CONFUSION IN CARDIAC TESTING. Bilal Aijaz M.D FACC FSCAI

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1 CONFUSION IN CARDIAC TESTING Bilal Aijaz M.D FACC FSCAI

2 WHY DOES CARDIOLOGY HAVE SO MANY TESTS? to create confusion (of course) to generate more business (maybe?) to accommodate the ever expanding patient needs (probably) increasingly complex/aging population and rapidly increasing knowledge (very likely)

3 WHAT DO THE REFERRING PROVIDERS WANT? simple answers to complex questions this is with utmost certainty a highly abnormal stress test and requires immediate cath, which will most certainly lead to stenting of his LAD, after which patient should be able to ride that unicorn that he always wanted but, more realistically borderline positive test, maybe artifact but attenuation correction suggests a small defect which maybe, sometimes is associated with clinical correlation is advised (one can never hedge enough-ask the radiologists)

4 BACK IN THE DAY A cardiologist was a cardiologist who managed the heart then a few pioneers started to learn more and do more: like injecting presumably lethal things into the heart arteries under pretense of an accident or burning the heart in every possible section

5 We still have general cardiologists, amongst invasive cardiologists interventional cardiologists electrophysiologists advanced heart failure preventive cardiologists imaging experts with individual fellowships for nuclear/echo/ct/mri cardiac intensivists vascular experts

6 TID LHR SPECT and PET LEXISCAN and Dobutamine RVSP IVC non compressible leg arteries Exercise and Pharmacological Diastolic Dysfunction

7 TID - IS WHAT EXACTLY? TID ratio of 1.30 is seen. And? Transient ischemic dilatation. Which is?

8 Transient ischemic dilatation Present when the diameter of the left ventricle (LV) cavity appears larger on stress images as compared with resting images. It is most likely due to stressinduced subendocardial ischemia (blood supply to the innermost layer of the ventricle). Underperfusion of the subendocardium region causes the LV's enlarged appearance rather than actual dilation

9 TID may also result from physical dilation (true dilation of the LV throughout the cardiac cycle, also caused by ischemia), or from systolic dysfunction (in which LV stunning decreases the ejection fraction at stress, thereby increasing ventricle size) A TID threshold of 1.22 or greater has been validated as having the highest sensitivity and specificity for detecting severe and extensive CAD in patients undergoing exercise stress. Patient management decisions should not be based solely on a finding of TID. When integrated with other clinical information (eg, typical angina, advanced age, diabetes), and MPI results, TID can be useful in selecting patients as candidates for further noninvasive testing or coronary angiography.4

10 LUNG HEART RATIO ratio of uptake of tracer in the lung to the heart normally lungs take less than 30% of uptake of heart situations where heart has decreased uptake relative to lungs include 3 vessel disease, large infarcts, low LVEF, high LVEDP etc ratio > abnormal note very high ratios >0.60/0.70

11 I WANT TO ORDER A STRESS TEST.. lexiscan dobutamine nuclear spect, or PET exercise adenosine sestamibi pharmacological dobutamine echo.

12 A stress test is functional study (distinct from just anatomic) Exercise treadmill stress test (ECG interpretation only) Stress test with imaging (Nuclear, Echo, CT, MRI)

13 IMAGING BASED STRESS TEST Nuclear scan Echocardiogram CT-Scan MRI The STRESS has to be either exercise or pharmacological pharmacological can be a vasodilator (adenosine, dipyridamole, regadenosine, which is lexiscan) or ionotrope (dobutamine)

14 Finally What is a MIBI? What is a Lexiscan? Both are adenosine nuclear stress tests MIBI: the technetium molecule is attached to sestamibi molecule. The combined sestamibi- Technitium-99 molecule is aka cardiolite Lexiscan: uses a derivative of adenosine called regadenosine, which has 2-3 minute half-life instead of 30sec, so is easier to work with.

15 PET SCAN OR SPECT SCAN They re both NUCLEAR tests PET Is position emission tomography and SPECT is single photon emission computed tomography Different cameras and different radio tracers Advantages and disadvantages of either For your purposes, order a nuclear stress test and the facility decided whether SPECT scan or PET scan

16 GRADE. DIASTOLIC DYSFUNCTION

17 Mild diastolic dysfunction: Grade I diastolic dysfunction:impaired Relaxation Moderate diastolic dysfunction: Grade II diastolic dysfunction: pseudonormal Severe diastolic dysfunction: Grade III/IV diastolic dysfunction: restrictive

18 don t confuse diastolic dysfunction with diastolic heart failure (HFePEF)

19 DILATED IVC COLLAPSIBLE IVC measurement > 2.1cm is dilated Inspiration generally collapses veins due to change in intrathoracic pressure unless high pressure So dilated IVC in simple terms means increased filling pressures (can be seen in anything from the LV backwards-lungs-rv)

20 RSVP/ PASP ON ECHO AND PULMONARY HTN RVSP: Right ventricular systolic pressure PASP: Pulmonary arterial systolic pressure Interchangable as both are generally equal measured from triscuspid regurgitation

21 RSVP ON ECHO/PASP PULMONARY HTN If you ordered the echo for pulmonary HTN, pay attention to RVSP (reported typically as 35mmHg + RA pressure) If not, so then still pay attention to moderate or severe pulmonary HTN Pay attention to lack of TR jet when you re suspecting pulmonary HTN

22 INTERATIAL SEPTAL ANEURYSM in and of itself no issues increase correlation with all embolic strokes increase prevalence with PFOs PFOs with IAA with stroke: strongly consider closure general population has 2% incidence

23 WHY IS LVEF 55 +/-3% what is normal LVEF? 55-65% range makes us look more consistent traditionally 5% is acceptable. So we write LVEF 55-60% 50-55% is low normal mild, moderate, <35 is severe

24 TAVR OR SAVR OR TAVI TAVI (transcatheter aortic valve implantation) TAVR (transcatheter aortic valve replacement) Semantics TAVI has been the universally-used name for the procedure during most of its development period, and in everywhere else but U.S TAVR came about when the procedure edged closer to US approval primarily for Medicare billing SAVR is surgical valve replacement

25 PAD ASSESSMENT?

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