Nuclear Stress TestingMnM Exercise Stress Testing )The most simple stress test Patient exercises on a treadmill with ECG, BP and HR monitoring Patient must be able to exercise to achieve goal HR of 85% of age-predicted maximum Test is considered positive if ST depression or elevation of >1 mm occurs or if anginal chest pain occurs during exercise# Exercise Stress Testing (cont.)QReport includes symptoms, exercise capacity, BP pattern, ECG changes and evaluation of risk of CAD Duke Treadmill score categorizes patients as low, intermediate or high risk of CAD based on exercise time, exercise capacity and presence/absence of angina Duke score has been validated among patients without known CAD in 5 year follow-upRZRExercise Stress Testing (cont.)Sensitivity of 50%, Specificity of 90% in comparison to coronary angiography Meta analysis revealed Sensitivity of 67% and specificity of 72% Exercise Stress Testing (cont.)Advantages: Low cost Low risk of complications Can be done by non-cardiologists Limitations: Difficult for patients with musculoskeletal disease, pulmonary disease, vascular disease  D Y D Y   Stress EchocardiographyBaseline 2-D Echo images obtained, along with baseline BP and ECG monitoring Patient then undergoes exercise protocol and repeat images are then obtained Exercise protocols superior than pharmacologic stress, especially for single vessel CADStress Echocardiography (cont.)Stress Echocardiography (cont.)Advantages Most specific of stress tests Ability to evaluate LV and valvular function Limitations Images affected by body habitus Less sensitive for single-vessel CAD L K G K G,D.(% Nuclear Stress Tests  Uses tracers Thallium and Technetium Thallium is a potassium analog and is renally excreted Technetium is lipid soluble and excreted through the GI tract Gamma camera used and computer then creates 3D reconstruction of resting and stress images which can be compared"Z Z L!Nuclear Stress Testing (cont.)Has both 1-day and 2-day protocols 2-day protocols provide superior images but 1-day protocols used more often because of logistics Exercise again preferred, but any of the mentioned pharamcologic agents can be used "Nuclear Stress Testing (cont.)#Nuclear Stress Tests (cont.)Advantages Evaluates LV function High Sensitivty Limitations Low specificity 1 day protocol provides poor images in obese patientsL & F & F& S$7'Approaching the patient with chest pain(((Goal is to effectively use stress test to help guide management, ie identify those patients with intermediate and possibly low risk of CAD Patients with high-risk of CAD may benefit from moving directly to cardiac catheterizationA8/Approaching the patient with chest pain (cont.)00(kNeed a method to determine pre-test probability of CAD Framingham Risk Score Based on Age, Sex and Symptoms&75759/Approaching the patient with chest pain (cont.)00(Framingham Score Categorizes patients as low, intermediate or high risk of death from CAD over the next 10 years Characteristics included in score are age, gender, total cholesterol, HDL cholesterol level, smoking status and systolic blood pressure 2:/Approaching the patient with chest pain (cont.)00( 45Case 1*54 yo male w/ DM, HTN, Hyperlipidemia, CAD s/p CABG 9 months ago presents with substernal chest pain that is pressure-like, non-radiating, associated with SOB and worsened with exertion. ECG shows old TWI in anterior leads. Pt admitted to telemetry and is AMI negative x3. What is the next step?P! ;Case 258 yo male w/ uncontrolled HTN and hyperlipidemia, medical non-compliance who presents to your office with anginal chest pain that started this AM. Pt has noted a few similar episodes over the past 2 weeks. Initial VS are stable. ECG shown on the next page.>:B C!Case 366 yo female w/ h/o HTN, hyperlipdemia who comes to the ED with burning chest pain that began earlier today. Pain is somewhat worse with exertion. She is a non-smoker. In the ED, ECG is unremarkable and her VS are notable for BP of 158/84. Her most recent lipid panel showed Total Cholesterol of 240 and HDL of 43. She is admitted to telemetry and ruled out for MI. What is the next step?>  eD" References^ Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina) [publishederrata appear in J Am Coll Cardiol 1999;34:314 and 2001;38:296]. J Am Coll Cardiol 1999;33:2092-197. Carlisle R, Fitzpatrick KM, Oreskovich JM, et al. Cardiac Stress Testing for Diagnosis of Coronary Artery Disease in Adults with Acute Chest Pain. Hospital Physician 2008; 44:21-29 Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committeeon Exercise Testing). Circulation 1997;96:345 54. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing. Available at www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf. Kim C, Kwok YS, Heagerty P, Redberg R. Pharmacologic stress testing for coronary disease diagnosis: a meta-analysis. Am Heart J 2001;142:934 44.  " d2 " d2 " d2  $/  <YMs 0/ & ' ( ) * +,-./01236<=>?@AEFG H!}  0 $$(  $r $ S Y  `}   r $ S $Z `  H $ 0޽h ? 3___PPT10i.P)2+D=' = @B +rHV$YH1