Case Question. Evaluation of Chest pain in the Office and Cardiac Stress Testing

Evaluation of Chest pain in the Office and Cardiac Stress Testing Chad Link, DO FACC Sparrow Hospital Thoracic and Cardiovascular Institute Chairman- TCI Cardiology Section Disclosures Speakers Bureau Actelion Pharmaceuticals, Pfizer and BMS Clinical Research Support Sanofi Aventis Case Question Cc: Chest pain HPI: This is a 30 year old male who presents to your office with complaints of substernal chest pain that has been going on for the past 5 days. He describes the pain as a sharp pain that is constant for most of the day. It doesn t change with position and can occur both at rest or with exertion. He does not experience the pain at night and has no trouble sleeping. He denies any other associated symptoms with the pain. He is otherwise healthy and has no previous medical conditions. He is taking no medications. 1

Case Question https://meds.queensu.ca/central/assets/modules/ecg/normal_ecg.html Case Question Which of the following is the most appropriate diagnostic test or strategy to perform next? a. Regadenoson Nuclear Perfusion Stress Test. b. Coronary Angiography c. Stress Echocardiography d. Exercise Treadmill e. NSAID and Observation f. Send to the ER g. Cardiology Consultation Case Question Cc: Chest pain HPI: This is a 45 y.o c female who presents to the ER with c/o substernal CP which started approx. 2 hours ago. The patient describes the pain as a pressure that radiates to her left shoulder and down her left arm. She noticed the pain while watching TV and states the pain lasted approximately 10 minutes before completely resolving. She states she felt SOB with the CP, but denies N/V, diaphoresis or pain radiating to the back or neck area. She states she took an NSAID which seemed to relieve the pain. She denies history of CAD, including previous MI, however, she does have multiple risk factors for CAD, including diabetes, hyperlipidemia, tobacco use and family history of premature CAD. She has never had a previous cardiac examination, but does see her doctor regularly. She states she has noticed this pain over the last several months with exercise, however it generally goes away with rest. She is currently pain free. 2

Case Question https://en.wikipedia.org/wiki/wellens'_syndrome Case Question Which of the following is the most appropriate diagnostic test or strategy to perform next? a. Regadenoson Nuclear Perfusion Stress Test. b. Coronary Angiography c. Stress Echocardiography d. Exercise Treadmill e. NSAID and Observation f. Send to the ER g. Cardiology Consultation Case Question The patient is referred to Cardiology for an Evaluation. Which of the following is the most appropriate diagnostic test to perform next? a. Regadenoson Nuclear Perfusion Stress Test. b. Coronary Angiography c. Stress Echocardiography d. Exercise Treadmill e. NSAID and Observation 3

History History Differential Diagnosis of Chest pain Chest pain- Cardiovascular Causes Angina Pectoris Unstable Angina Myocardial Infarction Pericarditis Myocarditis Aortic Dissection Aortic Stenosis Variant or Prinzmetal Angina (Coronary Spasm) Ventricular Septal Rupture History Differential Diagnosis of Chest pain Chest pain- Non-Cardiovascular Causes Gastrointestinal Esophageal Spasm Esophageal reflux Esophageal rupture Psychogenic Anxiety Depression Self-gain Neuromusculoskeletal Costochondritis Herpes Zoster Trauma/Chest Wall Pain DJD of cervical spine Pulmonary Pulmonary Embolism Pneumothorax Pleurisy 4

Stress Testing When? Indications What type? Modalities Who? Patient selection How often? Frequency How much? Cost The choice depends on: Ability to Exercise, PMHx, ECG, Body Habitus and Clinical Indication Indications of Stress Testing In patients with symptoms suggestive of coronary heart disease, cardiac stress testing is most often indicated to making the diagnosis and assessing risk OR In patients with known CAD for risk stratification. Stress testing for CHD in asymptomatic is RARELY indicated. Stress Testing: When? Patients with chest pain Change in clinical status Acute coronary syndromes Low, intermediate, high risk (H&P, ECG, markers TIMI risk score) Low: 8-12 h symptom-free Intermediate: 2-3 days symptom-free* High: consider chemical imaging study versus coronary angiography* 5

Stress Testing: When? Before and after revascularization (if residual disease) Demonstration of ischemia Evaluation of post-procedure chest pain Evaluation of territory at risk (if residual disease) Evaluation of restenosis Stress Testing: How Often? Change in clinical symptom pattern Prognostication: There is no absolute guarantee Progression of testing modality to higher sensitivity and specificity Depends on risk factors, their degree of control and intensity of modification Stress Testing: Who? Special Groups Women Lower sensitivity, similar specificity Elderly (>75 years of age) Other evaluated endpoints include chronotropic response, exercise-induced arrhythmias, and assessment of exercise capacity Diabetics Imaging study recommended 6

Stress Testing: Who? Asymptomatic patients Diabetics planning to start exercise Guide to risk reduction therapy in a patient with multiple risk factors Men > 45 and women > 55 Starting exercise Impact public safety High risk due to concomitant disease (PVD, CRF) Stress Testing: Who? Robert C. Hendel et al. JACC 2009;53:2201-2229 American College of Cardiology Foundation Stress Testing: Absolutely Who Not! Acute MI High risk unstable angina Uncontrolled arrhythmias with symptoms Symptomatic, severe aortic stenosis Uncontrolled, symptomatic heart failure Acute PE Acute myocarditis or pericarditis Acute aortic dissection Inability to obtain consent https://www.uptodate.com/contents/image?imagekey=card%2f80110&topickey=card%2f1494&rank=1%7 E150&source=see_link&search=exercise+stress+test&utdPopup=true 7

Stress Testing: Relative Contraindication Left main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities Severe hypertension (SBP > 200, DBP > 110) Tachy or bradyarrhythmias Outflow tract obstruction (HCM) Mental or physical impairment (unsafe) High-degree AV block https://www.uptodate.com/contents/image?imagekey=card%2f80110&topickey=card%2f1494&rank=1%7 E150&source=see_link&search=exercise+stress+test&utdPopup=true Indications of Stress Testing When are stress studies not generally indicated: - Asymptomatic patients < 5 years post CABG or < 2 years post PCI - Routine stress testing in patients undergoing non-cardiac surgery - Low pre test probability of < 10% Indications of Stress Testing The Guidelines- Summary - Symptoms suggestive of angina with an indeterminate or high pre test probability of CAD (exception UA). - Patients with acute CP following exclusion of ACS. - Patient with recent ACS who were treated conservatively or incomplete revascularization. - Known CAD with worsening symptoms. - Routine testing > 5 years post CABG and > 2 years post PCI. - Certain instances in valvular heart disease and preoperative evaluation when unable to function to a level of < 4 METs. 8

Pre-Test Probability ACC/AHA 2012 Guidelines Low probability - <10% - no further testing, except for prognostic information. Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise ECG as first modality). High probability - >90% - non invasive testing for prognosis/management prior to cardiac cath. Age Nonanginal pain Atypical angina Typical angina Men Women Men Women Men Women 30-39 4% 2% 34% 12% 76% 26% 40-49 13% 3% 51% 22% 87% 55% 50-59 20% 7% 65% 31% 93% 73% 60-69 27% 14% 72% 51% 94% 86% Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014 Indications of Stress Testing First, is the stress study indicated? Need to assess symptoms Unstable angina is a contraindication to stress testing Angina Precordial (retro-sternal) chest pain that Is triggered by physical or emotional stress Is relieved by rest or SL NTG Lasts for 15-20 minutes each episode 9

Indications of Stress Testing First, is the stress study indicated? YES indicated If indicated, can the patient exercise? (Exclusions from exercise include Paced rhythm, LBBB, WPW, > 1 mm ST depression at rest or significant ST changes due to LVH) Indications of Stress Testing First, is the stress study indicated? YES indicated If indicated, can the patient exercise? YES Then need to determine the pre-test probability and determine the appropriate test based on risk stratification Pre-Test Probability ACC/AHA 2012 Guidelines Low probability - <10% - no further testing, except for prognostic information. Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise ECG as first modality). High probability - >90% - non invasive testing for prognosis/management prior to cardiac cath. Age Nonanginal pain Atypical angina Typical angina Men Women Men Women Men Women 30-39 4% 2% 34% 12% 76% 26% 40-49 13% 3% 51% 22% 87% 55% 50-59 20% 7% 65% 31% 93% 73% 60-69 27% 14% 72% 51% 94% 86% Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014 10

Stress Testing: Who? Adults with intermediate (10-90%) pre-test probability of CAD Age Sex Typical Atypical Non-anginal Asymp Male Intermediate Intermediate Low Very low 30-39 Female Intermediate Very Low Very low Very low Male High Intermediate Intermediate Low 40-49 Female Intermediate Low Very low Very low 50-59 Male High Intermediate Intermediate Low Female Intermediate Intermediate Low Very low 60-69 Male High Intermediate Intermediate Low Female High Intermediate Intermediate Low Two Components Each cardiac imaging modality has two components: Stressing agent: treadmill, dobutamine, or regadenoson Imaging agent: EKG, echo, or radionuclide tracer (Cardiolite/technetium) NEED TO CHOSE ONE FROM EACH CATEGORY Stress Testing: What Type? EXERCISE ECG ALONE OR IN COMBINATION WITH AN IMAGING MODALITY? Exercise stress testing with electrocardiographic (ECG) monitoring should be the initial test for the majority of patients who can exercise and who have an interpretable ECG. While exercise stress testing with imaging has several advantages over the standard exercise ECG treadmill test. There is insufficient evidence to recommend exercise stress testing with imaging in all patients. https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stresstest?source=see_link&sectionname=indications+for+stress+testing&anchor=h45821 8799#H458218799 11

Stress Testing: What Type? There are also additional circumstances and patient characteristics besides the ability to exercise and resting ECG findings that determine whether a patient should undergo exercise alone or exercise with imaging. These include ischemia localization, viability assessment, prior revascularization, hemodynamic assessment for valvular disease, digoxin use and prior equivocal ECG findings. https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stresstest?source=see_link&sectionname=indications+for+stress+testing&anchor=h45821 8799#H458218799 Stress Testing: What Type? Exercise modality Treadmill Bruce, Modified Bruce, Branching, Naughton Bicycle (recumbent) Chemical/Pharmacologic Dipyridamole (Persantine ) Adenosine (Adenoscan ) Regadenason (Lexiscan ) Dobutamine The Bruce protocol Developed in 1949 by Robert A. Bruce, considered the father of exercise physiology. Published as a standardized protocol in 1963. Remains the gold-standard for detection of myocardial ischemia when risk stratification is necessary. 12

Protocol description Stage Time (min) km/hr Slope 1 0 2.74 10% 2 3 4.02 12% 3 6 5.47 14% 4 9 6.76 16% 5 12 8.05 18% 6 15 8.85 20% 7 18 9.65 22% 8 21 10.46 24% 9 24 11.26 26% 10 27 12.07 28% Exercise Testing: Contraindications Unstable Angina Decompensated CHF Uncontrolled hypertension (blood pressure > 200/115 mmhg) Acute myocardial infarction within last 2 to 3 days Relative contraindications (AS, HCM) Stress Testing: What Type? Non-imaging vs. Imaging Require imaging Intermediate risk non-imaging exercise test Pre-excitation Paced rhythm LBBB or QRS > 120 ms > 1 mm resting ST depression Vessel localization Improved prognostic information https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stresstest?source=see_link&sectionname=indications+for+stress+testing&an chor=h458218799#h458218799 13

Indications of Stress Testing First, is the stress study indicated? YES indicated If indicated, can the patient exercise? NO or has an exclusion then need to consider pharmacological testing Stress Testing: What Type? Choice of imaging modality is multi-factorial Body habitus attenuation, COPD, etc. Local expertise Claustrophobia Understanding of sensitivity and specificity Coincident information: Ejection fraction Valvular structure Exercise capacity https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stresstest?source=see_link&sectionname=indications+for+stress+testing&an chor=h458218799#h458218799 Stressing Agents Stressor Pro Con Treadmill Dobutamine Physiologic, simple, less expensive, good for patient who can walk No exercise needed Caution in patients with arrhythmias Regadenoson, Adenosine/Persantine (used with nuclear) No exercise needed; uncomfortable sensation of heart stoppage Adenosine may induce bronchospasm caution in COPD and asthma! 14

Imaging Agents Stressor Pro Con EKG Simple, less expensive Less information. May not be able to localize the lesion. Can not use if there are baseline EKG abnormalities i.e. LBBB with ST changes Echocardiogram Cardiolite/Technetium Good if patient has pre-existing EKG abnormalities. More info than EKG. Less expensive than nuclear. Localizes ischemia and infarcted tissue. Operator dependent to some extent. May have poor windows due to body habitus. Pre-existing wall motion abnormalities may make interpretation more challenging. Expensive Sensitivity and Specificity Sensitivity Specificity Exercise EKG 68% 77% Stress Echo 76% 88% Nuclear Imaging 79-92% 73-88% Last but not least cost TEST COST - done Hospital COST - done Office ETT $ 637 $ 239 STRESS ECHO $ 1600 $657 NUCLEAR SCAN $ 3000- $4400 $937 15

Case Question A 60yo man is evaluated for chest pain of 4 months duration. He describes the pain as sharp, located in the left chest, with no radiation or associated symptoms, that occurred with walking one to two blocks and resolves with rest. Occasionally, the pain improves with continued walking or occurs during the evening hours. He has hypertension. Family history does not include cardiovascular disease in any first-degree relatives. His only medication is amlodipine. On physical examination, he is afebrile, blood pressure is 130/80mHg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No carotid bruits are present, and a normal S1 and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are normal. EKG showed normal sinus rhythm. Case Question Which of the following is the most appropriate diagnostic test to perform next? a. Adenosine nuclear perfusion stress test. b. Coronary angiography c. Echocardiography d. Exercise treadmill 16

Case Question First, are the symptoms suspicious for unstable angina? Case Question First, are the symptoms suspicious for unstable angina? No Second, what are his risk Factors? Age and HTN Third, what is he pre-test probability of CHD? Pre-Test Probability ACC/AHA 2012 Guidelines Low probability - <10% - no further testing, except for prognostic information. Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise ECG as first modality). High probability - >90% - non invasive testing for prognosis/management prior to cardiac cath. Age Nonanginal pain Atypical angina Typical angina Men Women Men Women Men Women 30-39 4% 2% 34% 12% 76% 26% 40-49 13% 3% 51% 22% 87% 55% 50-59 20% 7% 65% 31% 93% 73% 60-69 27% 14% 72% 51% 94% 86% Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014 17

Case Question First, are the symptoms suspicious for unstable angina? No Second, what are his risk Factors? Age and HTN Third, what is he pre-test probability of CHD? 27% or intermediate risk Can he exercise? Case Question First, are the symptoms suspicious for unstable angina? No Second, what are his risk Factors? Age and HTN Third, what is he pre-test probability of CHD? 27% or intermediate risk Can he exercise? Yes So, now are choices are Exercise EST, Exercise Echocardiography and Exercise Cardiolite (technetium). Which one should we perform on this Intermediate Risk Patient? Case Question Do they have the following: WPW Paced Rhythm LBBB Greater than 1 mm ST depression at rest Digoxin use with ST changes LVH with ST Changes NO.. 18

Case Question First, are the symptoms suspicious for unstable angina? No Second, what are his risk Factors? Age and HTN Third, what is he pre-test probability of CHD? 27% or intermediate risk Can he exercise? Yes So, now are choices are Exercise EST, Exercise Echocardiography and Exercise Cardiolite (over utilized). Which one should we perform on this Intermediate Risk Patient? Sensitivity and Specificity Sensitivity Specificity Exercise EKG 68% 77% Stress Echo 76% 88% Nuclear Imaging 79-92% 73-88% 19

Take Home Points Stress testing is indicated for patients with intermediate pre-test probability Each stress test has two components: an imaging modality and stress modality When determining which stress test to order, keep in mind their ability to exercise, whether any contraindications are present, cost by LOCATION, body weight and specificity and sensitivity Take Home Points Preoperative Evaluation Robert C. Hendel et al. JACC 2009;53:2201-2229 American College of Cardiology Foundation Thank You for your attention! 20