1. Stress Testing and You: A Guide for the Interventionalist Matthew Schumaecker, MD Carilion Clinic April 7, 2014

2. Disclosures I read stress tests for a living The only reason I am not an interventionalist:

3. Trends in PCI

4. Trend in Nuclear Stress Test Results Rozanski et al J Am Coll Cardiol. 2013;61(10):1054-1065

5. Part I: Why do We Perform Stress Tests? Diagnose coronary disease? Avoid lawsuits? Make money?

6. You Can’t Cath Everyone with Chest Pain!

7. Stress Testing for Detection of CAD

8. Are we really trying to predict CAD? If not, what are we doing here?

9. Why Detecting (asymptomatic) CAD Might Not Matter

10. Why Detecting (Asymptomatic) CAD Might Not Matter

11. All-Cause Mortality — As Randomized HR 0.86 (0.72, 1.04) P = 0.123 HR 0.86 (0.72, 1.04) P = 0.123 0.46 0.41

12. Is there any role to stress testing asymptomatic individuals? NOT USUALLY

13. “Special” Asymptomatic Indications Consideration for class Ic antiarrhythmic Newly diagnosed cardiomyopathy CT calcium score > 400 Agatston units MAYBE – high risk (>20%/10 year) diabetics

14. Cumulative Event-Free Survival by SPECT Degree of Normalcy Hachamovitch R, Berman DS, Shaw LJ, et al. Circulation. 1998 Feb 17;97(6):535-43. n=5534

15. Elhendy et al Cumulative Event-Free Survival by Stress Echo Degree of Normalcy

16. Cardiac Death Rate Stratified by Revascularization vs. Medical Therapy and by SPECT Degree of Normalcy Hachamovitch R, Berman DS, Shaw LJ, et al. Circulation. 1998 Feb 17;97(6):535-43. Black boxes – Medical Therapy White boxes – Revascularization

17. Incremental Prognostic Value of MPI Hachamovich et al. Circulation. 2002 Feb 19;105(7):823-9

18. Incremental Prognostic Value of Echo Marwick J Am Coll Cardiol.Marwick J Am Coll Cardiol. 1997 Jul;30(1):83-90.

19. Prognostic Value of an Equivocal Study Berman DS, Hachamovitch R, Kiat H, et al. J Am Coll Cardiol. 1995 Sep;26(3):639-47.

20. Part II: Advances in Nuclear Cardiology

21. PET Advantages of PET over SPECT – Higher energy resolution – Mandatory attenuation correction – Quantification of coronary blood flow Disadvantages of PET over SPECT – Camera is MUCH more expensive – Radioisotopes are very short-lived

22. SPECT vs PET Tc 99m 140 keV ɣ ray F 18 E=mc 2 511keV photon 511keV photon e-e- β+β+

23. Cardiac PET Half life of currently utilized cardiac PET perfusion agents: AgentT 1/2 N-13132 seconds O-15148 seconds Rb-8275 seconds

24. Cardiac PET 18 F Fludeoxyglucose has t 1/2 of 110 minutes BUT This is a viability agent, not a perfusion agent

25. 18 F-Flurpiridaz PET Jamshid Maddahi, M.D., FACC, FASNC, and René R. S. Packard, M.D.

26. 123 I-BMIPP 99m Tc can be used to evalulate chest pain at rest but only if patient is having pain at the time.

27. Cardiac Memory Myocytes preferentially metabolize FFA In ischemia millieu, switch to glycolysis

28. Cardiac Memory Substrate switch can last up to 24 hours If injected with 123 I-BMIPP, SPECT images will show defect if patient has been ischemic within 24 hours Dilsizian et al, Circ 2005;112:2169-2174

29. BMIPP Trial J Am Coll Cardiol. 2010 Jul 20;56(4):290-9

30. D-SPECT

31. CZT Much more photosensitive than Na-I

32. Stress First/Only 60-70% nuclear studies normal If stress images are normal, rest images are not clinically valuable In lower risk patients, we could do stress imaging and only if abnormal bring back for rest

33. Radiation Exposure Normal BMI ProcedureRadiation Exposure Dual Isotope Imaging traditional SPECT24mSv Same Isotope (Tc-Tc) Imaging/ traditional SPECT 12mSV Same Isotope (Tc-Tc) Imaging / D-SPECT4 mSv Stress Only (Tc) / D-SPECT1 mSv

34. Part III: Discuss