Download Noninvasive CardiacTesting

Noninvasive Cardiac Testing
A Practical Guide to Selecting
Cardiac Stress Testing
Andrew C. Chiu, MD, FACC
Noninvasive Cardiovascular Laboratory
Essentia Health Heart & Vascular Center
Noninvasive Cardiac Testing
Clinical Context for Exercise
Testing
Test Selection Algorithm
Test Outcome Decision
Pathways
From: ACC/AHA 2002 Guideline Update for Exercise Testing
Noninvasive Cardiac Testing
Clinical Context
for Exercise
Testing
From: ACC/AHA 2002 Guideline Update for Exercise Testing
Noninvasive Cardiac Testing
Contraindication
to exercise
testing
From: ACC/AHA 2002 Guideline Update for Exercise Testing
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
2005 Heart Conference Guideline
Advantages
•Workable
•Fairly simple
Shortcomings
At initial branch
point:
•Not intuitive
•Not oriented
towards primary
clinical question
7
Noninvasive Cardiac Testing
Diagnostic/Prognostic
test to localize
ischemia or assess
viability?
NO
Abnormal EKG
≥ intermediate risk
structural disease
digoxin
Able to exercise?
YES
NO
NO
YES
Able to exercise?
YES
Able to exercise?
YES
NO
Standard
GXT
YES
Pharmacologic
Stress Imaging
Exercise
Stress
Imaging
Pharmacologic
Stress Imaging
NO
Exercise
Stress
Imaging
Pharmacologic
Stress Imaging
8
Noninvasive Cardiac Testing
Diagnostic/Prognostic
test to localize
ischemia or assess
viability?
NO
Abnormal EKG
≥ intermediate risk
structural disease
digoxin
YES
Standard
GXT
9
RE
YES
Able to exercise?
NO
Pharmacologic
Stress Imaging
TI
YES
AR
UL
C
S
VA
Exercise
Stress
Imaging
Exercise
Stress
Imaging
NO
Pharmacologic
Stress Imaging
O
N
A
Able to exercise?
IZ
YES
NO
Able to exercise?
YES
NO
Pharmacologic
Stress Imaging
Noninvasive Cardiac Testing
Diagnostic/Prognostic
test to localize
ischemia or assess
viability?
NO
Abnormal EKG
≥ intermediate risk
structural disease
digoxin
NO
Able to exercise?
YES
NO
OM
PT
Standard
GXT
&
EM
CH
IS
M
SYPharmacologic
Stress Imaging
IA
AT
UYES
AL
V
E
N
IO
Exercise
Stress
Imaging
Able to exercise?
YES
Able to exercise?
YES
YES
Exercise
Stress
Imaging
NO
Pharmacologic
Stress Imaging
NO
Pharmacologic
Stress Imaging
10
Noninvasive Cardiac Testing
• Reordered sequence of questions
• Step 1: Can patient exercise?
– Majority of symptom & ischemia evaluations
addressed
• Step 2: Which Pharmacologic Imaging Test?
– Asks if significant reactive airway disease present
– Notes exception of LBBB
• Step 3: Which Exercise Imaging Test?
– Asks if factors present limiting to stress echo
Noninvasive Cardiac Testing
Noninvasive Cardiac Testing
Noninvasive Cardiac Testing
Step 1:
1: Can Patient Exercise?
Yes
No
Treadmill Stress Test
Pharmacologic Imaging Test
Step 2
•Abnormal EKG
•LVH
•Digoxin, Beta Blockers, Calcium Channel Blockers
•Pre-menopausal women
•Prior equivocal stress tests
•Prior stents, CABG, MI
Yes
No
Exercise Imaging Test
Graded Exercise Test
Step 3
Noninvasive Cardiac Testing
Step 2: Which Pharmacologic Imaging Test?
Does patient have Reactive Airway Disease
(Asthma or Inhaler/Steroid Dependant)?
Yes
No**
Dobutamine
Echo
Nuclear
Vasodilator
MRI
Nuclear
**LBBB: Recommend Vasodilator Nuclear unless evaluating exertional symptoms
Dobutamine MRI Stress Test can provide additional information about viability. Can
also detect associated structural abnormalities, pericarditis, myocarditis, presence of
previous non-transmural infarcts (may not be detected by Nuclear stress in 50% of
patients with previous infarcts).
Noninvasive Cardiac Testing
Step 3: Which Exercise Imaging Test?
Does patient have any of the following:
•COPD
•Technically Difficult Echo
•Resting Wall Abnormality
Yes
Nuclear Stress*
No
Stress Echo
* Stress contrast echo may be utilized in
select circumstances
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
Exercise stress:
stress:
• Treadmill
– Protocols:
• Bruce & Modified Bruce
• Naughton
• UW branching
– Sensitivity: 66% for ASCAD
• (40% for single vessel, 90% for multivessel disease)
– Specificity: 84% of patients without significant
disease had negative GXT
• Bicycle
18
Noninvasive Cardiac Testing
• Adequacy of stress
Often defined as:
85% MPHR
MPHR = 220-age
19
Noninvasive Cardiac Testing
• Adequacy of stress
Rate Pressure Product
(or Double Product)
Product)
= BP x HR
(at peak exercise)
20
Noninvasive Cardiac Testing
• Adequacy of stress
Rate Pressure Product
(or Double Product)
Product)
best approximation of
myocardial oxygen demand
generated by exercise
21
Noninvasive Cardiac Testing
• Adequacy of stress
Rate Pressure Product
(or Double Product)
Product)
≥ 25,000
level of stress at which
test has best negative predictive value for
obstructive CAD
22
Noninvasive Cardiac Testing
• Advantage of stress
Symptom Limited Endpoint (SLEP)
achieved during exercise stress better
correlates symptoms to objective findings
than do pharmacologic tests
23
Noninvasive Cardiac Testing
• Advantage of stress
A wealth of data
with clinical and
prognostic value
From: ACC/AHA 2002 Guideline Update for Exercise Testing
24
Noninvasive Cardiac Testing
Comparison of test modalities by sensitivity and specificity:
Test Modality
Sensitivity
Exercise Stress
Specificit
y
66%
84%
82-85%
84%
Exercise Stress Cardiolite
90%
81%
Dobutamine Stress Echocardiography
80%
84%
Dobutamine Stress Contrast
Echocardiography
79%
76%
Dobutamine Stress Cardiolite
82%
75%
Dobutamine Stress Cardiac MRI
86%
86%
Vasodilator Cardiolite
89%
65%
Exercise Stress Echocardiography
25
Noninvasive Cardiac Testing
• Exercise Stress
– Regular Graded Exercise Test (GXT) appropriate
for low risk patients with low pretest probability
by clinical history
– Sensitivity too low for moderate to high risk
patients with moderate to high pretest
probability by clinical history
Noninvasive Cardiac Testing
• Exercise Stress
From: ACC/AHA 2002 Guideline Update for Exercise Testing
Noninvasive Cardiac Testing
Exercise stress imaging
• Why imaging?

Greater sensitivity and specificity
28
Noninvasive Cardiac Testing
Exercise stress imaging
• Why exercise over pharmacologic?

Provides physiologic assessment of:
Ischemia
Hemodynamic performance
Functional capacity
Correlation to symptoms
Prognosis
Greater sensitivity and specificity






29
Noninvasive Cardiac Testing
Comparison of test modalities by sensitivity and specificity:
Test Modality
Exercise Stress
Specificit
y
66%
84%
82-85%
84%
Exercise Stress Cardiolite
90%
81%
Dobutamine Stress Echocardiography
80%
84%
Dobutamine Stress Contrast
Echocardiography
81%
76%
Dobutamine Stress Cardiolite
82%
75%
Dobutamine Stress Cardiac MRI
86%
86%
Vasodilator Cardiolite
89%
65%
Exercise Stress Echocardiography (±
Contrast)
30
Sensitivity
Noninvasive Cardiac Testing
Comparison of test modalities by sensitivity and specificity:
specificity:
Test Modality
Sensitivity
Exercise Stress
Specificit
y
66%
84%
82-85%
84%
Exercise Stress Cardiolite
90%
81%
Dobutamine Stress Echocardiography
80%
84%
Dobutamine Stress Contrast
Echocardiography
81%
76%
Dobutamine Stress Cardiolite
82%
75%
Dobutamine Stress Cardiac MRI
86%
86%
Vasodilator Cardiolite
89%
65%
Exercise Stress Echocardiography
31
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Echocardiography
– advantages: faster, cheaper, more structural
information, higher specificity than Cardiolite®
– disadvantages: limited by acoustic factors, less
sensitive with pre-existing wall motion
abnormalities
32
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Echocardiography
– For detection of CAD by exercise induced wall
motion abnormalities in normal hearts:
• Sensitivity: 78%
• Specificity: 100%
33
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Contrast Echocardiography
– Definity® (synthetic
perflurocarbon
microspheres IV)
34
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Contrast Echocardiography
• improves sensitivity
• enhances subendocardial border
• 10-20% of patients with suboptimal
echocardiogram can undergo SCE with results
comparable to SE in patients with adequate
echocardiograms
• SCE approaches capabilities of nuclear
myocardial stress perfusion imaging
35
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Contrast Echocardiography
– contrast contraindicated in:
• severe hepatic or pulmonary disease
• known major intracardiac shunt
• severe allergic reaction
– adverse events extremely rare (1:10,000)
36
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Contrast Echocardiography
– contrast well tolerated
– side effects in clinical trial (N=279)
• headache (5.4%)
• nausea/vomiting (4.3%)
• flushing (3.6%)
• dizziness (2.5%)
• hypersensitivity in one patient (0.3%)
37
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Nuclear Myocardial
Perfusion Imaging
– IV injections of
radiopharmaceutical
tracer
– image acquisition with
gamma camera
38
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Nuclear Myocardial
Perfusion Imaging
Cardiolite®
Cardiolite® (99mTc - sestimibi)
– Less scatter
– More counts
– Faster image acquisition
39
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Nuclear Myocardial
Perfusion Imaging
Thallium (201Tl)
– Viability assessment
– Cheap
– Logistical challenges
– Image quality
40
Noninvasive Cardiac Testing
Exercise Stress Imaging:
Imaging:
• Stress Nuclear Myocardial
Perfusion Imaging
– Comparing rest and post-stress
images for inducible perfusion
defects as indication of flow
limiting coronary artery disease
Two head gamma camera
41
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
Pharmacologic stress agents:
• Dobutamine
– positive inotrope and chronotrope
– induces ischemia when obstructive CAD present
– beta blockers attenuates effects; reduces
sensitivity
– reversed by beta blockers
43
Noninvasive Cardiac Testing
Pharmacologic stress agents:
• Dobutamine
– contraindications: severe hypertension,
hypotension, uncontrolled arrhythmia.
– side effects: palpitations, paresthesias, nausea,
sensation of urinary urgency, may precipitate
ectopy, hyper/hypotension
– may be used in conjunction with atropine to
achieve target heart rate*
*unless contraindicated with
glaucoma or obstructive
uropathy present
44
Noninvasive Cardiac Testing
Pharmacologic vasodilator agents:
• Persantine (dipyridamole)
• Adenoscan (adenosine)
• Lexiscan (rogadenoson)
– coronary vasodilators revealing underlying
obstruction through relative perfusion defects
– caffeine within 24 hours attenuates sensitivity
– xanthine containing drugs with 3 days may reduce
sensitivity
45
Noninvasive Cardiac Testing
Pharmacologic vasodilator agents:
• Lexiscan (rogadenoson)
– A2A adenosine receptor agonist
– coronary vasodilator
– produces and maintains maximal hyperemia
quickly for optimal duration practical for
radionuclide myocardial perfusion imaging
– 2-3 minute half life allows single bolus
46
Noninvasive Cardiac Testing
Pharmacologic vasodilator agents:
• Lexiscan (rogadenoson)
– Contraindications:
• 2° or 3° AV block
• sinus node dysfunction
unless these patients have a functioning artificial pacemaker
47
Noninvasive Cardiac Testing
Pharmacologic vasodilator agents:
• Lexiscan (rogadenoson)
– Warnings/Precautions
• myocardial ischemia
• SA and AV Nodal Block
• hypotension
• bronchoconstriction
48
Noninvasive Cardiac Testing
Pharmacologic vasodilator agents:
• Lexiscan (rogadenoson)
– LBBB recommendation:
• When preexisting LBBB or paced rhythm,
vasodilator nuclear myocardial perfusion
imaging is preferred
• Dobutamine may be substituted
– validation: single small study data
49
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
•Alternate modalities
– Cardiac Magnetic Resonance
• MRI using dobutamine stress
• alternative to nuclear and echo stress imaging
51
Noninvasive Cardiac Testing
• Alternate modalities
– Cardiac Magnetic Resonance
52
Noninvasive Cardiac Testing
• CMR Indications
– Dobutamine stress testing where nuclear or echo
imaging problematic
– LV volumes, mass & EF
– Myocardial infarction & viability
– Arrhythmogenic Right Ventricular Dysplasia
– Evaluation of cardiac masses, thrombus
– Congenital heart disease, anomalous coronaries
– Aortic pathology
– Pericardial pathology
53
Noninvasive Cardiac Testing
• CMR Limitations
–
–
–
–
–
Time consuming
Dobutamine stress only
Prior authorization requirement
Claustrophobia
No ferrous metal
54
Noninvasive Cardiac Testing
• Alternate modalities
– Cardiac CT angiography
• permits definition of cardiac structures
including coronary arteries
55
Noninvasive Cardiac Testing
• Alternate modalities
– Cardiac CT angiography
• Example of a proximal right coronary artery
high grade lesion
56
Noninvasive Cardiac Testing
• Cardiac CT Indications
– Patients with an equivocal or a possible false
positive or false negative stress test
– Prior positive stress test or known disease where a
repeat stress test would remain abnormal (limiting
sensitivity for disease in another coronary
distribution)
57
Noninvasive Cardiac Testing
• Cardiac CT Indications
– Risk assessment in the elderly or those reluctant to
undergo coronary angiography
– Follow-up on old CABG
– New left main stent or early post-stent chest pain
58
Noninvasive Cardiac Testing
• Cardiac CT Contraindications
– atrial fibrillation
– renal insufficiency with other test options
– young women with other test options
(avoid extra radiation)
– highly calcified arteries
– asymptomatic screening
59
Noninvasive Cardiac Testing
• Cardiac CT Limitations
–
–
–
–
radiation
contrast
anatomic rather than physiologic assessment
if significantly abnormal, may still need additional
cath
60
Noninvasive Cardiac Testing
CT Coronary Angiography
Images courtesy of Dr. Glenn Albin
61
Noninvasive Cardiac Testing
CT Coronary Angiography
Images courtesy of Dr. Glenn Albin
62
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Noninvasive Cardiac Testing
Conditions precluding stress testing
•
•
•
•
unstable angina/ACS
MI < 72 hrs without revascularization and/or
risk factors for myocardial free-wall rupture.
decompensated CHF
unstable rhythm: VT / VF
Consider consultation
64
Noninvasive Cardiac Testing
Conditions precluding stress testing
•
•
•
•
•
•
unstable medical condition
uncontrolled HTN
neurologic injury
outflow obstruction: HOCM, severe/critical AS
pericardial disease: pericarditis, cysts, tumors
cardiac vegetations/endocarditis
Consider consultation
65
Noninvasive Cardiac Testing
Limitations to exercise
•
•
•
•
•
morbid obesity
severe limiting pulmonary disease
neuromuscular limitation
orthopedic limitation
gait instability or vertigo
•
limiting claudication
Pharmacologic Test
66
Noninvasive Cardiac Testing
Clinical Pitfalls to Avoid
•
•
•
•
lack of consent
NPO less than four hours
Nitroglycerin IV within last four hours
lack IV access for pharmacological or nuclear
imaging test
67
Noninvasive Cardiac Testing
Clinical Pitfalls to Avoid
in vasodilator nuclear MPI
•
caffeine < 24 hours of vasodilator nuclear
Soft drinks, coffee, chocolate, Anacin, Excedrin, NoDoz, Darvon, Caffregot or Fiorinal
•
xanthine < 3 days of a vasodilator nuclear
– Theodur, Theophylline, Slo-bid, Respid or Trental
68
Noninvasive Cardiac Testing
Clinical Pitfalls to Avoid
in vasodilator nuclear MPI
•
•
•
•
severe brochospastic disease
on dipyridamole, theophylline, aminophylline
known cerebral aneurysm
hypotension
69
Noninvasive Cardiac Testing
Clinical Pitfalls to Avoid
in dobutamine stress testing
•
•
•
•
on dobutamine
on beta blockers (should be held)
susceptible rhythm derangements
MI <72 hrs without PCI
70
Noninvasive Cardiac Testing
Stress and Imaging Choices
• Exercise test
• Exercise Imaging tests
– Nuclear
– Echo
• Pharmacologic tests
– Nuclear
– Echo
– MRI
(vasodilator or dobutamine)
(dobutamine)
(dobutamine)
71
Noninvasive Cardiac Testing
Rule 1
• Clinical history
determines indication
& direction of
evaluation
72
Noninvasive Cardiac Testing
Rule 2
• Consider whether
exercise stress test is
appropriate to clinical
risk or if imaging is
required
73
Noninvasive Cardiac Testing
Rule 3
• In imaging tests, exercise is
preferred over pharmacologic
exception: LBBB, paced
74
Noninvasive Cardiac Testing
Rule 3a
• Exercise stress to an adequate level is
generally superior in sensitivity to
pharmacologic testing
• Exercise stress yields hemodynamic
data, symptom correlation, estimation of
exercise tolerance
75
Noninvasive Cardiac Testing
Rule 3b
• Pharmacologic tests should be reserved
for those unable to exercise adequately to
answer clinical question
76
Noninvasive Cardiac Testing
Rule 4
• Chose pharmacologic
test based on patient
clinical profile
77
Noninvasive Cardiac Testing
Rule 4a
• Vasodilator superior to dobutamine
in nuclear MPI
–
–
–
–
78
Less time consuming
Better tolerated
Better sensitivity
Preferred method with LBBB or paced rhythm
when testing for ischemia
Noninvasive Cardiac Testing
Rule 4b
• If vasodilator preferred,
– Rule out contraindications to vasodilator and
instruct patient to avoid all caffeine products for
24 hours and xanthine containing agents for 3
days
• If dobutamine preferred,
– Rule out contraindications to dobutamine and to
hold beta-blockers/Ca++ channel blockers 12-24
hours before test if clinically appropriate
79
Noninvasive Cardiac Testing
Rule 5
• Select imaging method most
appropriate for each patient clinical
profile
– Cardiolite® better at:
– prior MI, COPD
– Echo better at:
– coexistent valve disease, hypertensive heart
disease or other structural heart disease
– CMR best when:
– neither Cardiolite® nor echo is adequate
80
Noninvasive Cardiac Testing
Noninvasive Cardiac Testing
Step 1:
1: Can Patient Exercise?
Yes
No
Treadmill Stress Test
Pharmacologic Imaging Test
Step 2
•Abnormal EKG
•LVH
•Digoxin, Beta Blockers, Calcium Channel Blockers
•Pre-menopausal women
•Prior equivocal stress tests
•Prior stents, CABG, MI
Yes
No
Exercise Imaging Test
Graded Exercise Test
Step 3
Noninvasive Cardiac Testing
Step 2: Which Pharmacologic Imaging Test?
Does patient have Reactive Airway Disease
(Asthma or Inhaler/Steroid Dependant)?
Yes
No**
Dobutamine
Echo
Nuclear
Vasodilator
MRI
Nuclear
**LBBB: Recommend Vasodilator Nuclear unless evaluating exertional symptoms
Dobutamine MRI Stress Test can provide additional information about viability. Can
also detect associated structural abnormalities, pericarditis, myocarditis, presence of
previous non-transmural infarcts (may not be detected by Nuclear stress in 50% of
patients with previous infarcts).
Noninvasive Cardiac Testing
Step 3: Which Exercise Imaging Test?
Does patient have any of the following:
•COPD
•Technically Difficult Echo
•Resting Wall Abnormality
Yes
Nuclear Stress*
* Stress contrast echo may be utilized in
select circumstances
No
Stress Echo
Noninvasive Cardiac Testing
Available at Essentia Health 27th Annual Heart and Vascular
Conference – see conference staff in lobby for brochure.
Noninvasive Cardiac Testing
• Test selection
– Algorithms: old and new
– Choosing stress & imaging modalities
• Why exercise over pharmacologic?
– Exercise stress
– Exercise stress imaging
• Why pharmacologic over exercise?
– Pharmacologic stress imaging
– Pharmacologic vasodilator imaging
– Alternative modalities
– Clinical pearls
• Case presentations
Essentia Health Heart
& Vascular
Center
Noninvasive
Cardiac
Testing
Noninvasive Cardiac Laboratory
__________________________________________________________________________________________
•
•
•
•
Stress Lab
Echo Lab
Supervisor:
Directors:
218-786-4457
218-786-4456
Ms. Leslee Peterson
(NCL) Andrew Chiu, MD, FACC
(Echo) Nizar Saleh, MD, FACC
87
Noninvasive Cardiac Testing
A Practical Guide to Selecting
Cardiac Stress Testing
Andrew C. Chiu, MD, FACC
Noninvasive Cardiovascular Laboratory
Essentia Health Heart & Vascular Center
Cente