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NON-INVASIVE TESTING

FOR CORONARY ARTERY

DISEASE

Joe Mobley, MD FACC

Cardiology Consultants PA

October 27, 2019

OBJECTIVES

Review current clinically relevant non-invasive testing

modalities for detecting CAD

Coronary calcium scoring

Exercise stress testing

Stress echo

Stress nuclear

Coronary CT angiography

Strengths, weaknesses, limitations, clinical quirks of each

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Britannica.com

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heartsofjersey.org

ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/

STS 2013 Multimodality Appropriate Use Criteria for

the Detection and Risk Assessment of Stable

Ischemic Heart Disease

A Report of the American College of Cardiology

Foundation Appropriate Use Criteria Task Force, American

Heart Association, American Society of Echocardiography,

American Society of Nuclear Cardiology, Heart Failure

Society of America, Heart Rhythm Society, Society for

Cardiovascular Angiography and Interventions, Society of

Cardiovascular Computed Tomography, Society for

Cardiovascular Magnetic Resonance, and Society of

Thoracic Surgeons

Michael J. Wolk, Steven R. Bailey, John U. Doherty,

Pamela S. Douglas, Robert C. Hendel, Christopher M.

Kramer, James K. Min, Manesh R. Patel, Lisa

Rosenbaum, Leslee J. Shaw, Raymond F. Stainback and

Joseph M. Allen

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WHICH TEST FOR WHICH PERSON?

Pretest Probability

History and Physical Exam!!!

Baseline EKG

Baseline medications

Ability to walk

History of prior non-invasive testing

image.slidesharecnd.com

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ebm.bmj.com

NONINVASIVE TESTING FOR CAD

Asymptomatic Patients

Coronary Calcium Scoring

Symptomatic Patients

Exercise Stress Testing

Stress Echo

Stress Nuclear Perfusion Imaging

Coronary CT Angiography

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CORONARY CALCIUM SCORING

Risk stratification tool in asymptomatic patients with

intermediate risk by traditional risk factor evaluation

Low cost

Low radiation

Can be diagnostic for CAD in a previously

undiagnosed and asymptomatic patient

Can change goals for risk factor modification if

abnormal

prweb.com

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clevelandclinic.org

dicardiology.com

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i0.wp.com

CORONARY CALCIUM SCORING

Does not tell you anything about degree of active ischemia or degree of stenosis, only presence/absence of underlying CAD and the volume of plaque

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SYMPTOMATIC PATIENTS OR ASYMPTOMATIC

PATIENTS WITH HIGH RISK CLINICAL FINDINGS

Non-invasive

Functional

Anatomic

Invasive

FUNCTIONAL TESTING FOR CAD

Stress testing

Stress EKG

Stress echo

Stress SPECT/PET

Stress MRI

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CONTRAINDICATIONS TO STRESS TESTING

Acute MI within 2 days

Pharmacologic Nuclear stress

Unstable angina

Uncontrolled arrhythmia

VT, Atrial fibrillation, etc

Severe symptomatic aortic stenosis

Decompensated CHF

Active Endocarditis/Myocarditis/Pericarditis

Acute aortic dissection

Acute PE

Acute noncardiac conditions that are not stable

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veteranshealthlibrary.gov

Treadmill Stress Test

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STRESS ECHO

Exercise

Pharmacologic Stress

Dobutamine

No radiation

Lower cost

Quick and easy with right equipment and personnel

toshiba.com

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STRESS NUCLEAR

SPECT and PET tracers

Exercise

Pharmacologic stress

Dobutamine

Vasodilator (Regadenoson, Adenosine, Persantine)

Higher cost

More time consuming

More costly

Radiation

Useful in patients who cannot walk, cannot be titrated off rate lowering

meds, or have baseline indecipherable EKGs (LBBB, LVH, WPW, marked

baseline STT changes)

STRESS NUCLEAR

Best studied stress imaging modality

Certainly the most quantitative

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slidesplayer.com

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ANATOMIC NON-INVASIVE EVALUATION

Coronary CT Angiography

Higher Cost

Contrast

Radiation exposure

More technically difficult

Sinus, controlled Heart Rate, Cooperative,

and able to hold their breath for 8-10 seconds

Zhonghua et al, QIMS Volume 4, Number 5, October 2014, 2223.

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amberusa.com

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helio.com

JACC 2005;46;147-154

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THE FUTURE: PLAQUE IMAGING

Vulnerabe Plaque

CTA – most accepted currently

MRA

Nuclear

slideshare.net

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annals.org

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researchgate.net

CONCLUSIONS

CAD is an enormous public health issue

Noninvasive testing preferable when feasible to limit procedural risk and

cost

Numerous options for noninvasive testing based on patient history and

symptoms

Asymptomatic

Symptomatic

Functional

Anatomic

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