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

2. 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

3. 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

5. 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

6. 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

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

8. HISTORY
AGE
SEX
CHEST PAIN QUALITIES
CARDIAC RISK SCORES

16. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

38. 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

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

40. 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

41. 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

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