CHEST PAIN Evaluation and Diagnostic Testing Jerome Yatskowitz, MD Assistant Professor, Division of Cardiology University of New Mexico Health Sciences Center

OUTPATIENT PRESENTATION CHEST PAIN 52 YEAR OLD FEMALE SHARP, RIGHT SIDED CHEST PAIN, REST/NOT EXERTIONAL LASTING 1 TO 2 MINUTES COMES AND GOES NO H/O CAD HTN, Mother MI age 52 PHYSICAL EXAM NORMAL WITH CHEST PAIN REPRODUCED BY PALPATION ECG NORMAL

WHAT WOULD YOU RECOMMEND FOR YOUR PATIENT? EXERCISE ECG TREADMILL STUDY EXERCISE STRESS ECHO RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST CT CORONARY ANGIOGRAM REASSURANCE WITH NO FURTHER TESTING

OBJECTIVES EVALUATE THE CHARACTERISTICS OF AGE, GENDER, CHEST PAIN QUALITY AND RISK FACTORS IN THE ASSESSMENT OF PATIENT PRESENTING WITH CHEST DISCOMFORT IDENTIFY LOW, INTERMEDIATE, AND HIGH RISK PATIENTS WITH CHEST PAIN APPLY THESE PRINCIPLES FOR OPTIMAL EVALUATION AND TESTING DIFFERENTIATE AMONGST THE MULTIPLE STRESS TESTING AND DIAGNOSTIC MODALITIES

CHEST PAIN IN THE OUTPATIENT SETTING HISTORY, PHYSICAL EXAM, AND AVAILABLE TESTS BENIGN TO LIFE THREATENING MOST COMMON ARE GI 20% AND MUSCULOSKLELETAL 50% CARDIAC STABLE 10%.  OUTPATIENT ACUTE 2-4%  ED

LIFE THREATENING CONDITIONS ACUTE CORONARY SYNDROME ACUTE AORTIC DISSECTION PULMONARY EMBOLISM TENSION PNEUMOTHORAX PERICARDIAL TAMPONADE ESOPHAGEAL RUPTURE

HISTORY AGE SEX CHEST PAIN QUALITIES CARDIAC RISK SCORES

DIAGNOSTIC STRESS TESTING PRETEST PROBABILITY OF DISEASE ESTIMATE OF THE LIKELIHOOD OF CAD BASED ON AGE, GENDER, SYMPTOMS (CHEST PAIN CHARACTERISTICS), AND CLINICAL HISTORY (HTN, DM, LIPIDS) PRE TEST PROBABILITY  POST TEST LIKELIHOOD OF DISEASE PRE TEST PROBABILITY DETERMINES THE NEED AND OPTIMAL TEST LOW PRE TEST PROBABILITY (POSITIVE TEST LIKELY TO BY FALSELY POSTIVE) PRE TEST PROBABILITY STRESS TESTING MOST USEFUL IN PATIENTS WITH INTERMEDIATE PRESTEST PROBABILITY STRESS TESTING LESS USEFUL IN PATIENTS WITH HIGH PRE TEST PROBABILITY (NEGATIVE TEST LIKELY TO BE FALSELY NEGATIVE)  CONSIDER FOR RISK STRATIFICATION AND/OR INVASIVE TESTING

CLINICAL SCENARIO 59 YEAR OLD FEMALE SUBSTERNAL CHEST PRESSURE RADIATING TO LEFT ARM LASTING UP TO 15 MINUTES OCCURING AT REST WITH RELIEF WITH HUSBAND’S NTG. NO CARDIAC HISTORY H/O HTN, DM, TOBACCO PHYSICAL EXAM NORMAL ECG LVH WITH REPOLARIZATION ABNORMALITY

WHAT WOULD YOU RECOMMEND FOR YOUR PATIENT? EXERCISE ECG TREADMILL STUDY EXERCISE STRESS ECHO RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST CT CORONARY ANGIOGRAM REASSURANCE WITH NO FURTHER TESTING

STRESS TESTING IMPORTANT DIAGNOSTIC AND PROGNOSTIC TOOL IN EVALUATION AND MANAGEMENT OF KNOWN OR SUSPECTED CAD MOST COMMON STRESS MODALITIES EXERCISE ECG – NONIMAGING STRESS IMAGING WITH RADIONUCLIDE MPI OR ECHO DIAGNOSIS OF CAD AND RISK STRATIFICATION SYMPTOM LIMITED EXERCISE PREFERRED ADDITIONAL INFO SYMPTOMS, EXERCISE CAPACITY, HEMODYNAMIC RESPONSE PHARMACOLOGIC STRESS UNABLE TO EXERCISE

CHOOSING THE APPROPRIATE STRESS TEST ABILITY TO PERFORM ADEQUATE EXERCISE RESTING ECG CLINICAL INDICATION FOR PERFORMING THE TEST BODY HABITUS/LUNG DISEASE/BREAST IMPLANTS HISTORY OF PRIOR CAD/REVASCULARIZATION CLINICAL DATA SIDE EFFECTS OF EACH TEST (MPI VASODILATORS VS. DOBUTAMINE) COSTS TEST AVAILABILITY & EXPERTISE RADIATION EXPOSURE ADDITIONAL DESIRED CLINICAL INFORMATION (ECHO)

INDICATIONS FOR STRESS TESTING SYMPTOMS SUGGESTIVE OF ANGINA & INTERMEDIATE TO HIGH RISK PRE TEST LIKELIHOOD OF CAD KNOWN CAD WITH NEW OR WORSENING SYMPTOMS (CLINICAL CHANGE) PRIOR CABG > 5 YEARS AND > 2 YEARS PCI VALVULAR HEART DISEASE SEVERITY ASSESSMENT OF NEWLY DIAGNOSED HEART FAILURE/CARDIOMYOPATHY ARRHTHYMIAS (CHRONOTROPIC INCOMPETENCE; EXERCISE INDUCED ARRHYTHMIAS NON CARDIAC SURGERY

STRESS TESTING NOT INDICATED SCREENING OF ASYMPTOMATIC LOW RISK PATIENTS (RARE EXCEPTIONS PATIENTS WITH MULTIPLE RISK FACTORS/HIGH RISK OCCUPATIONS) LOW RISK PATIENTS WITH ATYPICAL OR NONCARDIAC (NONANGINAL) CP UNSTABLE CAD/ACS NON CARDIAC SURGERY

MODATLITIES TO FOR STRESS TESTING/ASSESSMENT FOR CAD EXERCISE VS. PHARMACOLOGIC EXERCISE ELECTROCARDIOGRAPHIC TREADMILL ECHO NUCLEAR/MYOCARDIAL PERFUSION IMAGING CT CORONARY ANGIOGRAM (CTCA) CARDIAC MRI

CLINICAL SCENARIO 65 YEAR OLD MALE WITH BURNING CHEST DISCOMFORT AWAKES FROM SLEEP WITH DIAPHORESIS DOES ACTIVITIES OF DAILY LIVING BUT NEEDS TO USE STORE MOTORIZED SCOOTER WHEN SHOPS AT WALMART HTN, TOBACCO, DYSLIPIDEMIA, FATHER CABG AGE 68 LOSARTAN, METOPROLOL, SIMVASTATIN ECG NORMAL

WHAT WOULD YOU RECOMMEND EXERCISE ECG TREADMILL STUDY EXERCISE STRESS ECHO RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST CT CORONARY ANGIOGRAM REASSURANCE WITH NO FURTHER TESTING

CHOOSING A STRESS TEST EXERCISE VERSUS PHARMACOLOGIC ALL PATIENTS WHO CAN EXERCISE SHOULD UNABLE TO EXERCISE TO ADEQUATE WORKLOAD  PHARMACOLOGIC STRESS ELECTROCARDIOGRAM (ECG)NORMAL OR ABNORMAL (ECG VS. IMAGING) VENTRICULAR PREEXCITATION (WPW) VENTRICULAR PACED RHYTHM LBBB ST DEPRESSION DIGOXIN LVH WITH REPOLARIZATION ABNORMALITIES

WHICH STRESS TEST? FOR PATIENTS WHO CAN EXERCISE  EXERCISE TESTING WALK > 5 MINUTES ON FLAT SURFACE CLIMB 1 OR MORE FLIGHT OF STAIRS WITHOUT STOPPING VALUABLE INFORMATION BEYOND ECG/IMAGING EXERCISE DURATION, HR RECOVERY, BLOOD PRESSURE INABILITY TO PERFORM EXERCISE IS A MARKER OF INCREASED RISK FOR PATIENTS UNABLE TO EXERCISE.  PHARMACOLOGICAL STRESS TEST TYPICALLY PERFORMED IN PATIENTS UNABLE TO EXERCISE LBBB VENTRICULAR PACED RHYTHM

STRESS TESTING SELECTION PRE TEST LIKELIHOOD OF DISEASE EXERCISE  YES OR NO ECG  NORMAL OR ABNORMAL ACCURACY OF SPECIFIC STRESS TEST EXPERTISE OF YOUR PERFORMING INSTITUTION H/O KNOWN CAD, KNOWN PREVIOUS INFARCT  MPI LUNG DISEASE  ECHO BREAST IMPLANTS/OBESITY  MPI COSTS RADIATION ADVANTAGE OF ADDITIONAL INFORMATION  ECHO

EXERCISE ECG TESTING EFFECTIVELY RISK STRATIFY PATIENTS PHYSIOLOGIC, REPLICATES SYMPTOMS EXERCISE CAPACITY & HEMODYNAMIC RESPONSE PREDICTORS OF PROGNOSIS INABILITY TO EXERCISE ASSOCIATED WITH INCREASED CV RISK NORMAL RESTING ECG REASONABLE FOR WOMEN ANNUAL CARDIAC EVENT RATES IN PATIENT WITH NEGATIVE TEST/LOW RISK SCORE IS <1% SIMPLE, WIDELY AVAILABLE, LOW COST

EXERCISE OR PHARMACOLOGICAL STRESS IMAGING RADIONUCLIDE STRESS MYOCARDIAL PERFUSION IMAGING (MPI) STRESS ECHOCARDIOGRAPHY SIMILAR OVERALL DIAGNOSTIC ACCURACY BOTH BETTER PERFORMANCE THAN EXERCISE ECG PHARMACOLOGIC MPI PREFERRED IN LBBB/VENTRICULAR PACING EVEN IF PATIENT CAN EXERCISE

RADIONUCLIDE MYOCARDIAL PERFUSION IMAGING INFORMATION ON EXTENT, SEVERITY, & LOCATION OF ISCHEMIC TERRITORY INFORMATION ON LV FUNCTION INCREASED SENSITIVITY/SPECIFICITY OVER EXERCISE ECG TREADMILL VASODILATOR (PHARMACOLOGIC) TESTING WHEN UNABLE TO EXERCISE MORE COSTLY EXPOSURE TO RADIATION ARTIFACT ISSUES

STRESS ECHOCARDIOGRAPHY NO RADIATION MORE SENSITIVE AND SPECIFIC THAN EXERCISE ECG TREADMILL INFORMATION ON LV FUNCTION, ISCHEMIC TERRITORY, EXTENT OF ISCHEMIA DOBUTAMINE (PHARMACOLOGIC) IN THOSE UNABLE TO EXERCISE SHORTER TEST THAN RADIONUCLIDE MPI ADDITIONAL INFORMATION READILY AVAILABLE VALVULAR DISEASE, PROXIMAL AORTA DISEASE, PERICARDIAL, PULMONARY HTN LIMITATIONS OF SUBOPTIMAL IMAGING LUNG DISEASE, BREAST IMPLANTS, LARGE BODY HABITUS

CLINICAL DECISION SCENARIO 62 YEAR OLD FEMALE WITH KNOWN CAD, USA WITH PCI TO RCA 2015, NO MI PRESENTING WITH EXERTIONAL SOB ON WALKING UP HILLS ONLY RELIEVED BY REST FOR PAST 3 MONTHS. HTN, DYSLIPIDEMIA, TYPE 2 DM METOPROLOL, LISINOPRIL, ASA, ATORVASTATIN, NTG PRN PE. 2/6 SYSTOLIC MURMUR UPPER RSB ECG. NSR WITH NONSPECIFIC ST & T WAVE ABNORMALITIES

YOUR RECOMMENDATIONS EXERCISE ECG TREADMILL STUDY EXERCISE STRESS ECHO RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST CT CORONARY ANGIOGRAM REASSURANCE WITH NO FURTHER TESTING

DECISIONS TO DIAGNOSTIC STRESS TESTING SOUND CLINICAL JUDGEMENT BENEFITS AND HARMS OF TESTING MEDICAL COMMUNITY CONTINUES TO TEST TOO MANY LOW RISK PATIENTS “NO TEST” IS A CARDIAC TEST THE QUESTION IS NOT WHICH TEST TO ORDER, BUT IS ANY TEST NEEDED REMEMBER BEYOND THE CHEST PAIN EVALUATION, PRIMARY PREVENTIVE MEDICAL THERAPY AND LIFESTYLE MODIFICATIONS

CONCLUSION AGE, GENDER, CHEST DISCOMFORT CHARACTERISTICS, RISK FACTORS PRE TEST PROBABILITY OF CAD.  POST TEST PROBABILITY OF DISEASE LOW, INTERMEDIATE, HIGH RISK OF CORONARY ARTERY DISEASE IS TESTING NEEDED OPTIMAL STRESS TEST EXERCISE, ECG, PHARMACOLOGIC SIDE EFFECTS, RADIATION, H/O CAD, OTHER CLINICAL INFORMATION (ECHO) EVALUATE PATIENT FOR MEDICAL/LIFESTYLE THERAPIES FOR PREVENTION OF CORONARY ARTERY DISEASE

CHOOSING A STRESS TEST: CLINICAL FACTORS CLINICAL DATA SIDE EFFECTS COSTS TEST AVAILABILITY & EXPERTISE BODY HABITUS RADIATION EXPOSURE ADDITIONAL DESIRED CLINICAL INFORMATION (ECHO)