Case Question - c.ymcdn.comc.ymcdn.com/sites/€¦ · Case Question •Cc: ... consider chemical imaging study versus coronary angiography* 6 Stress Testing: ... and patient selection

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Evaluation of Chest pain in the Office and Cardiac Stress Testing

Chad Link, DO FACC

Sparrow Hospital

Thoracic and Cardiovascular Institute

Chairman- TCI Cardiology Section

Disclosures

Speakers Bureau – Actelion Pharmaceuticals, Pfizer and BMS

Clinical Research Support– Sanofi Aventis

Case Question

• Cc: Chest pain

• HPI: This is a 30 year old male who presents to your office with

complaints of substernal chest pain that has been going on for the

past 5 days. He describes the pain as a “sharp pain” that is constant

for most of the day. It doesn’t change with position and can occur

both at rest or with exertion. He does not experience the pain at night

and has no trouble sleeping. He denies any other associated

symptoms with the pain. He is otherwise healthy and has no previous

medical conditions. He is taking no medications.

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Case Question

https://meds.queensu.ca/central/assets/modules/ECG/normal_ecg.html

Case Question

• Which of the following is the most

appropriate diagnostic test or strategy to

perform next?

a. Regadenoson Nuclear Perfusion Stress Test.

b. Coronary Angiography

c. Stress Echocardiography

d. Exercise Treadmill

e. NSAID and Observation

f. Send to the ER

g. Cardiology Consultation

Case Question

• Cc: Chest pain

• HPI: This is a 45 y.o c female who presents to the ER with c/o

substernal CP which started approx. 2 hours ago. The patient

describes the pain as a “pressure” that radiates to her left shoulder

and down her left arm. She noticed the pain while watching TV and

states the pain lasted approximately 10 minutes before completely

resolving. She states she felt SOB with the CP, but denies N/V,

diaphoresis or pain radiating to the back or neck area. She states she

took an NSAID which seemed to relieve the pain. She denies history

of CAD, including previous MI, however, she does have multiple risk

factors for CAD, including diabetes, hyperlipidemia, tobacco use and

family history of premature CAD. She has never had a previous

cardiac examination, but does see her doctor regularly. She states

she has noticed this pain over the last several months with exercise,

however it generally goes away with rest. She is currently pain free.

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Case Question

https://en.wikipedia.org/wiki/Wellens'_syndrome

Case Question


appropriate diagnostic test or strategy to

perform next?






f. Send to the ER

g. Cardiology Consultation

Case Question

• The patient is referred to Cardiology for an

Evaluation. Which of the following is the

most appropriate diagnostic test to perform

next?






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History

History

• Differential Diagnosis of Chest pain

– Chest pain- Cardiovascular Causes

• Angina Pectoris

• Unstable Angina

• Myocardial Infarction

• Pericarditis

• Myocarditis

• Aortic Dissection

• Aortic Stenosis

• Variant or Prinzmetal Angina (Coronary Spasm)

• Ventricular Septal Rupture

History

Chest pain- Non-Cardiovascular

Causes

• Gastrointestinal

• Esophageal Spasm

• Esophageal reflux

• Esophageal rupture

• Psychogenic

• Anxiety

• Depression

• Self-gain

•Neuromusculoskeletal

• Costochondritis

• Herpes Zoster

• Trauma/Chest Wall Pain

• DJD of cervical spine

•Pulmonary

• Pulmonary Embolism

• Pneumothorax

• Pleurisy

• Differential Diagnosis of Chest pain

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Stress Testing

• When? – Indications

What type? – Modalities

Who? – Patient selection

How often? – Frequency

How much? – Cost

• The choice depends on:

– Ability to Exercise, PMHx, ECG, Body Habitus

and Clinical Indication

Indications of Stress Testing

• In patients with symptoms suggestive of coronary

heart disease, cardiac stress testing is most often

indicated to making the diagnosis and assessing

risk OR

• In patients with known CAD for risk stratification.

Stress testing for CHD in asymptomatic is RARELY

indicated.

Stress Testing: When?

• Patients with chest pain

– Change in clinical status

• Acute coronary syndromes

– Low, intermediate, high risk (H&P, ECG, markers –

TIMI risk score)

– Low: 8-12 h symptom-free

– Intermediate: 2-3 days symptom-free*

– High: consider chemical imaging study versus

coronary angiography*

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Stress Testing: When?

• Before and after revascularization (if residual

disease)

– Demonstration of ischemia

– Evaluation of post-procedure chest pain

– Evaluation of territory at risk (if residual disease)

– Evaluation of restenosis

Stress Testing: How Often?

• Change in clinical symptom pattern

• Prognostication:

– There is no absolute guarantee

• Progression of testing modality to higher

sensitivity and specificity

• Depends on risk factors, their degree of

control and intensity of modification

Stress Testing: Who?

• Special Groups

– Women

• Lower sensitivity, similar specificity

– Elderly (>75 years of age)

• Other evaluated endpoints include chronotropic response,

exercise-induced arrhythmias, and assessment of exercise

capacity

– Diabetics

• Imaging study recommended

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• Asymptomatic patients

– Diabetics planning to start exercise

– Guide to risk reduction therapy in a patient with

multiple risk factors

– Men > 45 and women > 55

• Starting exercise

• Impact public safety

• High risk due to concomitant disease (PVD, CRF)

Robert C. Hendel et al. JACC 2009;53:2201-2229

American College of Cardiology Foundation


Stress Testing:

Absolutely Who Not!

• Acute MI

• High risk unstable angina

• Uncontrolled arrhythmias with symptoms

• Symptomatic, severe aortic stenosis

• Uncontrolled, symptomatic heart failure

• Acute PE

• Acute myocarditis or pericarditis

• Acute aortic dissection

• Inability to obtain consent

https://www.uptodate.com/contents/image?imageKey=CARD%2F80110&topicKey=CARD%2F1494&rank=1%7

E150&source=see_link&search=exercise+stress+test&utdPopup=true

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Stress Testing:

Relative Contraindication

• Left main coronary stenosis

• Moderate stenotic valvular heart disease

• Electrolyte abnormalities

• Severe hypertension (SBP > 200, DBP > 110)

• Tachy or bradyarrhythmias

• Outflow tract obstruction (HCM)

• Mental or physical impairment (unsafe)

• High-degree AV block

https://www.uptodate.com/contents/image?imageKey=CARD%2F80110&topicKey=CARD%2F1494&rank=1%7

E150&source=see_link&search=exercise+stress+test&utdPopup=true


When are stress studies not generally indicated:

- Asymptomatic patients < 5 years post CABG or < 2 years post PCI

- Routine stress testing in patients undergoing non-cardiac surgery

- Low pre test probability of < 10%

ww.uptodate.cwom


The Guidelines- Summary

- Symptoms suggestive of angina with an indeterminate or high

pre test probability of CAD (exception UA).

- Patients with acute CP following exclusion of ACS.

- Patient with recent ACS who were treated conservatively or

incomplete revascularization.

- Known CAD with worsening symptoms.

- Routine testing > 5 years post CABG and > 2 years post PCI.

- Certain instances in valvular heart disease and preoperative

evaluation when unable to function to a level of < 4 METs. ww.uptodate.cwom

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Pre-Test Probability

Age Nonanginal pain Atypical angina Typical angina

Men Women Men Women Men Women

30-39 4% 2% 34% 12% 76% 26%

40-49 13% 3% 51% 22% 87% 55%

50-59 20% 7% 65% 31% 93% 73%

60-69 27% 14% 72% 51% 94% 86%

ACC/AHA 2012 Guidelines

Low probability - <10% - no further testing, except for prognostic information.

Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise

ECG as first modality).

High probability - >90% - non invasive testing for prognosis/management prior to

cardiac cath.

Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014


First, is the stress study indicated?

Need to assess symptoms

Unstable angina is a contraindication to stress

testing

ww.uptodate.cwom

Angina

Precordial (retro-sternal) chest pain that…

• Is triggered by physical or emotional stress

• Is relieved by rest or SL NTG

• Lasts for 15-20 minutes each episode

STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram

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YES indicated

If indicated, can the patient exercise?

(Exclusions from exercise include Paced

rhythm, LBBB, WPW, > 1 mm ST depression at rest

or significant ST changes due to LVH)

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YES indicated


YES

Then need to determine the pre-test probability and

determine the appropriate test based on risk

stratification

ww.uptodate.cwom




30-39 4% 2% 34% 12% 76% 26%

40-49 13% 3% 51% 22% 87% 55%

50-59 20% 7% 65% 31% 93% 73%

60-69 27% 14% 72% 51% 94% 86%






cardiac cath.



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Adults with intermediate (10-90%)

pre-test probability of CAD

Age Sex Typical Atypical Non-anginal Asymp

30-39Male Intermediate Intermediate Low Very low

Female Intermediate Very Low Very low Very low

40-49Male High Intermediate Intermediate Low

Female Intermediate Low Very low Very low


Female Intermediate Intermediate Low Very low


Female High Intermediate Intermediate Low


Two Components

• Each cardiac imaging modality has two

components:

– Stressing agent: treadmill, dobutamine, or

regadenoson

– Imaging agent: EKG, echo, or radionuclide tracer

(Cardiolite/technetium)

NEED TO CHOSE ONE FROM EACH CATEGORY


Stress Testing: What Type?

EXERCISE ECG ALONE OR IN COMBINATION WITH AN

IMAGING MODALITY?

Exercise stress testing with electrocardiographic (ECG)

monitoring should be the initial test for the majority of patients

who can exercise and who have an interpretable ECG. While

exercise stress testing with imaging has several advantages over

the standard exercise ECG treadmill test.

There is insufficient evidence to recommend exercise stress

testing with imaging in all patients.

https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test?source=see_link&sectionName=INDICATIONS+FOR+STRESS+TESTING&anchor=H45821

8799#H458218799

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• There are also additional circumstances and patient

characteristics besides the ability to exercise and resting

ECG findings that determine whether a patient should

undergo exercise alone or exercise with imaging.

• These include ischemia localization, viability assessment,

prior revascularization, hemodynamic assessment for

valvular disease, digoxin use and prior equivocal ECG

findings.

https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test?source=see_link&sectionName=INDICATIONS+FOR+STRESS+TESTING&anchor=H45821

8799#H458218799


• Exercise modality

– Treadmill

• Bruce, Modified Bruce, Branching, Naughton…

– Bicycle (recumbent)

– Chemical/Pharmacologic

• Dipyridamole (Persantine®)

• Adenosine (Adenoscan®)

• Regadenason (Lexiscan®)

• Dobutamine


The Bruce protocol

• Developed in 1949 by Robert A. Bruce, considered the “father of exercise physiology”.

• Published as a standardized protocol in 1963.

• Remains the gold-standard for detection of myocardial ischemia when risk stratification is necessary.


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Protocol description

Stage Time (min) km/hr Slope

1 0 2.74 10%

2 3 4.02 12%

3 6 5.47 14%

4 9 6.76 16%

5 12 8.05 18%

6 15 8.85 20%

7 18 9.65 22%

8 21 10.46 24%

9 24 11.26 26%

10 27 12.07 28%STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram

Exercise Testing: Contraindications

• Unstable Angina

• Decompensated CHF

• Uncontrolled hypertension (blood pressure >200/115 mmHg)

• Acute myocardial infarction within last 2 to 3 days

• Relative contraindications (AS, HCM)



• Non-imaging vs. Imaging

– Require imaging

• Intermediate risk non-imaging exercise test

• Pre-excitation

• Paced rhythm

• LBBB or QRS > 120 ms

• > 1 mm resting ST depression

• Vessel localization

• Improved prognostic information

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

test?source=see_link&sectionName=INDICATIONS+FOR+STRESS+TESTING&an

chor=H458218799#H458218799


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YES indicated


NO or has an exclusion then need to consider

pharmacological testing

ww.uptodate.cwom


• Choice of imaging modality is multi-factorial

– Body habitus – attenuation, COPD, etc.

– Local expertise

– Claustrophobia

– Understanding of sensitivity and specificity

– Coincident information:

• Ejection fraction

• Valvular structure

• Exercise capacity

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

test?source=see_link&sectionName=INDICATIONS+FOR+STRESS+TESTING&an

chor=H458218799#H458218799

Stressing Agents

Stressor Pro Con

Treadmill Physiologic, simple,

less expensive,

good for patient

who can walk

Dobutamine No exercise

needed

Caution in patients with

arrhythmias

Regadenoson,

Adenosine/Persantine

(used with nuclear)

No exercise

needed;

uncomfortable

sensation of “heart

stoppage”

Adenosine may induce

bronchospasm – caution in

COPD and asthma!


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Imaging Agents

Stressor Pro Con

EKG Simple, less

expensive

Less information. May not be

able to localize the lesion. Can

not use if there are baseline

EKG abnormalities i.e. LBBB

with ST changes

Echocardiogram Good if patient has

pre-existing EKG

abnormalities. More

info than EKG.

Less expensive

than nuclear.

Operator dependent to some

extent. May have poor

windows due to body habitus.

Pre-existing wall motion

abnormalities may make

interpretation more

challenging.

Cardiolite/Technetium Localizes ischemia

and infarcted

tissue.

Expensive


Sensitivity and Specificity

Sensitivity Specificity

Exercise EKG 68% 77%

Stress Echo 76% 88%

Nuclear Imaging

79-92% 73-88%


Last but not least… cost

TEST COST - done

Hospital

COST - done

Office

ETT $ 637 $ 239

STRESS ECHO

$ 1600 $657

NUCLEAR

SCAN

$ 3000-$4400

$937


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Case Question

A 60yo man is evaluated for chest pain of 4 months’ duration. He describes the pain as sharp, located in the left chest, with no radiation or associated symptoms, that occurred with walking one to two blocks and resolves with rest. Occasionally, the pain improves with continued walking or occurs during the evening hours. He has hypertension. Family history does not include cardiovascular disease in any first-degree relatives. His only medication is amlodipine.

On physical examination, he is afebrile, blood pressure is 130/80mHg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No carotid bruits are present, and a normal S1 and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are normal. EKG showed normal sinus rhythm.


Case Question


appropriate diagnostic test to perform next?

a. Adenosine nuclear perfusion stress test.

b. Coronary angiography

c. Echocardiography

d. Exercise treadmill


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Case Question

First, are the symptoms suspicious for unstable

angina?

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Case Question


angina? No

Second, what are his risk Factors? Age and HTN

Third, what is he pre-test probability of CHD?

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30-39 4% 2% 34% 12% 76% 26%

40-49 13% 3% 51% 22% 87% 55%

50-59 20% 7% 65% 31% 93% 73%

60-69 27% 14% 72% 51% 94% 86%






cardiac cath.


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Case Question


angina? No


Third, what is he pre-test probability of CHD? 27%

or intermediate risk

Can he exercise?

ww.uptodate.cwom

Case Question


angina? No




Can he exercise? Yes

So, now are choices are Exercise EST, Exercise

Echocardiography and Exercise Cardiolite

(technetium). Which one should we perform on this

Intermediate Risk Patient?

ww.uptodate.cwom

Case Question

Do they have the following:

WPW

Paced Rhythm

LBBB

Greater than 1 mm ST depression at rest

Digoxin use with ST changes

LVH with ST Changes

NO…..

ww.uptodate.cwom

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Case Question


angina? No




Can he exercise? Yes

So, now are choices are Exercise EST, Exercise

Echocardiography and Exercise Cardiolite (over

utilized). Which one should we perform on this

Intermediate Risk Patient?

ww.uptodate.cwom

Sensitivity and Specificity

Sensitivity Specificity

Exercise EKG 68% 77%

Stress Echo 76% 88%

Nuclear Imaging

79-92% 73-88%


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Take Home Points

• Stress testing is indicated for patients with intermediate

pre-test probability

• Each stress test has two components: an imaging

modality and stress modality

• When determining which stress test to order, keep in

mind their ability to exercise, whether any

contraindications are present, cost by LOCATION ,

body weight and specificity and sensitivity


Robert C. Hendel et al. JACC 2009;53:2201-2229

American College of Cardiology Foundation

Take Home Points

Preoperative Evaluation

Thank You for your attention!

Documents

Case Question - c.ymcdn.comc.ymcdn.com/sites/€¦ · Case Question •Cc: ... consider chemical imaging study versus coronary angiography* 6 Stress Testing: ... and patient selection