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Orlando, Florida – October 7-9, 2011
Detection of Ischemia: Which Test in Which Patient?
Thomas Ryan, MDDirector, Ohio State’s Heart and Vascular Center
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Method to Induce
Ischemia
Method to Induce
Ischemia
Method to Detect
Ischemia
Method to Detect
Ischemia
RobustFlexibleGeneralizableSafe
VersatileMultiparametricSafeAccurate
Clinical Utility of the Test
Clinical Utility of the Test
A General Approach to Stress Testing
Options
♥Plain-old treadmill♥Nuclear (eg, sestamibi)♥Stress echo♥Stress MRI♥PET
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Stress Testing: Cost vs YieldStress Testing: Cost vs Yield
ExEcho PET
ExECG
Approx Cost $
Accuracy
Clinical
ExMIBI
100 210 460 910 1200
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Limitations of the Stress ECG
Men Women
False-pos Rate 7-44% 39-67%
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When is POT Good Enough?
Baseline ECGMedsGenderLevel of stressLocalization?
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Comparing AdvantagesComparing Advantages
Echo Nuclear
Know which test is best in your hospital!
VersatileLower costConvenient NoninvasiveAccurate
High success ratePeri-infarct ischemiaExtensive data, eg, prognosisQuantitative
Prognostic Value of Stress Echo
Normal wall motionAbnormal studiesPreserved exercise capacitySevere LV dysfunctionWomenPost-MIPost-CABGPost-PTCAElderlyDiabetes
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Pretest Likelihood
Post
test
Lik
elih
ood
100%
100%
Factors Affecting Stress Testing Results
Pos Result
Neg Result
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100 pts100 ptsPretest LikelihoodPretest Likelihood
10%10%
Factors Affecting Stress Testing Results
A negative result is helpful, but
over half of patients
sent to the cath lab are normal!!A negative result is helpful, but
A negative result is helpful, but
over half of patients
over half of patients
sent to the cath lab are normal!!
sent to the cath lab are normal!!
When to do the test?(and when not to)
Good Idea! Bad Idea!64 yo man with CRF, abn ECG, and atypical chest pain
52 yo man with acute CP, neg ECG, and neg Tn
59 yo woman recovering from NSTE MI, no early cath
70 yo woman with EF 25% being considered for CABG
54 yo man with + Tn, but no Sx orischemic ECG changes
62 yo diabetic prior PVS
33 yo woman with atypical CP, nl ECG
68 yo man with multiple RF and increasing cp
60 yo obese woman with very poor apical windows78 yo woman with known CAD but no revasc targets
47 yo woman, new onset AF, no hx of CP or CAD60 yo man ASx, multiple RF, 2y after CABG41 yo woman with no RF and a normal ECG
48 yo diabetic prior to cataract surgery
56 yo ASx man with mod Framingham risk profile , interpretable ECG
55yo man with recent CP, low pre-test prob of CAD, NSSTTW changes
62 yo man with CP and recent cath showing 50% mid LAD lesion
Limitations of Stress Echo
Image quality – endocardial definitionModest sensitivity/specificitySubjective interpretationNonquantitativeReliance on wall motionOverutilization
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CMR-DME
mid
apex
Stress MRI:A 42 yo woman with atypical chest pain
ExerciseStress
Rest
SPECTCMR
Jekic M, Foster E, Ballinger M, Raman SV, Simonetti OP, J Cardiovasc Magn Res 2007
REST STRESS
70 bpm 150 bpm
Exercise MRI: Initial Experience
Feasibility of real-time exercise stress CMRExercise CMR Results
Resting cine
Stress cine
Stress perfusion
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Multidetector CT
Cardiac CT
LAD LCX RCA
19Raff et al, JACC ‘05
Limitations of CTA
Summary
More options than everExercise usually preferred over pharmacologicPretest probability more important than sensitivity/specificityCost and radiation should factor inPayers beginning to dictate choices
