BASICS OF STRESS TESTING

Name: BASICS OF STRESS TESTING
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Description: BASICS OF STRESS TESTING

BASICS OF STRESS TESTING
Medicine Conference 6/12/2015 BASICS OF STRESS TESTING BASSEL ARTIN MD Cardiology Many slides are generous courtesy of ENRIQUE GARCIA-SAYAN, MD Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 Lafayette Medical Education Foundation, Inc.

A case for the audience…
Medicine Conference 6/12/2015 A case for the audience… 32 y/o female with pressure-like constant chest pain for 3 weeks, not worsened by exertion or relieved by rest, negative troponins and normal ECG Next step? Reassure Plain (ECG) treadmill stress test Order a “Lexiscan” SPECT Proceed to coronary angiogram Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 A case for the audience… 56 y/o male with pressure-like atypical chest pain for 3 weeks, has h/o DM and HTN. Known LBBB on ECG. Negative Trop. Able exercise. Next step? Reassure Plain (ECG) treadmill stress test Order a “Lexiscan” SPECT Treadmill SPECT Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 A case for the audience… 56 y/o male with pressure-like recurrent chest pain for 2 months, has h/o CAD s/p PCI 2 years ago. Normal ECG Next step? Reassure Plain (ECG) treadmill stress test Order a treadmill Echo stress test Proceed to coronary angiogram Lafayette Medical Education Foundation, Inc.

? “WHAT is it” “HOW is it done” “WHY is it done” “WHEN to order”
Medicine Conference 6/12/2015 STRESS TESTING 101 ? “WHAT is it” “HOW is it done” “WHY is it done” “WHEN to order” “WHICH to order” Lafayette Medical Education Foundation, Inc.

WHAT … is it? Medicine Conference 6/12/2015
Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 INTRODUCTION Stress testing evaluates the cardiovascular reserve response It is used to assess inducible ischemia resulting from obstructive coronary artery disease (CAD) and for assessing prognosis in patients with established CAD. Stress is induced by either physical exercise or pharmacological agents The use of stress tests in the United States has increased steadily Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8e Lafayette Medical Education Foundation, Inc.

how … is it done? Medicine Conference 6/12/2015

+ STRESS IMAGING Exercise Dobutamine Vasodilators: Plain ECG
Medicine Conference 6/12/2015 + STRESS IMAGING Exercise Dobutamine Vasodilators: Adenosine Regadenoson Dipirydamole Plain ECG Echocardiogram MPI: SPECT PET MRI Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 ACC GUIDELINES ACC/AHA statistics 1:2500 patients undergoing stress test can experience MI or death. Perform only with appropriate indications and considerations Requires supervision by trained physician or individual who meets ACC/AHA competency guidelines Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

INDICATIONS FOR EXERCISE STRESS TEST
Medicine Conference 6/12/2015 INDICATIONS FOR EXERCISE STRESS TEST Diagnose suspected CAD in patients with chest pain and normal ECG Assess long term-risk in patients thought to be at intermediate / high risk for significant CAD Evaluate suspected arrhythmias Assess functional ability Evaluate effectiveness of medical/surgical therapy Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

ABSOLUTE CONTRAINDICATIONS
Medicine Conference 6/12/2015 ABSOLUTE CONTRAINDICATIONS Recent AMI (within 48 hrs), Unstable Angina Uncontrolled arrhythmias Severe symptomatic aortic stenosis Uncontrolled symptomatic CHF Acute pulm embolus/pulm infarction Acute aortic dissection/aneurysm Uncontrolled HTN Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

RELATIVE CONTRAINDICATIONS
Medicine Conference 6/12/2015 RELATIVE CONTRAINDICATIONS Left main disease Moderate stenotic valve disease Electrolyte abnormalities Severe HTN (SBP>200mm Hg, DBP>110mm Hg) Tachy/Brady arrhythmias HCM or LVOT obstruction Acute DVT CVA within 3 months Inability to adequately exercise Acute systemic illness (pneumonia, severe anemia…) Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

BRUCE PROTOCOL 220-age= 100% MPHR Need 85% for diagnostic study.
Medicine Conference 6/12/2015 BRUCE PROTOCOL 220-age= 100% MPHR Need 85% for diagnostic study. Low-level or Modified Bruce: Goal 75% MPHR or symptom limited. NPO for 3 hours Must be able to walk treadmill Notify if ICD present No smoking (no nicotine patches) Hold beta blockers, nitrates, certain CCB Comfortable clothing/shoes Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

DIAGNOSTIC ECG CHANGES
Medicine Conference 6/12/2015 DIAGNOSTIC ECG CHANGES Lafayette Medical Education Foundation, Inc.

Pharmacological stress test

ONE DAY Tc99m SPECT PROTOCOL
Medicine Conference ONE DAY Tc99m SPECT PROTOCOL 6/12/2015 Rest injection: mCi Stress injection: mCi Stress ECG gated Heller GV. Nuclear Cardiology: Technical Applications Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 STRESS MPI (SPECT) Heller G, et al. Nuclear Cardiology: Practical Applications, Second Edition Lafayette Medical Education Foundation, Inc.

DOBUTAMINE STRESS PROTOCOL
Medicine Conference DOBUTAMINE STRESS PROTOCOL 6/12/2015 Atropine 3 min min min min Lafayette Medical Education Foundation, Inc.

Stress echocardiography
Medicine Conference 6/12/2015 Stress echocardiography Teboroxime released in 1991, highest extraction rate of all agents but not used clinically Oh, Jae K.; The Echo Manual, 3rd Edition Lafayette Medical Education Foundation, Inc.

INDICATIONS FOR PHARMACOLOGIC STRESS
Medicine Conference INDICATIONS FOR PHARMACOLOGIC STRESS 6/12/2015 Inability to exercise CNS Orthopedic Limited capacity for exercise Poor conditioning / motivation PVD COPD Contraindications to exercise AAA Severe / critical aortic stenosis LBBB / pacemaker / uninterpretable ECG Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 UNINTERPRETABLE ECG Resting ECG abnormalities which render interpretation inconclusive and an additional imaging modality is indicated. Baseline ST segment depressions > 1mm Digoxin WPW Left Bundle Branch Block PPM ECG criteria for LVH with ST depression Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

CONTRAINDICATIONS TO PHARMACOLOGIC STRESS
Medicine Conference 6/12/2015 CONTRAINDICATIONS TO PHARMACOLOGIC STRESS General: Dipyridamole/Adenosine: Hypotension Use of dipyridamole ACS < 24h Severe Asthma or COPD ADHF Allergy to aminophylline Critical AS 2nd or 3d degree AV block Severe LM stenosis Caffeine or methylxanthine < 12 h Severe LVOT obstruction Dobutamine: Hypersensitivity to agent HTN Uncontrolled AF/flutter Large aortic aneurysm B-blockers < 24h Lafayette Medical Education Foundation, Inc.

Vasodilation and Tracer Uptake
Medicine Conference 6/12/2015 Vasodilation and Tracer Uptake Teboroxime released in 1991, highest extraction rate of all agents but not used clinically Braunwald's Heart Disease 8th ed 2007 Lafayette Medical Education Foundation, Inc.

Selective A2A Receptor Agonists
Medicine Conference 6/12/2015 Selective A2A Receptor Agonists Regadenoson (Lexiscan®) Lafayette Medical Education Foundation, Inc.

CARDIAC DRUGS AND IMAGING
Medicine Conference CARDIAC DRUGS AND IMAGING 6/12/2015 If study is to assess therapy / prognosis, all medications should be continued Is study is for diagnosis, DISCONTINUE: Beta blockers (at least 24 h, ideally 48h) Nitrates (24h) Calcium-channel blockers (24h) Metylxantines, Caffeine (12h), Dipyridamole (48h) for vasodilator stress Withdrawal of cardiac drugs must be done on an individual basis and as much as clinically feasible Ask patients to bring their medications Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 WHY … is it done? Does the patient have severe, hemodynamically obstructive coronary artery disease? Is the patient at risk for premature death or an early, major nonfatal cardiac event, such as a large myocardial infarction? Lafayette Medical Education Foundation, Inc.

- DUKE TREADMILL SCORE Exercise time (min) ST change (mm) x 5
Medicine Conference 6/12/2015 DUKE TREADMILL SCORE Exercise time (min) - ST change (mm) x 5 Chest Pain (0-2) x 4 Low risk: ≥+5 Moderate Risk: High Risk: ≤−11 Over 70% male gender Mark DB, et al. Ann Intern Med. 1987;106:793– 800. Lafayette Medical Education Foundation, Inc.

DTS AND SURVIVAL 4-YEAR SURVIVAL DUKE TREADMILL SCORE
Medicine Conference 6/12/2015 DTS AND SURVIVAL 4-YEAR SURVIVAL Validation in 1998 based on cath results, incremental value to history for severe CAD DUKE TREADMILL SCORE Adapted from: Mark DB, et al. N Engl J Med. 1991;325(12): Lafayette Medical Education Foundation, Inc.

FUNCTIONAL CAPACITY PREDICTS MORTALITY
Medicine Conference FUNCTIONAL CAPACITY PREDICTS MORTALITY 6/12/2015 Incremental prognostic information. Annual mortality of <1% when patients can exercise up to stage 3 or higher on the Bruce protocol Laukkanen JA, et al. J Am Coll Cardiol. 2010;56(18): Lafayette Medical Education Foundation, Inc.

DTS AND SURVIVAL 1-YEAR MORTALITY DUKE TREADMILL SCORE
Medicine Conference 6/12/2015 DTS AND SURVIVAL 1-YEAR MORTALITY Validation in 1998 based on cath results, incremental value to history for severe CAD DUKE TREADMILL SCORE Adapted from: Mark DB, et al. N Engl J Med. 1991;325(12): Lafayette Medical Education Foundation, Inc.

WHEN … to order? Medicine Conference 6/12/2015

THE KEY ISSUE OF PRE-TEST PROBABILITY
Medicine Conference 6/12/2015 THE KEY ISSUE OF PRE-TEST PROBABILITY Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 BAYESIAN ANALYSIS Formal way of doing explicitly what most clinicians do implicitly: interpret the results of a diagnostic test in light of the clinical situation. Basic paradigm: What was thought before the test was done combined with the test result → what is thought after the test result In summary: What was thought before the test was done = pretest probability of disease The test result = likelihood ratio (LR) What is thought after = posttest probability Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 POST TEST PROBABILITY Curves plotted for test with 80% sensitivity and 90% specificity. This does not take into account degree of test abnormality. Gibbons RJ. In: Evidence-Based Cardiology, Third Edition Lafayette Medical Education Foundation, Inc.

APPLICATION OF BAYES THEOREM
Medicine Conference 6/12/2015 APPLICATION OF BAYES THEOREM Low probability of CAD (5%) - the positive predictive value of an abnormal test result is only 21%. If 1000 pts tested, 120 will test positive, of which 95 will not have significant CAD. Intermediate probability of CAD (50%), a positive test result increases the likelihood of disease to 83% and a negative test result decreases the likelihood to 36%. High probability of CAD (90%) - a positive test result raises the probability of disease to 98% and a negative test result lowers probability to 83%. Lafayette Medical Education Foundation, Inc.

DIAMOND AND FORRESTER APPROACH
Medicine Conference 6/12/2015 DIAMOND AND FORRESTER APPROACH The simple clinical observations of pain type, age, and gender were powerful predictors of the likelihood of CAD in 4952 subjects undergoing coronary arteriography a 64-year-old man with typical angina has a % likelihood of having significant CAD a 32-year-old woman with non-anginal chest pain has a 1 % chance of CAD Diamond GA, Forrester JS. N Engl J Med 1979;300:1350–1358. Lafayette Medical Education Foundation, Inc.

PRE-TEST PROBABILITY OF CAD
Medicine Conference 6/12/2015 PRE-TEST PROBABILITY OF CAD Age Gender Typical Atypical Non-anginal Asymptomatic 30-39 M 70 22 5 2 W 26 4 1 <1 40-49 87 46 14 6 55 13 3 50-59 92 59 9 79 32 8 60-69 94 67 28 11 91 54 19 Similar results in CASS study, large 15-center study that compared clinical and angiographic findings in more than patients Diamond GA, Forrester JS. N Engl J Med 1979;300:1350–1358. Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 DUKE MODEL Confirmed that age, gender, and chest pain symptoms were the most powerful predictors of CAD Other characteristics also increase the probability including DM, smoking (> 1/2 PPD within 5 y or > 25 pack-years), HL, and history of MI or Q waves on the resting ECG, ST/T changes. 23 clinical characteristics examined in 3,627 consecutive, symptomatic patients referred for cardiac catheterization between 1969 and 1979, 9 found to be important for estimating likelihood of CAD, model applied prospectively to 1,811 patients referred since 1979 Pryor DB, Harrell FE, Lee KL, Califf RM, Rosati RA. Am J Med 1983;75: Lafayette Medical Education Foundation, Inc.

PRE TEST PROBABILITY: CAVEATS
Medicine Conference 6/12/2015 PRE TEST PROBABILITY: CAVEATS Apply prediction rules only in non-ACS settings Rules do not replace clinical judgment Some studies suggest that approach could underestimate PTP in women (esp. young) TIMI / GRACE scores do not determine PTP for CAD, they were developed as a risk-stratification tool in patients with ACS Women ’ s Ischemic Syndrome Evaluation (WISE) Study. Also more microvascular disease causing angina. Evidence nor robust enough to support a new approach. Lafayette Medical Education Foundation, Inc.

WHICh … to order? Medicine Conference 6/12/2015

PROBLEMS WITH PLAIN ETT
Medicine Conference 6/12/2015 PROBLEMS WITH PLAIN ETT In comparison with imaging ETT is thought to have: Limited sensitivity Limited prognostic value Limited accuracy in certain subsets of patients (women) Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 PROBLEMS WITH PLAIN ETT In comparison with imaging ETT is felt to have: Limited sensitivity Limited prognostic value Limited accuracy in certain subsets of patients (women) Lafayette Medical Education Foundation, Inc.

SENSITIVITY AND SPECIFICITY
Medicine Conference 6/12/2015 SENSITIVITY AND SPECIFICITY Speficicity about the same, but specificity about 20% lower in ETT. Huge impact of post-test referral bias which can increase sensitivity and decrease specificity. True sensitivity is not much different once corrected for referral bias. Adapted from: Kim C, et al. Am Heart J. 2001;142(6): Lafayette Medical Education Foundation, Inc.

INCREMENTAL PROGNOSTIC VALUE
Medicine Conference 6/12/2015 INCREMENTAL PROGNOSTIC VALUE Great incremental value considering global chi square but this doen’t tell you what% of pts get re-classified. Other authors have applied a net reclassification index to these studies, there are no additional “high risk” cases detected, and a modest increase in low and intermediate risk cases. Clinical ETT SPECT Clinical ETT echo Hachamovitch R, et al. Circulation. 1996;93(5): Marwick TH, et al. J Am Coll Cardiol. 1997;30(1):83-90. Lafayette Medical Education Foundation, Inc.

DTS AND SURVIVAL 1-YEAR MORTALITY DUKE TREADMILL SCORE
Medicine Conference 6/12/2015 DTS AND SURVIVAL 1-YEAR MORTALITY Validation in 1998 based on cath results, incremental value to history for severe CAD DUKE TREADMILL SCORE Adapted from: Mark DB, et al. N Engl J Med. 1991;325(12): Lafayette Medical Education Foundation, Inc.

INCREMENTAL PROGNOSTIC VALUE
Medicine Conference 6/12/2015 INCREMENTAL PROGNOSTIC VALUE SPECT results: Great incremental value considering global chi square but this doen’t tell you what% of pts get re-classified. Other authors have applied a net reclassification index to these studies, there are no additional “high risk” cases detected, and a modest increase in low and intermediate risk cases. (overall event rate 0.9% Hachamovitch R, et al. Circulation. 1996;93(5): Lafayette Medical Education Foundation, Inc.

WOMEN TRIAL Shaw LJ, et al. Circulation. 2011;124(11):1239-49.
Medicine Conference 6/12/2015 WOMEN TRIAL Looked at low risk women able to exercise with intermediate pretest probability, randomized to ETT or SPECT. No difference in outcomes. Shaw LJ, et al. Circulation. 2011;124(11): Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 DIAGNOSIS “ Class I: Exercise testing in adult patients with an intermediate pretest probability of CAD, based on gender, age, and symptoms ” Gibbons RJ, et al. J Am Coll Cardiol. 2003;41(1): Lafayette Medical Education Foundation, Inc.

SELECTING THE APPROPRIATE TEST
Medicine Conference 6/12/2015 SELECTING THE APPROPRIATE TEST Gibbons RJ, et al. J Am Coll Cardiol. 1997;30(1): Lafayette Medical Education Foundation, Inc.

IMAGING STUDIES FOR DIAGNOSIS IN INTERMEDIATE PRE-TEST PROBABILITY
Medicine Conference 6/12/2015 IMAGING STUDIES FOR DIAGNOSIS IN INTERMEDIATE PRE-TEST PROBABILITY Pharmacologic studies in patients who cannot exercise Exercise MPI or echo in pts with digoxin, have WPW syndrome or > 1 mm of rest ST depression. Dipyridamole or adenosine MPI in pts with LBBB or paced ventricular rhythm. Exercise MPI or echo in patients with prior revascularization. Exercise MPI in patients with intermediate Duke treadmill score - As initial test in selected high risk patients (DM…) with normal rest ECG (IIa) - Controversial: as the initial stress test in patients who have a normal rest ECG and are not taking digoxin (IIb) Do not order exercise MPI in LBBB ACC guidelines for chronic stable angina J Am Coll Cardiol. 2002;41(1): Circulation. 2003;108(11): Lafayette Medical Education Foundation, Inc.

ADDITIONAL INDICATIONS FOR PROGNOSIS
Medicine Conference 6/12/2015 ADDITIONAL INDICATIONS FOR PROGNOSIS Low risk ACS for risk stratification Change in symptoms Incomplete revascularization To assess functional significance of intermediate (25% to 75%) lesions Preoperative risk stratification (IIa or b) More controversial indications in asymptomatic patients with: High CHD risk High CAC score High risk occupation Routine evaluation after revascularization ACC guidelines for chronic stable angina J Am Coll Cardiol. 2002;41(1): Circulation. 2003;108(11): Lafayette Medical Education Foundation, Inc.

IMAGING CAN BE INAPPROPRIATE IN EVALUATION OF CHEST PAIN
Medicine Conference 6/12/2015 IMAGING CAN BE INAPPROPRIATE IN EVALUATION OF CHEST PAIN Chest pain with low pretest probability of CAD, interpretable ECG and able to exercise Acute chest pain with definite ACS (ischemic ECG changes and/or significant Troponin elevation) Hendel RC, et al. Circulation. 2009;119(22):e Douglas PS,et al. J Am Soc Echocardiogr. 2011;24(3): Lafayette Medical Education Foundation, Inc.

OBTAIN STRESS IMAGING STUDIES
Medicine Conference 6/12/2015 IN SUMMARY OBTAIN STRESS IMAGING STUDIES CAN’T EXERCISE UNINEPRATTABLE ECG ETT WITH INTERMEDIATE DTS PRIOR REVASCULARIZATION LOCALIZE ISCHEMIA (PROGNOSIS) Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 A case for the audience… 32 y/o female with pressure-like constant chest pain for 3 weeks, not worsened by exertion or relieved by rest, negative troponins and normal ECG Next step? Reassure Plain (ECG) treadmill stress test Order a “Lexiscan” SPECT Proceed to coronary angiogram Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 A case for the audience… 56 y/o male with pressure-like atypical chest pain for 3 weeks, has h/o DM and HTN. Known LBBB on ECG. Negative Trop. Able exercise. Next step? Reassure Plain (ECG) treadmill stress test Order a “Lexiscan” SPECT Treadmill SPECT Lafayette Medical Education Foundation, Inc.

Medicine Conference 6/12/2015 A case for the audience… 56 y/o male with pressure-like recurrent chest pain for 2 months, has h/o CAD s/p PCI 2 years ago. Normal ECG Next step? Reassure Plain (ECG) treadmill stress test Order a treadmill Echo stress test Proceed to coronary angiogram Lafayette Medical Education Foundation, Inc.

QUESTIONS? Medicine Conference 6/12/2015

IMAGING STUDIES FOR CHEST PAIN
Medicine Conference 6/12/2015 IMAGING STUDIES FOR CHEST PAIN I Exercise MPI or echo in pts who are using digoxin, have WPW syndrome or > 1 mm of rest ST depression. Dipyridamole or adenosine MPI in pts with LBBB or paced ventricular rhythm. Exercise MPI or echo in patients with prior revascularization. Exercise MPI in patients with intermediate Duke treadmill score IIA As initial test in selected high risk patients (DM…) with normal rest ECG IIB Exercise or dobutamine echocardiography in patients with LBBB. Exercise, dipyridamole, adenosine MPI, or exercise or dobutamine echo as the initial stress test in patients who have a normal rest ECG and are not taking digoxin. III Exercise MPI in patients with LBBB. In patients with severe comorbidity likely to limit life expectation or prevent revascularization. ACC guidelines for chronic stable angina J Am Coll Cardiol. 2002;41(1): Circulation. 2003;108(11): Lafayette Medical Education Foundation, Inc.

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