When Should I Order a Stress Test or an Echocardiogram Updates in Cardiology 2015 March 7, 2015 Donald L. Lappé, MD, FAHA, FACC Chairman, Cardiovascular Department Medical Director, Intermountain Cardiovascular Clinical Program
What about stress test screening in asymptomatic patients?--no No evidence of benefit Lessons from FACTOR-64 trial Possibly only to determine functional capacity as part of a structured fitness program Revascularization in stable CAD is indicated for limiting angina on maximal medical therapy, evidence of significant myocardial ischemia Best care--provide guideline directed medical therapy to for primary or secondary prevention
Background Coronary artery disease (CAD) is a major cause of cardiovascular morbidity and mortality in patients with diabetes mellitus. Yet CAD is often asymptomatic, prior to myocardial infarction (MI) and death, potentially justifying routine screening. Prior attempts to assess screening for asymptomatic CAD have been limited to non-invasive tests that only detect myocardial ischemia, with variable sensitivity and specificity, and without a structured approach to therapy.
Coronary CT Angiography (CCTA) CCTA provides the opportunity to noninvasively evaluate both the extent and severity of coronary atherosclerosis. FACTOR-64 Aim: Assess whether routine screening for CAD by CCTA in higher risk patients with diabetes, and without signs or symptoms of cardiovascular disease, followed by CCTA-directed therapy, would reduce cardiovascular risk.
Conclusions Among asymptomatic patients with type 1 or type 2 diabetes, screening for CAD by CCTA did not reduce the composite rate of all-cause mortality, nonfatal MI, or hospitalization for unstable angina at 4 years despite differential use of coronary interventions and favorable trends in lipids and blood pressure. Overall, annual event rates in both control and intervention groups were low (<2%/yr). This may be attributed to the excellent medical management received by all enrollees within Intermountain Healthcare, with baseline levels near or exceeding system targets for HgA1C, LDL-C, and systolic BP. These findings do not support CCTA screening in this population.
Evidencebased Indications for Stress Testing
Stress Testing Indications Significant abnormality of the EKG (ie LBBB, ischemia) Anginal syndrome/equivalent, assess degree and severity of ischemia Arrhythmia--non-sustained ventricular tachycardia, new onset atrial fibrillation New onset heart failure Known CAD with new or worsening anginal symptoms Coronary calcium score of >400 Planned significant vascular surgery with poor functional capacity Intermediate to high-risk general surgery with poor functional capacity and intermediate to high risk of coronary heart disease (CHD)
Advantages of Cardiac PET-CT Best sensitivity and specificity for ischemia Much lower radiation Shorter scan times Pharmacologic stress protocol Provides coronary calcium information
Echocardiography Indications
Echocardiography Indications Pertinent cardiac symptoms (ie dyspnea, syncope, embolic event (but not screening for PFO)) Arrhythmia (frequent PVC, atrial fib, VT, SVT) Suspected pulmonary hypertension Initial evaluation of valvular heart disease Re-evaluation of valvular heart disease with a change in clinical status Initial and repeat evaluation of ascending aortic aneurysm Suspected pericardial effusion, cardiac mass
Echocardiography Indications (cont d) Initial evaluation of heart failure or cardiomyopathy Baseline and serial evaluation in patient undergoing therapy with cardiotoxic agents Syncope if suspected cardiac involvement Familial heart disease including hypertrophic cardiomyopathy, idiopathic cardiomyopathy, Marfan s syndrome
Transesophageal Echo Indications Suspected acute aortic pathology (ie, dissection, transsection, intramural hematoma) Suspected prosthetic valve dysfunction To diagnose infective endocarditis in patients with moderate or high pretest likelihood (ie, patients with prosthetic valves, certain pathogens) or suspected complications of endocarditis (eg, fistula, abscess) Evaluation for left atrial/laa thrombus in a patient with atrial fibrillation/atrial flutter to facilitate clinical decision making regarding anticoagulation, cardioversion, or ablation Evaluation of source of embolism in a young patient for whom a TEE would be performed if the TTE was normal
Transesophageal Echo Indications (cont d) To evaluate for cardiac source of embolus To evaluate for suspected acute aortic pathology (ie, dissection) As follow-up to prior TEE when an interval change would result in a change in therapy (eg, resolution of vegetation fllowing antimicrobial therapy) To evaluate for cardiac pathology when transthoracic echocardiography is nondiagnostic To facilitate clinical decision making regarding anticoagulation, cardioversion, or ablation in patients with atrial fibrillation/flutter To provide guidance for noncoronary percutaneous cardiac interventions (eg, placement of closure devices, valvuloplasty, percutaneous valves) Assist in critical care patient assessment and management