Stress Testing:Which Study is Indicated for My Patient?

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Kerry Oliver
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1 Stress Testing:Which Study is Indicated for My Patient? Cardiology-Primary Care Conference 7/14/17 Peter Casterella, MD Co-Executive Director Swedish Heart and Vascular Institute 1

2 Stress Testing Options ETT- standard treadmill test Nuclear Stress Test Exercise or pharmacologic Stress Echocardiogram Exercise or pharmacologic Stress MRI Pharmacologic only Newer Modalities PET nuclear imaging pharmacologic only Coronary CTA anatomic information only 2

3 Case Study 1 55 year old man with Type II DM, Obesity,hyperlipidemia and HTN comes to your office with complaints of exertional dyspnea sometimes associated with chest pressure. Resting ECG is normal Meds include: diuretic, amlodipine, atorvastatin and metformin Which Type of stress test would you order? A. Stress Echocardiogram B. Exercise Treadmill Test C. Stress Nuclear Study D. Coronary CTA 3

4 Case Study 2 65 year old man comes in for pre-op clearance for left hip replacement surgery. His walking is limited by his hip, but he does get dyspnea after walking 3 blocks or 1 flight of stairs. He denies chest pain. Cardiac risk factors: DM, HTN, Lipids, smoking Baseline ECG: Sinus rhythm, LBBB present for 5 years What would you do next? A. Modified Bruce ETT B. Clear him for surgery since he has no definite ischemic symptoms C. Vasodilator Stress Nuclear study D. Stress Echocardiogram 4

5 Indications for Stress Testing Diagnosis: evaluate suspected CAD in patients with symptoms, +/- risk factors for CAD and without established diagnosis of CAD Diagnosis: evaluate possible ischemic symptoms in patients with known CAD, i.e. prior MI/ACS, prior revascularization (PCI/CABG) Prognosis: reassessment of patients with known CAD, prior events, high risk of adverse events, and current asymptomatic status Screening: CAUTION while stress testing of various types has been used in the past to evaluate at risk individuals or as part of executive health evaluations, there is minimal value of stress testing in individuals without ischemic symptomatology regardless of cardiovascular risk status 5

6 Stress Testing: Key Questions Can the patient exercise? YES or NO Baseline ECG Normal? YES or NO Baseline ECG has interpretable ST segments for ischemia? YES/NO Is there a LBBB? YES or NO 6

7 Stress Testing: Key Points Whenever possible, an exercise study is preferred as exercise capacity is a KEY predictor of CV outcomes and survival. Pharmacologic stress should ONLY be selected if the patient can t exercise OR the test performed can only be done with pharmacologic stress (PET, MRI) LBBB: ETT and exercise nuclear imaging are contraindicated with LBBB due uninterpretable ECG (ETT), and false (+) results exercise nuclear imaging. Preferred tests with LBBB are: exercise stress echo, pharmacologic nuclear (MRI or PET are acceptable as well) Bayes Theorem: Test results are strongly impacted by the pre-test probability of CAD 7

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10 Exercise Treadmill Testing: An Unappreciated Valuable Test Inexpensive The best first approach in patients able to exercise with a normal resting ECG Normal results have strong negative predictive value Specificity is close to nuclear and stress echo testing Sensitivity not as good as stress + imaging Should be the first test ordered in low-intermediate risk patients with normal resting ECG and able to exercise Main prognostic factors from ETT: exercise time, symptoms, ST changes 10

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21 Stress Echocardiography 21

22 Stress Echocardiography Perform with exercise (preferred) or pharmacologic (dobutamine) stress Echo imaging performed pre and post stress from 5 views-can use contrast for image enhancement Advantages vs. Nuclear imaging No radiation Overall fewer false (+) studies/artifacts Higher specificity Disadvantages Logistically challenging to complete exercise and obtain all images within 2 minutes of completion of exercise Achieve all images with HR still elevated Challenges with imaging immediately at peak exercise 22

23 Stress Echocardiography in Symptomatic Patients Journal of the American Society of Echocardiography , DOI: ( /j.echo ) 23

24 Stress Echocardiography In Asymptomatic Patients Journal of the American Society of Echocardiography , DOI: ( /j.echo ) 24

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29 Problems with Nuclear Imaging Sensitivity is higher than ETT Specificity is suboptimal due to false positives Artifact issues Nuclear Medicine vs Unclear Medicine Diaphragm attenuation artifact looks like inferior MI/ischemia Breast attenuation artifact looks like anterior MI/ischemia GI tracer uptake poor visualization of the inferior wall Results sometimes read like I can t rule out anything 29

30 Cardiac Stress MRI No Radiation No issues with artifact Excellent image quality Ischemia and viability data provided Pharmacologic stress only Increasingly used due to outstanding results 30

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32 Cardiac PET Imaging Better image quality vs nuclear Eliminates artifacts and false (+) s Less radiation vs standard nuclear Excellent for viability analysis Provides perfusion data extent of ischemia Pharmacologic stress only Higher cost Not currently available at Swedish 32

33 Algorithm for Risk Assessment of Patients With SIHD* *Colors correspond to the ACCF/AHA Classification of Recommendations and Levels of Evidence Table. 33

34 Case Study 1 55 year old man with Type II DM, Obesity,hyperlipidemia and HTN comes to your office with complaints of exertional dyspnea sometimes associated with chest pressure. Resting ECG is normal Meds include: diuretic, amlodipine, atorvastatin and metformin Which Type of stress test would you order? A. Stress Echocardiogram B. Exercise Treadmill Test C. Stress Nuclear Study D. Coronary CTA 34

35 Case Study 2 65 year old man comes in for pre-op clearance for left hip replacement surgery. His walking is limited by his hip, but he does get dyspnea after walking 3 blocks or 1 flight of stairs. He denies chest pain. Cardiac risk factors: DM, HTN, Lipids, smoking Baseline ECG: Sinus rhythm, LBBB present for 5 years What would you do next? A. Modified Bruce ETT B. Clear him for surgery since he has no definite ischemic symptoms C. Vasodilator Stress Nuclear study D. Stress Echocardiogram 35

36 Key Take Home Points Exercise is always preferred to pharmacologic stress If baseline ECG is interpretable/normal, start with the simplest test (ETT), and add imaging as needed if ECG not interpretable Stress testing is most appropriate in the following situations: Evaluation of patients with signs and symptoms of myocardial ischemia Evaluation of patients with known CAD at high risk for adverse cardiac events Stress testing is least appropriate in the following situations: Screening tool for asymptomatic at risk patients consider Coronary CT calcium scan Frequent assessment of asymptomatic, low risk stable patients with known CAD The most appropriate and common stress tests to be ordered by primary care are: ETT Stress Echo exercise or pharmacologic Stress Nuclear exercise or pharmacologic 36

37 Thank You! 37

Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018

Choosing the Appropriate Stress Test: Brett C. Stoll, MD, FACC February 24, 2018 Choosing the Appropriate Stress Test: Does it Really Matter? Brett C. Stoll, MD, FACC February 24, 2018 Conflicts of Interest