Cardiac Stress Testing What Stress is Best?

Jennifer Gerryts, Registered Respiratory Therapist

Kati Tuomi, Medical Radiation Technologist, Nuclear Medicine

Thunder Bay Regional Health Sciences Centre

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Presenter Disclosure

■ Jennifer Gerryts and Kati Tuomi

■ Relationships with commercial interests: None

■ I have no conflict of interest or affiliations that have

influenced this presentation to disclose

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Disclosure of Commercial

Support

■This program has not received financial or in-kind support

■Potential for conflict(s) of interest : Jennifer Gerryts and

Kati Tuomi has not received payment/funding, etc. from an

organization supporting this program AND/OR

organization whose product(s) are being discussed in this

program].

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Learning Objectives

■Describe the differences between a stress test and a

nuclear stress test

■Differentiate the clinical indications for a stress test and a

nuclear stress test

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What is a Stress Test?

■Diagnostic tool in the management and evaluation of

patients with known or suspected heart disease

■Aids in assessing the risk related to CHD

■Evaluation of efficacy of therapeutic interventions

■Exercise electrocardiography is the most common

■Can be combined with imaging (MPI)

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Indications For Stress Testing

■Symptoms suggesting angina (stable)

■Patients with known coronary heart disease with new or

worsening symptoms

■Acute coronary syndrome (ACS)

■Coronary revascularization

■Valvular heart disease

■Pre-op

■Changes in resting ECG

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General Contraindications

■Acute myocardial infarction (within two days)

■Ongoing unstable angina

■Uncontrolled arrhythmias with hemodynamic compromise

■Symptomatic severe valvular stenosis

■Acute aortic dissection

■Acute pulmonary embolism, pulmonary infarction, or deep

venous thrombosis

■Physical disability that precludes safe and adequate

testing

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Contraindications For Stress Testing

■Exercise Stress Test

■De-condition/Unable

■Beta Blocker

■ LVH (hides ischemia)

■ Left Bundle Branch, Right Bundle Branch (V2, V3)

■Ventricular Paced Rhythm

■Greater than 1 mm ST depression at rest

■Hypertension

■Pharmacological Stress Test (Persantine)

■Severe Asthma

■Caffeine within 24hrs

■Medications: aggrenox

■ 2nd or 3rd degree block without pacemaker

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Choosing The Optimal Stress Test

■Clinical Indication / Patient History?

■Can the Patient Exercise?

■Does the patient have a large body habitus?

■Lung Disease?

■Abnormal resting ECG?

■Contraindications?

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Stress Test Protocol Differences

■1. Exercise Stress Test

■2. Cardiolite Stress Test (Exercise)

■3. Persantine Stress Test

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Positive Exercise Stress Test

■V tach ( 3 or more PVCs in a row)

■ST depression

■ST horizontal

■ST elevation

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Myocardial Perfusion Imaging

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Protocol

■Fasting for 4 hours prior to test

■Caffeine free for 24 hours

■Sestamibi Technetium 99m

■Low rest dose high stress dose

■2 day procedure for high BMIs

■Injection at rest -60 minute wait until images

■Stress injection – 45-60 minute wait until images

How?

■Vasodilation of arteries to heart muscle

■Rest vs stress

■More workload put on heart during stress

■Improper patient preparation or sub optimal stress test can

lead to false negatives

Gamma Camera

■Acquires an image from

the gamma rays

■Low dose CT used for

attenuation correction

■Patient considerations

■Lie flat

■Claustrophobia

■Tolerate protocol

Raw Data

Processing

Normal

MI

Ischemia

References

■M. Kacmarek, Robert. Dimas, Steven. W. Mack, Craig. (2005). The Essentials of Respiratory Care, Fourth

Edition. St. Louis, Missouri: Mosby. Inc.

■Des Jardins, Terry. G. Burton, George. (2011). Clinical Manifestations and Assessment of Respiratory

Disease. Maryland Heights, Missouri: Mosby. Inc.

■A. Alessi, BS, CNMT, NCT, RT(N). (2010). Nuclear Cardiology Technology Study Guide. Reston, VA: Society

of Nuclear Medicine. Inc.

■Up To Date. (2018). Noninvasive Ventilation in Selecting The Optimal Stress Test. Contraindications.

Indications, Clinical Factors, Optimal Tests. Retrieved April 1, 2018, from

https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-

test?search=stress%20tests&source=search_result&selectedTitle=1~150&usage_type=default&display_ran

k=1

■American Society of Nuclear Cardiology

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