View
218
Download
0
Category
Preview:
Citation preview
1
Evaluation of Chest pain in the Office and Cardiac Stress Testing
Chad Link, DO FACC
Sparrow Hospital
Thoracic and Cardiovascular Institute
Chairman- TCI Cardiology Section
Disclosures
Speakers Bureau – Actelion Pharmaceuticals, Pfizer and BMS
Clinical Research Support– Sanofi Aventis
Case Question
• Cc: Chest pain
• HPI: This is a 30 year old male who presents to your office with
complaints of substernal chest pain that has been going on for the
past 5 days. He describes the pain as a “sharp pain” that is constant
for most of the day. It doesn’t change with position and can occur
both at rest or with exertion. He does not experience the pain at night
and has no trouble sleeping. He denies any other associated
symptoms with the pain. He is otherwise healthy and has no previous
medical conditions. He is taking no medications.
2
Case Question
https://meds.queensu.ca/central/assets/modules/ECG/normal_ecg.html
Case Question
• Which of the following is the most
appropriate diagnostic test or strategy to
perform next?
a. Regadenoson Nuclear Perfusion Stress Test.
b. Coronary Angiography
c. Stress Echocardiography
d. Exercise Treadmill
e. NSAID and Observation
f. Send to the ER
g. Cardiology Consultation
Case Question
• Cc: Chest pain
• HPI: This is a 45 y.o c female who presents to the ER with c/o
substernal CP which started approx. 2 hours ago. The patient
describes the pain as a “pressure” that radiates to her left shoulder
and down her left arm. She noticed the pain while watching TV and
states the pain lasted approximately 10 minutes before completely
resolving. She states she felt SOB with the CP, but denies N/V,
diaphoresis or pain radiating to the back or neck area. She states she
took an NSAID which seemed to relieve the pain. She denies history
of CAD, including previous MI, however, she does have multiple risk
factors for CAD, including diabetes, hyperlipidemia, tobacco use and
family history of premature CAD. She has never had a previous
cardiac examination, but does see her doctor regularly. She states
she has noticed this pain over the last several months with exercise,
however it generally goes away with rest. She is currently pain free.
3
Case Question
https://en.wikipedia.org/wiki/Wellens'_syndrome
Case Question
• Which of the following is the most
appropriate diagnostic test or strategy to
perform next?
a. Regadenoson Nuclear Perfusion Stress Test.
b. Coronary Angiography
c. Stress Echocardiography
d. Exercise Treadmill
e. NSAID and Observation
f. Send to the ER
g. Cardiology Consultation
Case Question
• The patient is referred to Cardiology for an
Evaluation. Which of the following is the
most appropriate diagnostic test to perform
next?
a. Regadenoson Nuclear Perfusion Stress Test.
b. Coronary Angiography
c. Stress Echocardiography
d. Exercise Treadmill
e. NSAID and Observation
4
History
History
• Differential Diagnosis of Chest pain
– Chest pain- Cardiovascular Causes
• Angina Pectoris
• Unstable Angina
• Myocardial Infarction
• Pericarditis
• Myocarditis
• Aortic Dissection
• Aortic Stenosis
• Variant or Prinzmetal Angina (Coronary Spasm)
• Ventricular Septal Rupture
History
Chest pain- Non-Cardiovascular
Causes
• Gastrointestinal
• Esophageal Spasm
• Esophageal reflux
• Esophageal rupture
• Psychogenic
• Anxiety
• Depression
• Self-gain
•Neuromusculoskeletal
• Costochondritis
• Herpes Zoster
• Trauma/Chest Wall Pain
• DJD of cervical spine
•Pulmonary
• Pulmonary Embolism
• Pneumothorax
• Pleurisy
• Differential Diagnosis of Chest pain
5
Stress Testing
• When? – Indications
What type? – Modalities
Who? – Patient selection
How often? – Frequency
How much? – Cost
• The choice depends on:
– Ability to Exercise, PMHx, ECG, Body Habitus
and Clinical Indication
Indications of Stress Testing
• In patients with symptoms suggestive of coronary
heart disease, cardiac stress testing is most often
indicated to making the diagnosis and assessing
risk OR
• In patients with known CAD for risk stratification.
Stress testing for CHD in asymptomatic is RARELY
indicated.
Stress Testing: When?
• Patients with chest pain
– Change in clinical status
• Acute coronary syndromes
– Low, intermediate, high risk (H&P, ECG, markers –
TIMI risk score)
– Low: 8-12 h symptom-free
– Intermediate: 2-3 days symptom-free*
– High: consider chemical imaging study versus
coronary angiography*
6
Stress Testing: When?
• Before and after revascularization (if residual
disease)
– Demonstration of ischemia
– Evaluation of post-procedure chest pain
– Evaluation of territory at risk (if residual disease)
– Evaluation of restenosis
Stress Testing: How Often?
• Change in clinical symptom pattern
• Prognostication:
– There is no absolute guarantee
• Progression of testing modality to higher
sensitivity and specificity
• Depends on risk factors, their degree of
control and intensity of modification
Stress Testing: Who?
• Special Groups
– Women
• Lower sensitivity, similar specificity
– Elderly (>75 years of age)
• Other evaluated endpoints include chronotropic response,
exercise-induced arrhythmias, and assessment of exercise
capacity
– Diabetics
• Imaging study recommended
7
Stress Testing: Who?
• Asymptomatic patients
– Diabetics planning to start exercise
– Guide to risk reduction therapy in a patient with
multiple risk factors
– Men > 45 and women > 55
• Starting exercise
• Impact public safety
• High risk due to concomitant disease (PVD, CRF)
Robert C. Hendel et al. JACC 2009;53:2201-2229
American College of Cardiology Foundation
Stress Testing: Who?
Stress Testing:
Absolutely Who Not!
• Acute MI
• High risk unstable angina
• Uncontrolled arrhythmias with symptoms
• Symptomatic, severe aortic stenosis
• Uncontrolled, symptomatic heart failure
• Acute PE
• Acute myocarditis or pericarditis
• Acute aortic dissection
• Inability to obtain consent
https://www.uptodate.com/contents/image?imageKey=CARD%2F80110&topicKey=CARD%2F1494&rank=1%7
E150&source=see_link&search=exercise+stress+test&utdPopup=true
8
Stress Testing:
Relative Contraindication
• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities
• Severe hypertension (SBP > 200, DBP > 110)
• Tachy or bradyarrhythmias
• Outflow tract obstruction (HCM)
• Mental or physical impairment (unsafe)
• High-degree AV block
https://www.uptodate.com/contents/image?imageKey=CARD%2F80110&topicKey=CARD%2F1494&rank=1%7
E150&source=see_link&search=exercise+stress+test&utdPopup=true
Indications of Stress Testing
When are stress studies not generally indicated:
- Asymptomatic patients < 5 years post CABG or < 2 years post PCI
- Routine stress testing in patients undergoing non-cardiac surgery
- Low pre test probability of < 10%
ww.uptodate.cwom
Indications of Stress Testing
The Guidelines- Summary
- Symptoms suggestive of angina with an indeterminate or high
pre test probability of CAD (exception UA).
- Patients with acute CP following exclusion of ACS.
- Patient with recent ACS who were treated conservatively or
incomplete revascularization.
- Known CAD with worsening symptoms.
- Routine testing > 5 years post CABG and > 2 years post PCI.
- Certain instances in valvular heart disease and preoperative
evaluation when unable to function to a level of < 4 METs. ww.uptodate.cwom
9
Pre-Test Probability
Age Nonanginal pain Atypical angina Typical angina
Men Women Men Women Men Women
30-39 4% 2% 34% 12% 76% 26%
40-49 13% 3% 51% 22% 87% 55%
50-59 20% 7% 65% 31% 93% 73%
60-69 27% 14% 72% 51% 94% 86%
ACC/AHA 2012 Guidelines
Low probability - <10% - no further testing, except for prognostic information.
Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise
ECG as first modality).
High probability - >90% - non invasive testing for prognosis/management prior to
cardiac cath.
Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014
Indications of Stress Testing
First, is the stress study indicated?
Need to assess symptoms
Unstable angina is a contraindication to stress
testing
ww.uptodate.cwom
Angina
Precordial (retro-sternal) chest pain that…
• Is triggered by physical or emotional stress
• Is relieved by rest or SL NTG
• Lasts for 15-20 minutes each episode
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
10
Indications of Stress Testing
First, is the stress study indicated?
YES indicated
If indicated, can the patient exercise?
(Exclusions from exercise include Paced
rhythm, LBBB, WPW, > 1 mm ST depression at rest
or significant ST changes due to LVH)
ww.uptodate.cwom
Indications of Stress Testing
First, is the stress study indicated?
YES indicated
If indicated, can the patient exercise?
YES
Then need to determine the pre-test probability and
determine the appropriate test based on risk
stratification
ww.uptodate.cwom
Pre-Test Probability
Age Nonanginal pain Atypical angina Typical angina
Men Women Men Women Men Women
30-39 4% 2% 34% 12% 76% 26%
40-49 13% 3% 51% 22% 87% 55%
50-59 20% 7% 65% 31% 93% 73%
60-69 27% 14% 72% 51% 94% 86%
ACC/AHA 2012 Guidelines
Low probability - <10% - no further testing, except for prognostic information.
Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise
ECG as first modality).
High probability - >90% - non invasive testing for prognosis/management prior to
cardiac cath.
Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
11
Stress Testing: Who?
Adults with intermediate (10-90%)
pre-test probability of CAD
Age Sex Typical Atypical Non-anginal Asymp
30-39Male Intermediate Intermediate Low Very low
Female Intermediate Very Low Very low Very low
40-49Male High Intermediate Intermediate Low
Female Intermediate Low Very low Very low
50-59Male High Intermediate Intermediate Low
Female Intermediate Intermediate Low Very low
60-69Male High Intermediate Intermediate Low
Female High Intermediate Intermediate Low
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Two Components
• Each cardiac imaging modality has two
components:
– Stressing agent: treadmill, dobutamine, or
regadenoson
– Imaging agent: EKG, echo, or radionuclide tracer
(Cardiolite/technetium)
NEED TO CHOSE ONE FROM EACH CATEGORY
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Stress Testing: What Type?
EXERCISE ECG ALONE OR IN COMBINATION WITH AN
IMAGING MODALITY?
Exercise stress testing with electrocardiographic (ECG)
monitoring should be the initial test for the majority of patients
who can exercise and who have an interpretable ECG. While
exercise stress testing with imaging has several advantages over
the standard exercise ECG treadmill test.
There is insufficient evidence to recommend exercise stress
testing with imaging in all patients.
https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test?source=see_link§ionName=INDICATIONS+FOR+STRESS+TESTING&anchor=H45821
8799#H458218799
12
Stress Testing: What Type?
• There are also additional circumstances and patient
characteristics besides the ability to exercise and resting
ECG findings that determine whether a patient should
undergo exercise alone or exercise with imaging.
• These include ischemia localization, viability assessment,
prior revascularization, hemodynamic assessment for
valvular disease, digoxin use and prior equivocal ECG
findings.
https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test?source=see_link§ionName=INDICATIONS+FOR+STRESS+TESTING&anchor=H45821
8799#H458218799
Stress Testing: What Type?
• Exercise modality
– Treadmill
• Bruce, Modified Bruce, Branching, Naughton…
– Bicycle (recumbent)
– Chemical/Pharmacologic
• Dipyridamole (Persantine®)
• Adenosine (Adenoscan®)
• Regadenason (Lexiscan®)
• Dobutamine
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
The Bruce protocol
• Developed in 1949 by Robert A. Bruce, considered the “father of exercise physiology”.
• Published as a standardized protocol in 1963.
• Remains the gold-standard for detection of myocardial ischemia when risk stratification is necessary.
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
13
Protocol description
Stage Time (min) km/hr Slope
1 0 2.74 10%
2 3 4.02 12%
3 6 5.47 14%
4 9 6.76 16%
5 12 8.05 18%
6 15 8.85 20%
7 18 9.65 22%
8 21 10.46 24%
9 24 11.26 26%
10 27 12.07 28%STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Exercise Testing: Contraindications
• Unstable Angina
• Decompensated CHF
• Uncontrolled hypertension (blood pressure >200/115 mmHg)
• Acute myocardial infarction within last 2 to 3 days
• Relative contraindications (AS, HCM)
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Stress Testing: What Type?
• Non-imaging vs. Imaging
– Require imaging
• Intermediate risk non-imaging exercise test
• Pre-excitation
• Paced rhythm
• LBBB or QRS > 120 ms
• > 1 mm resting ST depression
• Vessel localization
• Improved prognostic information
https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-
test?source=see_link§ionName=INDICATIONS+FOR+STRESS+TESTING&an
chor=H458218799#H458218799
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
14
Indications of Stress Testing
First, is the stress study indicated?
YES indicated
If indicated, can the patient exercise?
NO or has an exclusion then need to consider
pharmacological testing
ww.uptodate.cwom
Stress Testing: What Type?
• Choice of imaging modality is multi-factorial
– Body habitus – attenuation, COPD, etc.
– Local expertise
– Claustrophobia
– Understanding of sensitivity and specificity
– Coincident information:
• Ejection fraction
• Valvular structure
• Exercise capacity
https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-
test?source=see_link§ionName=INDICATIONS+FOR+STRESS+TESTING&an
chor=H458218799#H458218799
Stressing Agents
Stressor Pro Con
Treadmill Physiologic, simple,
less expensive,
good for patient
who can walk
Dobutamine No exercise
needed
Caution in patients with
arrhythmias
Regadenoson,
Adenosine/Persantine
(used with nuclear)
No exercise
needed;
uncomfortable
sensation of “heart
stoppage”
Adenosine may induce
bronchospasm – caution in
COPD and asthma!
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
15
Imaging Agents
Stressor Pro Con
EKG Simple, less
expensive
Less information. May not be
able to localize the lesion. Can
not use if there are baseline
EKG abnormalities i.e. LBBB
with ST changes
Echocardiogram Good if patient has
pre-existing EKG
abnormalities. More
info than EKG.
Less expensive
than nuclear.
Operator dependent to some
extent. May have poor
windows due to body habitus.
Pre-existing wall motion
abnormalities may make
interpretation more
challenging.
Cardiolite/Technetium Localizes ischemia
and infarcted
tissue.
Expensive
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Sensitivity and Specificity
Sensitivity Specificity
Exercise EKG 68% 77%
Stress Echo 76% 88%
Nuclear Imaging
79-92% 73-88%
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Last but not least… cost
TEST COST - done
Hospital
COST - done
Office
ETT $ 637 $ 239
STRESS ECHO
$ 1600 $657
NUCLEAR
SCAN
$ 3000-$4400
$937
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
16
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Case Question
A 60yo man is evaluated for chest pain of 4 months’ duration. He describes the pain as sharp, located in the left chest, with no radiation or associated symptoms, that occurred with walking one to two blocks and resolves with rest. Occasionally, the pain improves with continued walking or occurs during the evening hours. He has hypertension. Family history does not include cardiovascular disease in any first-degree relatives. His only medication is amlodipine.
On physical examination, he is afebrile, blood pressure is 130/80mHg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No carotid bruits are present, and a normal S1 and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are normal. EKG showed normal sinus rhythm.
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Case Question
• Which of the following is the most
appropriate diagnostic test to perform next?
a. Adenosine nuclear perfusion stress test.
b. Coronary angiography
c. Echocardiography
d. Exercise treadmill
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
17
Case Question
First, are the symptoms suspicious for unstable
angina?
ww.uptodate.cwom
Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD?
ww.uptodate.cwom
Pre-Test Probability
Age Nonanginal pain Atypical angina Typical angina
Men Women Men Women Men Women
30-39 4% 2% 34% 12% 76% 26%
40-49 13% 3% 51% 22% 87% 55%
50-59 20% 7% 65% 31% 93% 73%
60-69 27% 14% 72% 51% 94% 86%
ACC/AHA 2012 Guidelines
Low probability - <10% - no further testing, except for prognostic information.
Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise
ECG as first modality).
High probability - >90% - non invasive testing for prognosis/management prior to
cardiac cath.
Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014
18
Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise?
ww.uptodate.cwom
Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise? Yes
So, now are choices are Exercise EST, Exercise
Echocardiography and Exercise Cardiolite
(technetium). Which one should we perform on this
Intermediate Risk Patient?
ww.uptodate.cwom
Case Question
Do they have the following:
WPW
Paced Rhythm
LBBB
Greater than 1 mm ST depression at rest
Digoxin use with ST changes
LVH with ST Changes
NO…..
ww.uptodate.cwom
19
Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise? Yes
So, now are choices are Exercise EST, Exercise
Echocardiography and Exercise Cardiolite (over
utilized). Which one should we perform on this
Intermediate Risk Patient?
ww.uptodate.cwom
Sensitivity and Specificity
Sensitivity Specificity
Exercise EKG 68% 77%
Stress Echo 76% 88%
Nuclear Imaging
79-92% 73-88%
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
20
Take Home Points
• Stress testing is indicated for patients with intermediate
pre-test probability
• Each stress test has two components: an imaging
modality and stress modality
• When determining which stress test to order, keep in
mind their ability to exercise, whether any
contraindications are present, cost by LOCATION ,
body weight and specificity and sensitivity
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Robert C. Hendel et al. JACC 2009;53:2201-2229
American College of Cardiology Foundation
Take Home Points
Preoperative Evaluation
Thank You for your attention!
Recommended