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Cardiac Testing Pete Bell, MD in collaboration with Julia Smith, FLMI Cardiac Testing Heart Anatomy Who needs cardiac testing? Clinically: New onset of chest pain, dyspnea Pre-operative evaluation Elderly Special occupation (pilot, police officer, bus driver) In presence of known risk factors for heart disease Known heart disease. Who needs cardiac testing? Underwriting--Applicants Age and amount (ECG/ Treadmill for older ages/ higher face amounts) Abnormal resting ECG History of heart disease Cardiac Testing: pros and cons Cardiac Test Pros Cons Resting ECG Non-invasive/Easy/Portable 5-10 min Low sensitivity/Low specificity Holter Monitor Evaluates arrhythmia Painless/Non-invasive Wear for a few days Can’t take off/bathe Exercise ECG aka Stress Test aka Treadmill test Easy/Available Duration of exercise Inducible Changes False positives Nuclear Stress Test aka Perfusion study aka SPECT akaThallium/Cardiolite/ Myoview Often follows an abnormal resting ECG; Good sensitivity/specificity Evaluates blood flow at rest and at exercise False Positives – chest wall attenuation Invasive/radiation Costly Stress Echo Often follows an abnormal stress test; Anatomy/function before and after stress Technical difficulties Intra and Inter Observer Variation Cardiac Testing: pros and cons Cardiac Test Pros Cons M-mode Echo Non invasive/Portable Anatomy/Structure/Function More expensive Technical difficulties 2D/3D Echo Non invasive, Anatomy/Structure/Function in fuller view, safe Technical difficulties Transesophageal Echo aka TEE Clear, high quality, precise image, visualize LAE, clot, mitral value and LV More invasive/mild anesthesia CT Angiography or heart scan Detailed view of arteries Quick (pictures in 5-10 sec) Non invasive Substitute for catheterization unless surgery contemplated EBCT Electron beam computer tomography, calcium scan Non Invasive/painless/quick Early atherosclerosis Radiation, over sensitive $200-500 out of pocket Catheterization The “gold standard”, CABG/Stent Invasive, complications: bleeding, arterial damage Labs (Troponin, cardiac enzymes, pro-BNP, C-reactive protein) Troponin very sensitive indicator of myocardial damage, pro-BNP indicative of myocardial disease High dose radiation (equivalent to 600 CXRs) Expensive ($1000) Poor images when increased Ca deposit, obese patients or CKD Pro-BNP has poor sensitivity and specificity, CRP non-specific marker, Does chest pain mean heart disease? Common causes of chest pain: Angina due to coronary artery disease, spasm, syndrome X Heart Attack Mitral Valve Prolapse Pericarditis Recent chest trauma Peptic Ulcer Aortic dissection Atypical chest wall pain Anxiety or panic disorder Asthma, bronchitis, pneumonia, pleuritis Gastrointestinal If chest pain is new onset, worsening, accompanied with chest tightness, dyspnea or risk factors associated with heart disease, then getting an ECG is the first step to evaluate. If chest pain is chronic or recurrent, angina due to coronary artery disease is a possibility and treadmill testing is the first step Chest Pain in Males In men: Men delay evaluation and treatment. Musculoskeletal, respiratory, GI CAD symptoms classic: Exertional chest pressure Dyspnea, nausea and vomiting CAD risk factors remain very powerful prognosticators: Chest Pain in Females In women: Coronary artery disease onset is typically ten years later than men Chest pain often due to other causes – Mitral Valve Prolapse – Musculoskeletal, respiratory, gastro-intestinal Symptoms of coronary artery disease may not be classic: – Mid back pain – Nausea and vomiting Risk factors for coronary artery disease remain very powerful prognosticators: Risk Factors for Coronary Artery Disease Tobacco exposure-includes cigarette/cigar smoking/chewing tobacco/secondhand cigarette smoke Dyslipidemia Hypertension Diabetes Obesity Physical inactivity and low fitness Family history of cardiovascular disease in 1-st degree relative < 55 years old in men < 65 years old in women Medical Case #1 55 year old female, applying for 2.5 million of life insurance Exam :BP 135/85, 5.5/145, no pertinent physical findings, family history negative for CAD Labs: total cholesterol 217, HDL = 58, Ratio = 4.2 glucose 109, HOS WNL Minor ST-T changes on ECG Present History: – Sharp, fleeting (less than a minute) chest pain, onset 2 months ago – No shortness of breath, no palpitations. – Non-positional, stops spontaneously Past Medical History: – Mild osteoarthritis – Hypertension, treated x five years – Meds: Dyazide, Lisinopril and Aspirin as needed – Non-smoker Probability of Disease Medical case #1 Offer, postpone for additional testing? ECG abnormalities Major ST-T changes may give the appearance of ischemia even if NO real ischemia is present. Juvenile T Waves can be a normal variant-mostly seen in young healthy females, persistently negative T wave leads V1-V3, usually not deeply inverted. Major T wave inversions – ischemia or LVH Minor T wave changes potential causes: CAD * Obesity * Electrolyte Imbalance-Hypokalemia * Hyperventilation * Hypothyroid * Medication Non specific ST changes are not diagnostic Probability of Disease 1 in 10 chance of coronary heart disease Risk Assessment Low risk for CAD Medical case #2 Same applicant, 55 year old female, applying for 2.5 million of life insurance Same Minor T changes on insurance resting ECG. Producer is concerned. Medical Case #2 How to improve the offer? Stress test? Bruce Protocol Stage Minutes % grade km/h MPH METS 1 3 10 2.7 1.7 4.7 2 6 12 4.0 2.5 7.0 3 9 14 5.4 3.4 10.1 4 12 16 6.7 4.2 12.9 5 15 18 8.0 5.0 15.0 6 18 20 8.8 5.5 16.9 7 21 22 9.6 6.0 19.1 METS and activity level 2-3 Walking at a slow pace ,Playing musical instrument, Dancing (slow), Golf using power cart, Bowling, Fishing 4-5 Walking at a very brisk pace , Climbing stairs, Dancing (moderately fast), Bicycling <10 mph, leisurely, Slow swimming, Golf, carrying clubs 6 Slow jogging (one mi/ 13 to 14 min) , Ice or roller skating, Doubles tennis (if you run a lot) 6-8 Rowing, canoeing, kayaking vigorously, Dancing (vigorous), Some exercise apparatuses 7-12 Singles tennis, squash, racquetball 8 Jogging (1 mile every 12 min), Skiing downhill or cross country 10 Running 6 mph (10-minute mile) 13.5 Running 8 mph (7.5-minute mile) 16 Running 10 mph (6-minute mile) Poor prognostic findings on Stress Test Low workload Mets <6.5 Time: < 5-6 minutes on Bruce protocol Low peak Heart Rate Pulse < 120 without Beta-Blocker therapy Systolic Blood Pressure decreased or flat response Remains under 130 mmHg ST segment depression >2mm ST segment depression in multiple leads Prolonged ST depression after Exercise (>6 min) ST Elevation without abnormal Q wave Increase in complex ventricular ectopy Exercise induced typical Angina Frequent ventricular ectopy Medical case #2 Same applicant, 65 year old female, applying for 2.5 million of life insurance Same Minor T changes on insurance resting ECG. How to reconsider the offer? Minor ST changes on ECG=> Negative stress ECG Producer no longer concerned Medical case #3 Same applicant, 55 year old female, applying for 2.5 million of life insurance Sharp, fleeting (less than a minute) chest pain, onset 2 months ago no dyspnea or palpitations ECG with minor ST-T changes Standard treadmill test performed to consider for improved offer, but it comes back with 1- 2 mm ST depression at 7 METS exercise. Stress Test Tracing Medical case #3 Minor ST changes on ECG=> Positive stress ECG Now what? Probability of Disease Post-Test Probability Post Test probability of disease is now 47% Post-Test Decision Flip a coin Medical Case #2 Oh boy, what now? Stress Echo? Perfusion Stress Test? Stress test, Stress Echo, Nuclear stress If the treadmill is equivocal or positive -- a stress perfusion treadmill or stress echocardiogram can be performed to investigate further. If the workload on the follow up stress perfusion/echo is equal to or higher than that achieved on the original treadmill, then follow up stress perfusion/ echo results are considered valid. Stress Echo The echocardiogram is a cardiac ultrasound performed at rest and after exercise. It shows the structure of the heart valves chambers size and wall motion function wall thickness wall motion during exercise - abnormal may be indicative of ischemia. Stress Echo Nuclear stress AKA - Perfusion study, Cardiolite study, Nuclear Test, Thallium Study, Myocardial Perfusion Imaging (MPI), Stress SPECT. involves injecting a radioactive tracer into the bloodstream obtains images of the heart using a gamma camera. pictures are taken shortly after exercise and then after resting for 2/3 hours If the perfusion is normal during rest, but diminished following exercise, the results are consistent with a obstruction in one or more coronary arteries. If the test shows reduced perfusion during both rest and exercise, then the blood flow is limited at all times and is consistent with a prior myocardial infarction Stress Echo 6.0 minutes – stage II of Bruce protocol BP 173/98 Max HR = 159 7 METS Stopped because target heart rate achieved No chest pain or palpitations Echo showed no wall motion abnormalities, normal wall thickness, chamber size and valves Post-Test Probability Post Test probability of disease is 10% Risk Assessment Low risk for CAD Happy Producer Medical case - #4 70 year old male, non smoker applying for $500,000, Term 5.6, 180 lbs 130/86, 140/80, 130/70 Ins labs 4/12 - Chol 171, ratio 3.4, HDL = 48. LDL 104 Meds – Vytorin, Lisinopril History of hypertension, hyperlipidemia, OSA treated with CPAP Family history – non contributory Medical case - #4 APS: 1/11/11 – Asymptomatic, resting ekg read as previous inferior myocardial infarction 1/17/11 – treadmill to 10 METS, stopped due to MPHR, no symptoms, normal BP response. NSSTW changes on tracings, SPECT scan => normal wall motion and thickness, mild inferior defect, can not exclude attenuation. 1/18/11 - Cath => 20 – 30% LM lesion, can not exclude catheter induced spasm, 30 – 40% mid – LAD lesion, 90% distal LAD lesion with collateral flow. MD notes “no significant CAD, continue with clinical treatment” Cardiac Catheterization Coronary Artery Catherization Diagnostic gold standard. Invasive Bleeding Arterial damage Infection Also, can be therapeutic Stent Percutaneous Transluminal Coronary Angiography Rate of progression Hard to predict Evidence of regression Satins ACE inhibitor Exercise Favorable Factors Coronary Artery Stenosis CAD Significance over 50% plaque obstruction coupled with typical angina symptoms at the bifurcation of 2 major (e.g.,LAD and Circumflex) or a major and second-level (LAD and obtuse marginal ) vessel. 20 mm or greater in length in that it usually impedes flow reserve regardless caliber. the report of “no flow-limiting lesions” has to be taken into context with risk factors and symptoms. lesions < 50%, more significance for women than men, as women are more prone to coronary artery spasm diffuse small lesions are fairly innocuous only in the elderly or at any age if risk factors are meticulously controlled. lesions as they appear on cath are smaller when actually seen, so the presence of symptoms are important to assess the significance. Catheterization Medical case - #4 - Solution 70 male with stable CAD per MD notes, good control of blood pressure and lipids. The cath is equivocal for LM disease. Definite mid-LAD obstruction and a significant distal lesion. Assuming the reason there is no obstruction to blood flow is due to collateralization, as otherwise a lesion that size would obstruct proximal flow. MD is continuing with clinical treatment only and doesn’t note CAD as significant. Moderate risk of disease Summary Look at the likelihood of disease being present: Consider the history, symptoms and risk factors to develop a sense of whether or not disease is present. And if so, what disease it is it? Look at the studies: Does one appear better quality? Full versus sparse descriptions, etc. A better quality testing labs? Referral center versus private office? What about the tests? One is very positive while the other may be more ambiguous. Draw a conclusion: No risk factors and the negative tests are more accurate, while the positive tests are more likely false positive Many risk factors and the positive tests are more accurate, while the negative tests are more likely to be false negative Consider the probability of disease being present. It may not be what you think! Questions