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Cardiac Stress Testing in Contemporary Practice: Maximizing Value to Your Patient Ritesh Dhar, MD, MS Intermountain Heart Institute Intermountain Medical Center, Murray, UT

Question 72 yo woman with palpitations. ECG shows AF, rate 95. No prior CV history. Going for total knee replacement next week. 1) Stress nuclear 2) Dobutamine echo 3) Echo 4) ECG alone

Question 68 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged. 1) Repeat stress echo 2) Stress nuclear 3) Stress MRI 4) Coronary CTA

An Imaging Epidemic?

Copyright 2010 American College of Cardiology Foundation. Restrictions may apply. Medicare Fee-for-Service Spending for Imaging Services Shaw, L. J. et al. J Am Coll Cardiol Img 2010;3:789-794

Why? Shift from in-patient to out-patient testing? Medical cultural reasons? Fear of litigation? (Out-pt, ER settings) True increase in imaging services/options? Technology-driven society? Patient expectations? Sicker patient population?

IMAGING UTILIZATION AND A NEED FOR GUIDANCE Unprecedented focus on assessment and improving quality Substantial regional variation True nature of utilization unknown Clinicians, patients, and payers seeking guidance Hendel, ASNC 2015

Example

A = Appropriate M = May be appropriate R = Rarely appropriate

ACCF APPROPRIATENESS USE CRITERIA Literature-based (when available) approach to improve utilization of resource-intensive tests and procedures Serves as a method for focused reduction of procedures based on clinical value, not indiscriminant volume reduction Preserves patient/provider relationship Hendel, ASNC 2015

SPECT Nuclear Study ACCF/United Healthcare 2010 study with 6,000 patients 71% Appropriate 15% May be appropriate 14% Rarely appropriate Hendel, 2010, JACC 55:156-62

Question Which of the following indications comprised the greatest number of inappropriately ordered tests? 1) Detection of CAD Asymptomatic, low CHD risk 2) Preoperative assessment 3) Asymptomatic - < 2 years after PCI 4) Evaluation of chest pain low CHD risk, interpretable ECG and able to exercise Hendel, 2010, JACC 55: 156-62

Question Which of the following indications comprised the greatest number of inappropriately ordered tests? 1) Detection of CAD Asymptomatic, low CHD risk 44% 2) Preoperative assessment 4% 3) Asymptomatic - < 2 years after PCI 24% 4) Evaluation of chest pain low CHD risk, interpretable ECG and able to exercise 16% Hendel, 2010, JACC 55: 156-62

Section 1

Question 35 yo man, DM1, asymptomatic, wants to check his heart 1) Echo 2) Coronary Calcium score 3) Stress nuclear 4) Stress echo

Question 48 yo asymptomatic man with HL is worried about his heart. Younger brother had PCI last year, and remembers his father had CABG in his 60s. 1) ECG alone 2) Exercise ECG 3) Stress nuclear 4) Coronary calcium score

Question 57 yo woman, asymptomatic, comes to you with Heart Screening Score of 955. You advise a statin, aspirin, and: 1) Echo 2) Stress echo 3) Coronary CTA 4) Stress nuclear

Ex ECG RNI Echo

Asymptomatic patients Coronary calcium score ideal: Men > 45 years, Women > 55 years Intermediate-risk pts by Framingham Low-risk with strong family history Improved risk-stratification over Framingham Supercedes risk-stratification from lipids, etc

Question 48 yo man s/p PCI RCA 5 years ago, asymptomatic. ECG interpretable. Able to exercise. Select the best test. 1) Stress echo 2) Exercise ECG 3) Stress nuclear 4) Coronary CTA 5) No further testing

Question 64 yo woman with nonischemic cardiomyopathy. Insurance change, new patient. Feels well. Some edema managed with prn Lasix. Last echo 3 years ago, LVEF 45%. 1) Stress echo 2) Echo 3) No testing 4) Stress nuclear

Section 2

Question 65 yo woman with HTN, HL and 3 months progressive SOB. Twisted her ankle last week. 1) Echo 2) Dobutamine echo 3) Pharmacologic nuclear stress 4) Coronary CTA

Diamond-Forrester Classification of Pre-Test Probability Typical quality and duration Provocation stress or exertion Relieved with rest or NTG Age Gender

Imaging Should Alter Clinical Decision Making Pre-test probability scale Test Threshold Treatment Threshold 0% 100%

Modified Pre-Test Probability Score Morise. Am J Med. 1997; 102:350-56

Global CAD Risk Derived from well known Framingham studies Used to predict 10 year risk in asymptomatic pts (ATP III) Age Gender Total Cholesterol HDL Smoking status Blood Pressure Family history

Question 48 yo woman with HTN, HL, and strong family history with atypical chest pain. What is her pre-test probability for obstructive CAD? 1) Low 2) Low-intermediate 3) Intermediate 4) High

Modified Pre-Test Probability Score Morise. Am J Med. 1997; 102:350-56

Question Stress echo is discouraged in the evaluation of chest pain except in those with: 1) LBBB 2) RBBB 3) Prior MI 4) Prior PCI 5) Pacemaker 6) Prior CABG

Question 48 yo man s/p PCI RCA 5 years ago with recurrent chest pain; less intense and different in character to prior angina. ECG interpretable. Able to exercise. Select the best test. 1) Stress echo 2) Exercise ECG 3) Stress nuclear 4) Coronary CTA

Question 72 yo woman, new patient, has edema, SOB for 6 months, and states she had a heart attack 6 years ago. 1) Stress echo 2) Stress nuclear 3) Echo + Stress nuclear 4) Stress echo + Stress nuclear

Question 68 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged. 1) Repeat stress echo 2) Stress nuclear 3) Stress MRI 4) Coronary CTA

The Ischemic Cascade Schinkel A et al. Eur Heart J 2003;24:789-800 The European Society of Cardiology

CARDIAC PET

Functional testing Ability of coronary artery (and collaterals) to provide blood supply to myocardium Measure perfusion and wall motion Reflect both severity and consequences of obstructive CAD

Anatomic/functional caveats Normal perfusion does not exclude atherosclerosis, but has outstanding prognosis Most plaques not hemodynamically significant Neither strategies detect nonobstructive vulnerable plaque that lead to MI

Cardiac PET Improved diagnostic accuracy, less artifacts Fewer false positives Much shorter 30 minutes Less radiation Viability testing Quantitative blood flow measurements PET/CT: With calcium score

Cardiac PET Obese patients Equivocal prior stress test Negative prior stress test with recurrent symptoms Procedural planning in those with CAD Detect microvascular CAD Disadvantage: only vasodilator, not exercise

Section 3

Question 68 yo woman with colon cancer pre-op evaluation for hemicolectomy. No CV symptoms. Cleans house and grocery shops fine, but no other exercise. 1) Echo 2) ECG alone 3) Stress echo 4) Stress nuclear

Clinical Risk Factors for Pre-Operative Assessment

Question 55 yo otherwise healthy man with syncope. 1) ECG 2) Echo 3) Stress echo 4) Stress nuclear

Question 72 yo woman with palpitations. ECG shows NSR with occasional PVCs. No prior CV history. Total knee replacement next week. 1) Stress nuclear 2) Dobutamine echo 3) No testing 4) Echo

Question 72 yo woman with palpitations. ECG shows AF, rate 95. No prior CV history. Total knee replacement next week. 1) Stress nuclear 2) Dobutamine echo 3) Echo 4) ECG alone

Question 58 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged. 1) Repeat stress echo 2) Stress nuclear 3) Stress MRI 4) Coronary CTA

Cardiac CT Angiography Anatomic test with exceptional NPV Outstanding in low-intermediate risk pts Establishes anatomy, and diagnoses CAD: Aggressive risk factor modification With coronary calcium scoring, excellent risk stratification and prognostic data Use to confirm normal coronaries in those you believe do not have CAD

Cardiac CT Angiography

Typical Radiation Doses Stress Echo CMR CXR SPECT (Tc-99m) SPECT (Thallium) Coronary CTA Chest CTA (ro PE) Abdomen/Pelvic CT PET Coronary Calcium Score Cardiac Cath 0 msv 0 msv 0.05 msv 12-14 msv 20-26 msv 4-8 msv 10-20 msv 15-20 msv 4-8 msv 1-2 msv 4-10 msv

TAKE-AWAY POINTS

Take-away points Tremendous monetary cost, radiation, and false-positive rate associated with cardiac imaging History taking and assessing pre-test probability, minimize false positives Understand the ischemic cascade. Stress echo for greater specificity (lower false positive), Nuclear perfusion for greater sensitivity

Take-away points Minimize Radiation Exposure: Echo < PET < CT <= SPECT Escalate testing. Avoid repeat stress testing of identical modality. Refer for Cardiology evaluation Cardiac PET Cardiac CTA

Take-away points Follow-up testing is rarely appropriate in asymptomatic patients or those with stable symptoms Follow-up testing is rarely appropriate in asymptomatic patients after revascularization For preoperative assessments, those with > 4 METS do not require testing, regardless of type of surgery or risk profile. Rarely perform stress testing in asymptomatic patients

Thank You Ritesh Dhar, MD, MS Intermountain Heart Institute Cell: 801-783-6790 Email: Ritesh.Dhar@imail.org