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TO STRESS OR NOT TOSTRESS ?

Karam Paul MS, MD, MBA, FACC

Community Heart and Vascular

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Cardiac stress testing - learningobjectives

►Know why to undertae a

stress test►Know who should have one►Know how it is !er"or#ed►$nderstand the li#itations►$nderstand which to choose►Know what to do with theresult

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Cardiac stress testing

%hy do a stresstest?

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&i#s o" stress testing

►Elicit abnor#alities not !resentat rest

►Esti#ate "unctional ca!acity

►Esti#ate !rognosis

►'ielihood o" coronary artery

disease ►E(tent o" coronary arterydisease

►E)ect o" treat#ent

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Cardiac stress testing

%ho should haveone?

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*iagnostic test

►+ayes, Theore#

►Consider the !re-test ris,

►Sensitivity . s!eci/city o" the test

►0ost-test !robability o" C&*

 ►*iagnostic !ower o" EST is #a(i#alwhen the !re-test !robability isinter#ediate1

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Ris assess#ent

►0re-e(isting coronaryartery disease

►*iabetes

►2y!ertension

►S#oing history

►3a#ily history ►Renal disease

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Consider other ris "actors

0re-e(isting coronaryartery disease►*iabetes

►2y!ertension ►2y!erli!ide#ia►S#oing history►3a#ily history

►Renal disease

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Consider other ris "actors

►0re-e(isting coronaryartery disease

►*iabetes►2y!ertension

►2y!erli!ide#ia►S#oing history►3a#ily history►Renal disease

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4alvular heart disease

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Rhyth# disorders

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Contraindications

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Cardiac Stress Testing

2ow is it done?

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E(ercise !rotocol

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0ositive5

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6easure#ents

►EC7

►E(ercise ca!acity86ETS 9 #etabolic

e:uivalent;

►Sy#!to#s

►+lood !ressure

►2eart rate res!onse .recovery

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EC7

 

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► The nor#al and ra!id u!slo!ing STseg#ent res!onses are nor#alres!onses to e(ercise1► 6inor ST de!ression can occur

occasionally at sub#a(i#alworloads in !atients with coronarydisease1► The slow u!slo!ing ST seg#ent!attern o"ten de#onstrates anische#ic res!onse in !atients withnown coronary disease or those with

a high !retest clinical ris o" coronarydisease1► *ownslo!ing ST seg#entde!ression re!resents a severeische#ic res!onse1► ST seg#ent elevation in an in"arct

territory 8> wave lead; indicates asevere wall #otion abnor#ality andin #ost cases is not considered anische#ic res!onse1

(From Chaitman BR: Exercise electrocardiographicstress testing. @n Beller GA [ed]: Chronic IschemicHeart isease. @n Bra!n"ald E [series ed]: Atlas o#

Heart iseases. $ol %. Chronic Ischemic Heartisease. &hiladelphia' C!rrent edicine' )**%' pp

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T wave changes

► @nAuenced byB +ody !osition Res!iration

2y!erventilation *rug R( 6yocardial ische#ia Necrosis

► 0seudonor#alisationB $sually non-diagnostic Consider ancillaryi#aging

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6ETs

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2eart rate res!onse

►0ea 2R DF o" #a(i#al !redicted"or age

►2R recovery

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2eart rate res!onse

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0rognostic value o" stresstesting

0ara#eters associated with adverse!rognosis or #ulti-vessel disease

► Duration of symptom-limiting eercise !" M#$s► Failure to increase sBP %&'(mmHg, or a sustaineddecreased % &(mmHg, or )elo* rest le+els, duringprogressi+e eercise► S$ segment depression %'mm, do*nsloping S$ segment,starting at !" M#$s, in+ol+ing %" leads, persisting %" mininto reco+ery► #ercise-induced S$ segment ele+ation aV ecluded.► Angina pectoris at lo* eercise *or/loads► eproduci)le sustained 01( sec. or symptomatic

+entricular tac2ycardia

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'i#itations o" tread#ill stresstest

► Non-diagnostic EC7 changes► 3alse !ositivesH"alse negatives

► %o#en 9 "alse !ositives► Elderly 9 #ore sensitiveHless s!eci/c► *iabetics 9 autono#ic dys"unction► 2y!ertension► @nability to e(ercise

► *rugs 9 digo(inI anti-anginals

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Non-coronary causes o" STseg#ent de!ression

► &ne#ia► Cardio#yo!athy► *igo(in► 7lucose load

► 2y!erventilation► 2y!oale#ia► @ntraventricular conductiondisturbance► 6itral valve !rola!se► 0re-e(citation syndro#e

► Severe aortic stenosis► Severe hy!ertension► Severe hy!o(ia► Severe volu#e overload 8aortic or#itral regurgitation;► Sudden e(cessive e(ercise

► Su!raventricular tachycardiaJs

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'i#itations o" tread#ill stresstest

Sensitivity DF

S!eci/city LLF

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&ncillary techni:ues to enhancecontent

Echocardiogra!hy Radionuclidei#aging

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Stress echocardiogra!hy

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Stress echocardiogra!hy

Co#!ares !re . !ostB  Regional

contractility Overall systolic"unction 4olu#es

0ressure gradients 3illing !ressures 0ul#onary!ressures 4alvular "unction

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*obuta#ine stress echo

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Stress echo - li#itations

3actors which e)ect i#age:ualityB

+ody habitus 'ung disease +reast i#!lants

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Nor#al stress echocardiogra#

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Case <

►M year old ban !roject#anager 

►E(ertional chest !ain .dys!nea ►E(-s#oer 

►TC 1L##olH' ►Stress EC7 9 G## STseg#ent de!ression in leads

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Stress echocardiogra#

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Coronary angiogra#

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Case G

►G year old "e#ale

►Chest !ain . dys!nea

►Tread#ill e(ercise test 9 non-diagnostic sub-#a(i#al 2y!ertension

No EC7 changes

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Case G

►E(ercised L #inutes8P1M 6ETS;

►No chest !ain

►EC7 changes

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Case G

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Case G

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Case =

►GM year old "e#aleengineer 

►E(ertional dys!nea

►0al!itations

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Case =

@nducible dys!nea►EC7 !artial right bundle

branch bloc no ische#ic changes

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Case =

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Case =

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Case =

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Case M

►M= year old #ale -airline catering 

►Chest !ain

►*ys!nea

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Case M

►@nducible dys!nea ►Non-s!eci/c T wave

changes ►No ST seg#ent shi"t ►7lobal deterioration in

le"t ventricular "unction

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Case M

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Case M

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Case M

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Nuclear S0ECT i#aging

►Radio-tracer injection ►@soto!esB Thalliu#-GQ< Technetiu# PP# 8sesta#ibi;

►6yocardial u!tae ►0hoton e#ission ca!tured byga##a ca#era ►Rest . redistribution !hases

 ►0har#acologic !rotocolsavailable ►*igital !resentation

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Nuclear S0ECT i#aging

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Nuclear S0ECT i#aging

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Nuclear S0ECT i#aging

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Nuclear S0ECT i#aging

Reversible in"erior wall de"ect

6ilder reversible in"erior wall de"ect

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

►Ti#e-consu#ing

►&rti"acts ►+alanced ische#ia ►Radiation

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

Nor#al a!ical thinning1

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

&1 +reast attenuation +1 &nterior ische#ia

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

►Ris o" iatrogenic #alignancy

►'inear no-threshold #odel ►ConsiderB age

gender bacground

'i#itations o" nuclear S0ECT

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'i#itations o" nuclear S0ECTi#aging

Einstein &1 1 et al1 Circulation GQQLI

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6R@ cardiac stress test

$se"ul "orB►0atients unable toe(ercise

►EC7 uninter!retable►$nsuitable "or *SE

&nd1

►No radiation

+ut►Not currently available

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>uestion

►M year old diabetic #an

►&nterior chest disco#"ort withe(ertion 

►E(ercised "or G #ins =Q secs8M1 6ETs; ►PF #a(i#al !redicted heartrate

►6ild chest !ain

►+0 increased "ro# baseline to

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%hich is true?

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&nswer

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Re#e#ber

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Re#e#ber

0ara#eters associated with adverse !rognosisor #ulti-vessel disease

► Duration of symptom-limiting eercise !" M#$s► Failure to increase sBP %&'(mmHg, or a sustained decreased %&(mmHg, or )elo* rest le+els, during progressi+e eercise► S$ segment depression %'mm, do*nsloping S$ segment, starting at!" M#$s, in+ol+ing %" leads, persisting %" min into reco+ery► #ercise-induced S$ segment ele+ation aV ecluded.

► Angina pectoris at lo* eercise *or/loads► eproduci)le sustained 01( sec. or symptomatic +entriculartac2ycardia

%hen ordering a stress test

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%hen ordering a stress testconsider

►0re-test ris o" disease

►Sensitivity . s!eci/city o" thetest

►4alue o" su!!le#entary data

►&N* $ST ONE 6ORE T@011

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6R@ cardiac stress test

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Cardiac stress testing

So1which one to choose?

%hat to do with the

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%hat to do with theresult?

►Re#e#ber +ayes,theore#

►Consider the !re-test

ris

►+e aware o" thesensitivity . s!eci/city

o" the test

►&!!ly the !ost test!robability

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C C l i

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CT Calciu# score

►Correlates with !resence . e(tent o" C&* ►Strong negative !redictive value

►Cannot !redict "unctional signi/cance

►2igher scores can !redict events

►Reco##ended "or asy#!to#atic withinter#ediate ris 

CT C l i

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CT Calciu# score

Calci/cation o" the le"tanterior descending

coronary artery 8largearrow; and le"tcircu#Ae( coronaryartery 8s#all arrow;1

CT C l i

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CT Calciu# score

Score description Q nil< 9 PP #ild

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CT Calciu# score

► @ndicated 9 asy#!to#atic withinter#ediate ris

► Not "or low risH!o!ulation screening ► 2igh ris 9 use current guidelines

► *o not reduce R( i" inter#ediate ris .

Q, score

CT i h

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CT coronary angiogra!hy

►G-di#ensional . =-di#ensionalreconstructions

►Relies on slow regularheart rate

►2igh negative!redictive value 8ruleout, ability;

CT coronary angiogra!hy -

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CT coronary angiogra!hy li#itations

►'ower !ositive!redictive value 8over-esti#ation tendency;

►7rading o" stenosisli#ited

►*oes not evaluate"unctional signi/cance

►Radiation e(!osure

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CT coronary angiogra!hy

►Role not yet clearly de/ned

►0otential "or those with

inter#ediate lielihood o"diseaseB%here stress testing not!ossible

Stress teste:uivocalHuninter!retable &cute chest !ainHno EC7changesHnor#al eny#es

►Role in ano#alous anato#y

CT i h

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CT coronary angiogra!hy