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GET WITH THE GUIDELINES:
PREPROCEDURAL CARDIAC
EVALUATION
Jennifer FM Del Campo MD MSN FNP-C CCRN CMC
Mount Sinai Heart Cardiac Cath Lab
Mount Sinai, New York
June 17,2014
NO DISCLOSURE
CARDIAC STRESS TEST
OBJECTIVES
 To understand the indications and
contraindications for stress testing.
 To learn the different modalities of
cardiac stress test.
 To effectively select the optimal
cardiac stress test for each patient
TESTS FOR ASSESSING CARDIAC
ANATOMY AND FUNCTION
LV Function
Echocardiography
Multiple Gated Acquisition
(MUGA) Radionuclide
Imaging
CAD prognosis
and Diagnosis
Myocardial
Viability
Exercise or Pharmacologic
stress testing with ECG,
myocardial perfusion imaging
or echocardiography
SPECT MPI
MRA
Coronary Angiography
Gated MRI
Contrast Ventriculography
Intravascular ultrasonography
CTA
Stress testing (using low-dose
dobutamine) with
echocardiography
Positron emission tomography
(PET)
Gated MRI
Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac
Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society
of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the
Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine.
JAm Coll Cardiol 2009; 53:2201.
AIMS OF STRESS TESTING
Elicit
abnormalities
not present at
rest
Estimate
functional
capacity
Extent of CAD
Likelihood of
Coronary
Artery Disease
Estimate
Prognosis
INDICATIONS
Who
needs
stress
test?
Symptoms suggesting angina.
Acute chest pain
Recent ACS after 3 months of conservative therapy
Known CAD and change in clinical status.
Prior coronary revascularization
Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the
1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40:1531.
INDICATIONS
Who
needs
stress
test?
Valvular heart disease.
New heart failure or cardiomyopathy.
Chronic left ventricular dysfunction and CAD
who are candidates for revascularization.
Selected arrhythmias
Undergoing non-urgent non-cardiac
surgery.
CONTRAINDICATIONS
Who
NOT to
request
stress
test?
Unstable Angina
Acute MI
Arrhythmia with hemodynamic Instability
Aortic Dissection
Symptomatic Aortic Stenosis
Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997
Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40:1531.
CONTRAINDICATIONS
Who
Symptomatic Heart Failure
NOT to
Pulmonary Embolism
request
stress
Myocarditis
test?
Pericarditis
CLASSIC ANGINAL FEATURES
Precordial (Retrosternal ) Chest pain that:
TYPICAL ANGINA:
2-3/3 Features
ATYPICAL ANGINA:
1/3 Features
Likely NON Cardiac
Chest pain:
0/3 Features
Is triggered by
emotional or
physical stress
Lasts for 1520 minutes
each
episode
Is relieved
by rest or SL
NTG
PRE-TEST PROBABILITY OF CAD BY AGE, GENDER & SYMPTOMS
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.
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%
Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40:1531.
CARDIAC STRESS TESTING: HOW IS IT DONE?
TWO COMPONENTS
Each Cardiac Imaging Modality has two components
STRESSING AGENT:
Treadmill, Dobutamine
or Adenosine
IMAGING AGENT:
ECG, Echo, or
Radionuclide Tracer
Thallium or Technitium
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
Adenosine or
dipyridamole (used
with nuclear)
No exercise needed;
uncomfortable sensation
of “heart stoppage”
Adenosine may induce
bronchospasm –
caution in COPD and
asthma!
IMAGING AGENTS
Imaging Agent
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.
Thallium or technetium
Localizes ischemia
and infarcted tissue.
Expensive
EXERCISE STRESS TEST
also called a stress test,
exercise electrocardiogram,
Treadmill test, Graded
Exercise test, or stress ECG–
usually involves walking on a
treadmill or pedaling a
stationary bike at increasing
levels of difficulty, while your
ECG, Heart Rate, and Blood
Pressure are monitored.
STRESS ECHOCARDIOGRAPHY
Compares Pre & Post:

Regional contractility

Overall systolic function

Volumes

Pressure gradients
 Filling pressures

Pulmonary pressures
 Valvular function
DOBUTAMINE STRESS ECHO
NUCLEAR SPECT IMAGING
Radio – tracer injection
Isotopes:
o Thallium- 201
oTechnetium 99m ( SESTAMIBI)
Myocardial Uptake
Photon Emission Captures by Gamma
Camera
Rest and redistribution Phases
What is a MIBI?
MIBI: the technetium molecule
is attached to sestamibi
molecule. The combined
sestamibi-Technitium-99
molecule is aka “cardiolite
What is a LEXISCAN?
Lexican: uses a derivative of
adenosine called
regadenosine, which has 2-3
minute half-life instead of
30sec, so is easier to work with.
SENSITIVITY AND SPECIFICITY
MODALITY
Exercise Test
Nuclear Imaging
Stress echo
SENSITIVITY
SPECIFICITY
68%
77%
87-92%
80-85%
76%
80-85%
CT CORONARY ANGIOGRAPHY
CT CALCIUM SCORE
Score Description
•
•
•
•
•
0
1 – 99
100 - 399
400 – 999
>1000
No Evidence of CAD
Mild Evidence
Moderate Evidence
Severe Evidence
Extensive Evidence
CT LIMITATIONS OF CARDIAC CT FOR
CALCIUM SCORING
• Not all health insurance plans cover cardiac CT for
calcium scoring.
• A high heart rate may interfere with the image quality
of the test.
• A person who is very large may not fit into the opening
of a conventional CT scanner or may be over the
weight limit
SELECTING MODALITIES
Indication
Diagnosis or Prognosis
yes
no
Exercise?
Localize Ischemia
no
Exercise?
Pharmacologic test
with Imaging
Normal EKG
Not on Digoxin
No prior revascularization
yes
Exercise EKG
no
Exercise Imaging
yes
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 and whether any contraindications are
present
CARDIAC STRESS TEST
THANK YOU