Stress testing 2013

Tom Marker MD FACC

Cardiovascular Consultants of Oregon

Questions on Stress Testing What are the indications for a treadmill test (what

type of patient should we consider)?How do Beta –blockers effect stress testing?

Should they be discontinued before testing?How long does the patient need to be NPO prior to

test?What contraindications exist for treadmill testing?

What about LBBB (or RBBB)?How is understanding of Bayesian statistical theory

important when ordering stress tests?

NPO and Stress TestingFor ETT, overnight fast or 2 hours post prandialFor MPI (myocardial perfusion imaging) want > 4

hours NPO for both resting and stress imaging

PURPOSES OF CARDIAC STRESS TESTINGTo aid in establishing the diagnosis of CAD and

assess suspected or proven CADTo estimate prognosis (risk stratification)As a tool to determine functional capacity or the

effects of therapyResults can be enhanced by combining with

Metabolic Gas Analysis, Radionuclide Imaging, Echocardiography

I. Diagnosis of Obstructive Coronary Artery Disease

II. Risk Assessment and Prognosis in Patients with Symptoms or a Prior History of Coronary Artery Disease

III. Post MI Risk Assessment and Prognosis

IV. Special GroupsAsymptomatic PatientsPost Revascularization PatientsRhythm DisordersWomen

Indications for Non-Invasive Cardiac Stress Testing

• Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective

• Class II: Conditions for which there is conflicting evidence and /or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

IIA Weight of evidence/opinion is in favor of usefulness/efficacy

IIB Usefulness/efficacy is less well established by evidence/opinion

• Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

I. Diagnosis of Obstructive Coronary Artery Disease Using ETT

• Class I: Adult patients with an intermediate pretest probability of CAD. Includes RBBB or less than 1 mm of resting ST depression

• Class II A: Patients with vasospastic angina

• Class II B: High pretest likelihood of CAD

Low pretest likelihood of CAD

Patients taking digoxin

Patients with LVH on EKG

• Class III: WPW, Paced, LBBB, >1mm ST depression at rest

ACC/AHA 2002 Guideline Update for Exercise Testing

Age (Yr)

Gender Typical Angina

Atypical Angina

Non-Anginal

Asymptomatic

30-39 Men Intermediate Intermediate Low Very Low

Women Intermediate Very Low Very Low Very Low

40-49 Men High Intermediate Intermediate Low

Women Intermediate Low Very Low Very Low


Women Intermediate Intermediate Low Very Low


Women High Intermediate Intermediate Low

Pretest Probability of Obstructive CAD

Diagnostic Utility Greatest in the Intermediate Pretest Probability Group

Diagnosis of Obstructive Coronary Artery Disease

High > 90% Intermediate-> 10-90% Low 5-10% Very Low <5%

Circulation 64, no. 2, 1981

Typical Angina

Patients with substernal discomfort precipitated by exertion and relieved by rest or NTG lasting 5 to 10 minutes; often radiating to jaw, neck, shoulder or inner aspect of the arm.

Probable Angina

Patients described most of the features of typical angina but were atypical in some respects, e.g.; atypical radiation, non-exertional, NTG ineffective, prolonged for more than 15-20 minutes after rest if exertional.

Non-anginal chest pain

Patients with overall pattern of chest pain different from above, e.g., different character of discomfort (sharp), nonexertional or unrelieved by rest, unrelieved by NTG, or otherwise apparently non-cardiac in origin.

The Importance of Bayesian Theory on Noninvasive Testing for CAD

PV = % of pts with abnormal test who have CAD TP/TP + FP

ETT Sensitivity and SpecificitySensitivity = 68%Specificity = 77%Predictive Accuracy = 73%Based on Meta Analysis of 147 studies including

24,047 subjects

Predictive Accuracy = % of true test results TP +TN/total # tests performed

STRESS TESTING FOR THE DIAGNOSIS OF CAD

Ischemia Induction (or demonstration of differences in perfusion)

Exercise

Pharmacological

Adenosine (with or without exercise)

Dipyridamole (with or without exercise)

Dobutamine (with or without Atropine)

Ischemia Detection (or ‘differences in perfusion’ detection)

Surrogate for Ischemia

EKG (ETT) ST Segment Changes

Echocardiography Regional Wall Motion Changes

(Stress Echo)

SPECT MPI Regional Photon Count Changes

Cardiac Stress Testing in the Adult

Advantages of the Standard Exercise EKG Stress Test

Low Cost, Availability, Acceptability, Convenience

Exercise tolerance determined

Provides independent prognostic information

Correlate symptoms with activity

Assess rhythm, rate, BP, response to activity

Disadvantages of the Standard Exercise EKG Stress Test

Limited Sensitivity and Specificity

Does not localize ischemia

No Estimate of LV Function

Requires Cooperation and Ability to Walk

Benefits of Pharmacological Stress Testing with Imaging over Exercise Stress (+/- Imaging)

• Can be applied to almost all patients

• Less motion artifact (Ex. Echo)

• % of Patients not able to reach adequate HR may approach 40% - provides an alternative with comparable sensitivity/specificity


ETT: Myocardial Physiology

Myocardial oxgen consumption is affected by: HR, SBP, LVEDV, Wall Thickness, Contratility

RPP = HR x SBP => Estimates MO2With normal individual’s Myocardial O2 Supply is

determined by demand and is sufficient (Coronaries, Valves, Myocardium, Hgb, etc all normal)

Myocardium is Aerobic (little capacity for anaerobic fx) AND Myocardial O2 extraction is at near-Max at rest: therefore to increase MO2 must increase coronary blood flow

There is a direct linear relationship between MO2 and Coronary Blood Flow

In obstructive CAD demand can exceed ability to supply and ischemic threshold can be crossed

Normal response to progressive treadmill protocol in healthy subjects. bpm Indicates beats per minute.

Fletcher G F et al. Circulation 1995;91:580-615

Copyright © American Heart Association

Cardiac Stress Testing in the AdultAssessment of Maximal Effort

Borg scale 17-20

Signs of fatigue, profound dyspnea

Age-predicted maximal heart rate (MPHR = 220-age)

Age-predicted MET level attained (Max MET = 18.0 - 0.15(age)

Example

60 YO patient

MPHR = (220-60) = 160

Max MET = 18.0 - (.15x60)

= 18.0-9.0 = 9.0* Morris CK, Myers J. Kawaguchi, T, et al: Nomogram based on metabolic equivalents and age for assessing aerobic exercise capacity in men. J Am coll Cardiol 1993; 22: 175-182

Borg Scale for Rating Perceived Exertion

Decreased Myocardial Perfusion resulting in the onset

of Ischemia

Regional Wall Motion

Changes

ST Segment Changes

Development of Angina

Start Exercise

Timeline of Events During Exercise Stress

Time

Timeline not to scale

The Ischemic Cascade

EKG Exercise Testing

Positive: Classical Definition

A. ST Segment Depression > 0.1x mV 80mSec after the J Point

B. Horizontal ST Segment Depression > 0.1 mV

C. Downsloping ST Segment Depression

Normal Abnormal

A B C

SlowUpslope

Horizontal DownSloping

AHA/ACC 2013 Exercise Standards for Stress Testing


Exercise Test Termination

Absolute Reasons

Drop in Systolic BP > 10 mm Hg when accompanied by other evidence of ischemia

Moderate to severe angina

Increasing nervous system symptoms(e.g. ataxia, dizziness)

Signs of poor perfusion (pallor, cyanosis)

Subject’s desire to stop

Sustained VT

ST elevation > 1 mm in leads without diagnostic Q waves (other than V1 or aVR)



Exercise Test Termination

Relative Reasons

Drop in systolic BP > 10 in the absence of other symptoms of ischemia

ST or QRS changes such as excessive ST depression (> 2 mm) or marked axis shift

Arrhythmias other than sustained VT

Fatigue, dyspnea, wheezing, leg cramps, claudication

Development of BBB or an IVCD that cannot be distinguished from VT

Increasing chest pain

Hypertensive response to exercise (>250/115)


EXERCISE PARAMETERS ASSOCIATED WITH A POOR PROGNOSIS AND INCREASE LIKELIHOOD OF

MULTIVESSEL CADDuration of symptom-limited exercise < 6 METsFailure to increase SBP > 12o mmHg; or sustained

decrease SBP of over 10 mmHg.ST segment depression > 2 mm; downsloping ST

depression starting at < 6 METs, involving > 5 leads, lasting over 5 minutes in recovery

ST segment elevation in a lead without Q waves (and not aVr or V1)

Angina during exerciseReproducible sustained (>30 sec) or symptomatic VT

Data Demonstrating Prognostic Value of ETT

Copyright ©1997 American Heart Association

Gibbons, R. J. et al. Circulation 1997;96:345-354

Nomogram of the prognostic relations embodied in the treadmill score

DUKE TREADMILL SCORE

MEASUREMENTS AVAILABLE FROM ETT EKG

Maximum ST depression or elevation ST depression slope (downsloping, horizontal, upsloping) Number of leads with ST depression Duration of ST changes into recovery ST/HR indexes Exercise –induced ventricular arrhythmias Time to onset of ST deviation

HEMODYNAMIC Maximum exercise HR and SBP Maximum Double Product (HRxSBP) Total exercise duration/METS achieved Exertional hypotension (lower than baseline pre-exercise BP) Chronotropic incompetence

SYMPTOMATIC Exercise induced Angina Pectoris Exercise limiting symptoms Time to onset of Angina Pectoris

SAFETY AND RISKS OF EXERCISE TESTING

Nonselected patient population: Mortality < 0.01% and Morbidity < 0.05%

Within 4 weeks of MI: Mortality = 0.03% and Morbidity = 0.09% (reinfarction, cardiac arrest)


Absolute

Acute MI

High Risk UA

Uncontrolled Arrhythmias causing symptoms or hemodynamic compromise

Uncontrolled Heart Failure

Symptomatic Severe Aortic Stenosis

Acute Pulmonary Embolism or Pulmonary Infarction

Acute Pericarditis / Myocarditis

Acute Aortic Dissection

Relative

Left Main Stenosis

Moderate Aortic or Mitral Stenosis

Electrolyte abnormalities

Severe Hypertension(>200/110)

IHSS

Mental or Physical Impairment leading to inability to exercise

High Grade AV Block

Tachycardias or Bradyarrhythmias

Mental or Physical impairment that limits adequate levels of exercise

Contraindications to Exercise Stress


Contraindications to Pharmacologic Stress

ACTIVE ASTHMA -- ADENOSINE/DIPYRIDAMOLE

HIGH GRADE AV BLOCK -- ADENOSINE

First Degree or Wenchebach AV Block -- Adenosine

Mild Bronchospastic disease – Adenosine/Dipyridamole

Absolute

Acute MI

High Risk UA

Uncontrolled Arrhythmias causing symptoms or hemodynamic compromise

Uncontrolled Heart Failure

Symptomatic Severe Aortic Stenosis

Acute Pulmonary Embolism or Pulmonary Infarction

Acute Pericarditis / Myocarditis

Acute Aortic Dissection

Relative

Left Main Stenosis

Moderate Aortic or Mitral Stenosis

Electrolyte abnormalities

Severe Hypertension(>200/110)

IHSS

Mental or Physical Impairment leading to inability to exercise

High Grade AV Block

Tachycardias or Bradyarrhythmias

Mental or Physical impairment that limits adequate levels of exercise

Beta BlockersReduce mortality and reinfarction after MIReduce frequency of angina and increase the anginal

thresholdSlow HR, reduce MVO2, prolong diastole and

perfusion time, reduce RPPReduce the sensitivity of Stress testing for the

diagnosis of CAD (Exercise as well as Pharmacologic stress tests)

BETA BLOCKER THERAPY AND ETT

In general, when doing ETT for the purpose of (new) diagnosis of CAD, try to withdraw Beta Blocker therapy prior to test

In general, when trying to assess the effectiveness of medical therapy for CAD or symptoms in a patient with known CAD on Beta Blocker therapy, best to continue their use prior to the test

Comparative Sensitivity, Specificity, and Accuracy of EKG and Imaging Stress Tests

Test Sensitivity Specificity Accuracy

ETT 68% 77% 73%

MPI 87% 78% 82%

SEcho 88% 80% 84%

Costs of Exercise Stress Tests at GSRMC

Cardiac Test Total Cost at GSRMC

CXR, 2V $299.00

EKG $45.00

ETT $489.00

COMPLETE ECHO $1,128.00

STRESS ECHO, ETT $1,350.00

STRESS ECHO, DOBUT $1,550.00

MPI STRESS, ETT $2,000.00

MPI STRESS, ADENOSINE $2,797.00

MPI STRESS, DOBUT $2,446.00

STRESS ECHOCARDIOGRAPHY

2D Echo imaging before, during and after cardiovascular stress

Cost effective means to assess CPStress ETT, Bicycle ergometer, DobutCompare wall motion at rest to stress can identify

inducible ischemic dysfx and assign a specific coronary territory

Sensitivity~88% (74-97): Specificity~84% (62-93%)

Stress Echocardiography

Advantages

Comprehensive – Ischemia, EF, Valvular function

Widely available

Relatively low cost

Disadvantages

Limited by echocardiographic windows and body habitus

Highly technician dependent

Steep technician learning curve

Interpreting physician dependent

FACTORS AFFECTING STRESS ECHOCARDIOGRAPHY

False Negatives False PositivesInadequate stressAntianginal therapyLeft Circumflex diseasePoor image qualityDelayed image acquisition

Interpreter bias (“over-call”)Basal Inferior Wall locationAbnormal septal motion due

to LBBB, Paced Rhythm, post CABG

CardiomyopathyHypertensive response to

stress

Nuclear Cardiology: SPECT Perfusion

Injected isotope extracted by viable myocytesPhotons emitted from myocardium in proportion to

uptake, which is related to perfusionGamma camera captures gamma photons and converts to

digital data representing magnitude and location of uptakePhotons Collimator Detector crystal Scintillation

events photo multiplier Processing computerSingle Photon Emission Computed Tomography SPECT

images: Myocardial perfusion images (MPI) represent distribution of perfusion throughout myocardium

Advantages

Applicable to almost all patients

Incremental value - prognosis, guidance to therapy

Assessment of LV function

Disadvantages

Detects coronary heterogeneity as a surrogate for ischemia

Relatively Expensive

Artifacts

Isotope availability

Radiation exposure

Cardiac Scinitgraphy Techniques

CAPTURE OF EMITED PHOTONS BY A GAMMA CAMERA

SPECT IMAGING TECHNIQUE

SPECT TOMOGRAPHIC DISPLAY SHORT AXIS

SPECT TOMOGRAPHIC DISPLAY VERTICAL LONG AXIS

SPECT TOMOGRAPHIC DISPLAY HORIZONTAL LONG AXIS

EFFECT OF CORONARY RESISTANCE ON CORONARY BLOOD FLOW RESERVE 1

EFFECT OF CORONARY RESISTANCE ON CORONARY BLOOD FLOW RESERVE 2

CORONARY BLOOD FLOW RESERVE ABNORMALITIES

MPI SPECT REVERSIBLE DEFECTS: ANTETERIOR AND APICAL

MPI STRESS TEST REPORTS INormalFixed defect implies Myocardial InfarctionReversible defect implies obstructive CAD/ischemiaMixed defect implies “partial thickness infarct” with

ischemia in remaining, viable myocardium

MPI STRESS TEST REPORT II

17 Segment Cardiac modelScored 0 – 4 (0 is normal, 4 is severely abnormal);

total = 68 (4x17)SSS (sum stress score) SRS (sum rest score) SDS (sum

difference score): Normal – 0 - 3 Mild – 4-8 Moderate – 8-12 Severe – 13 or greater

Total Perfusion Defect (TPD) - % myocardium estimated involved (SSS/68)

Severity predicts prognosis/risk of MACE

PET IMAGING

II. Risk Assessment and Prognosis in Patients with Symptoms or a Prior History of Coronary Artery Disease

• Class I: Patients undergoing initial evaluation with suspected CAD (Specific exceptions noted in II B below)

Patients with suspected or known CAD previously evaluated with significant change in clinical status

Low risk unstable angina patients 8 hrs post presentation free of active ischemia or CHF

Intermediate risk UA patients 2 days post presentation free of active ischemia or CHF

• Class II A: Intermediate risk UA with negative markers and EKGs 6 hrs post symptoms

• Class II B: Patients with resting EKG abnormalities including

Pre-excitation

Paced Rhythm

Greater than 1 mm resting ST depression

Complete LBBB

• Class III: Patients with severe comorbidity likely to limit life expectacy and/or candidacy for revascularization


III. Post MI Risk Assessment and Prognosis

Class I

Before discharge for prognostic assessment, activity prescription, evaluation of medical therapy (submaximal at about 4 to 6 days.

Early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the predischarge exercise test was not done (symptom limited; about 14 to 21 days).

Late after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the early exercise test was submaximal(symptom limited; about 3 to 6 weeks

Class IIa

After discharge for activity counseling and/or exercise training as part of cardiac rehabilitation in patients who have undergone CABG

Class IIb

Patients with the following EKG abnormalities:

LBBB, Pre-excitation, LVH, Digoxin, >1mm ST depression, Ventricular paced rhythm

Periodic monitoring in patients who continue to participate in exercise training or cardiac rehabilitation

Class III

Severe comorbidity limiting life expectancy


IV. Exercise Testing Special Groups

A. Asymptomatic Patients without known CAD

• Class I: None• Class II A: Diabetics who plan to start vigorous exercise

• Class II B: Evaluation of patients with multiple risk factors

Evaluation of Asymptomatic men older than 40 years and women older than 50 years:

who plan to start exercise program

Who are involved in occupations in which impairment might impact public safety

Who are at high risk for CAD due to other diseases (e.g. chronic renal failure, diabetes mellitus)

• Class III: Routine Screening of asymptomatic men or women



B. Exercise Testing Before and After Revascularization

Class I: Demonstration of ischemia before revascularization

Evaluation of patients with recurrent symptoms suggesting ischemia after revascularization

Class II

A: After discharge for activity counseling and/or exercise training as part of cardiac rehab in patients who have undergone coronary revascularization

Class II

B: Detection of restenosis in selected, high-risk asymptomatic patients within the first months after angioplasty

Periodic monitoring of selected, high-risk asymptomatic patients for restenosis, graft occlusion, or disease progression

Class III: Localization of ischemia for determining the site of intervention (EKG stress testing only) Routine, periodic monitoring of asymptomatic patients after PTCA or CABG

Routine periodic monitoring following PCI or CABG without indications



C. Assessment of Rhythm Disorders

Class I:

Identification of appropriate settings in patients with rate-adaptive pacemakers

Evaluation of congenital CHB in patients considering increased physical activity or participation in competitive sports

Class II A:

Evaluation of patients with known or suspected exercise-induced arrhythmias

Evaluation of medical, surgical, or ablative therapy in patients with exercise induced arrythmias (including atrial fibrillation)

Class II B:

Investigation of isolated ventricular ectopic beats in middle-aged patients without other evidence of CAD

Investigation of prolonged 1st degree or 2nd degree AVB, LBBB, RBBB, or isolated VPC’s in young patients considering participation in competitive sports

Class III:

Investigation of isolated ectopic beats in young patients



D. Women

Exercise Testing in Women Less Sensitive than Men

Sensitivity = 61%

Lower Prevalence of Severe CAD (from Bayesian standpoint, this creates a difficult situation for noninvasive testing)

Higher incidence of Single Vessel CAD

Inability to exercise to maximum aerobic capacity

The ST response to exercise appears to be gender-related from an early age, with ST-segment abnormalities more common in third-grade girls than boys

Exercise Testing In Women Less Specific than Men

Specificity = 68%

Greater prevalence of:

Mitral Valve Prolapse

Syndrome X

Prognostic Factors for Patients with Coronary Disease


D. Women

“ Concerns about false-positive ST-segment responses may be addressed by careful assessment of post test probability and selective use of stress imaging tests before proceeding to angiography”

“The optimal strategy for circumventing false-positive test results for diagnosis of CAD in women remains to be defined”

ACC/AHA Guideline for Exercise Testing 1997

ACC/AHA Guideline for Exercise Testing 2002“Although the optimal strategy for circumventing false-positive test results for diagnosis of CAD in women remains to be defined, there are currently insufficient data to justify routine stress imaging tests as the initial test for CAD in women

A Negative Standard Maximal Exercise Test Gives Important Information Predicting Low Likelihood of Occlusive Coronary Artery Disease

A Positive Standard Maximal Exercise Test has lower Predictive Value than in men for the dx of Occlusive Coronary Artery Disease - Further Testing may be appropriate. Concern about false-positive ST-segment responses may be addressed by careful assessment of posttest probability and selective use of stress imaging tests before the patientproceeds to angiography.


D.Women

Vasodilators Inotropes Dipyridamole Adenosine Dobutamine Arbuamine

Side effect (n = 3911) (n = 9256) (n = 1118) (n = 697)

Total S/E 47% 81% 35% (cardiac) 51%Fatal MI 0.05% 0% 0 0Nonfatal MI 0.05% 0.01% 0 0.10%Bronchospasm 0.15% 0.07% 0 0Anxiety/tremor — — 6 % 14%Chest pain 20% 35 % 19 % 51 %Dizziness 12 % 9 % — 5 %Dyspnea 3 % 35 % 5 % 21 %Flushing 3 % 37 % — 6 %Headache 12 % 14 % 4 % 11 %Hypotension 5 % — 3 % 6 %

Cardiac Stress Testing in the AdultPharmacologic Stress Testing -- Side Effects

Factors That Affect Sensitivity and Specificity of Exercise or Pharmacologic Stress

Scintigraphy

False negatives False positivesDecreases Sensitivity Decreases Specificity

• Inadequate stress • Over interpretation, interpreter bias

• Antianginal therapy • Tissue Attenuation Artifacts• Mild CAD Breast, Diaphragm• Planar views only • LBBB• Balanced Ischemia (LM + RCA)

Author N = Imaging Modality Sensitivity Specificity

Quinones 1992 112 StressEcho 74 88

Tl SPECT 76 81

Pozzoli 1991 75 Stress Echo 71 96

MIBI SPECT 84 88

Salustri 1992 37 Stress Echo 83 86

MIBI SPECT 87 71

Direct Diagnostic Comparisons between Exercise Stress Echocardiography and Exercise Perfusion Scintigraphy

Author N = Imaging Modality Sensitivity Specificity

Gunalp 1993 19 Dobut Echo 70 89

MIBI SPECT 90 89

Marwick 1993 217 Dobut Echo 72 83

MIBI SPECT 76 67

Forster 1993 21 Dobut Echo 75 89

MIBI SPECT 83 89

Senior 1994 61 Dobut Echo 93 94

MIBI SPECT 95 71

Total 390 Function 80 91

Perfusion 81 71

Direct Diagnostic Comparisons between Dobutamine Stress Echocardiography and Dobutamine Stress Perfusion

Scintigraphy

Echocardiographic vs. Scinitigraphic Methods for the Detection of Occlusive

Coronary Artery Disease

SUMMARY

• Both techniques have comparable sensitivity and sensitivity

• Echocardiography is highly dependent on technician expertise

• Echocardiography is less costly

• Scintigraphy can be applied to almost all patients

The LBBB Problem

EKG: Insensitive due to resting ST repolarization changes

Echo: Resting wall motion changes due to paradoxical septal motion

SPECT MPI Septal asynchrony with decreased diastolic time interval (coronary filling time) results in relative septal hypoperfusion

Patients with resting LBBB, or those that develop rate related LBBB should undergo adenosine perfusion imaging without exercise.

The Future 64 Slice CT Scan

Non-Invasive Angiography

Sensitivity 94%

Specificity 97%

PPV 97%

NPV 93%

Am J Cardiol 2006; 98:145-148

Relative Costs of Exercise Stress Tests based on RVU Analysis

Test HCPCS Description RVU'sTotal Test

RVU'sMedicare

Cost

EKG Stress Test 93015 Cardiovascular stress test 2.85 2.85 $105.45

Stress Echocardiography 93015 Cardiovascular stress test 2.85 6.85 $253.4593350 Echo transthoracic 4

Stress MPI 93015 Cardiovascular stress test 2.85 22.37 $827.69

78465 Heart image (3d), multiple 14.4778478 Heart wall motion add-on 2.5378480 Heart function add-on 2.52

64 Slice CT Scan 71275 Ct angiography, chest 15.45 15.45 $571.65

Coronary Angiography 93545 Inject for coronary x-rays 46.17 54.53 $2,017.6193555 Imaging, cardiac cath 0.57 93510 Left heart catheterization 7.79

Exercise TestingSuggested Approach

Dx CAD Certain?

Risk Prognosis Uncertain ?

Assess Rx, Exercise, or disability?

Contraindications to Stress?

Can Patient Exercise

Is Resting EKG Suitable for detecting Ischemia?

Do EKG Stress Test

C/W High Risk CAD ?

Dx Certain?

Consider Angiography

Pharmacologic Imaging

LBBB ?

Consider Angiography/Revascularization

Consider imaging study or angiography

Y

Y

N

N

N

Y NN

Continue/Initiate/Modify Plan

N

Y

Y

Y

N

N

Continue/Initiate/Modify Plan

N Adenosine SPECT MPI with Exercise

Y

Adenosine SPECT MPI

Inappropriate Use of SPECT MPI

Evaluation of chest pain in patient with low pretest likelihood of CAD, EKG interpretable and able to exercise

Symptomatic acute chest pain with high pretest probability of CAD and EKG showing ST elevation

Asymptomatic patient with low CAD risk based on Framingham Risk Criteria

Asymptomatic or stable symptoms with previously normal MPI, high CAD risk and annual MPI study ****

Inappropriate Use of SPECT MPI JACC Oct 18, 2005

Asymptomatic or stable symptoms with previously normal MPI, high CAD risk and annual MPI study

Exercise Testing After Coronary Artery Bypass Graft Surgery

“Because of these considerations, together with the need to document the site of ischemia, stress imaging tests are more favored in this group, although there are insufficient data to justify recommending a particular frequency of testing.”

ACC/AHA 2002 Guidline Update for Exercise Testing

Inappropriate Use of SPECT MPI****

Inappropriate Use of SPECT MPI

Asymptomatic and prior calcium agatston score less than 100

Preoperative risk assessment in Low-Risk Non-Cardiac surgery (eye, superficial)

Preoperative risk assessment in Intermediate-Risk Non-Cardiac surgery in patients with exercise tolerance > 4 METS

Preoperative Evaluation for High Risk, Non-Cardiac Surgery in Asymptomatic patients up to one year**** post normal cath, noninvasive test, or previous revascularization

Following ACS with complications (e.g. shock) in patients who underwent thrombolytics

Asymptomatic Post Revascularizatrion prior to “routine” hospital discharge

Asymptomatice Post-Revascularization in patients that were symptomatic prior to revascularization and less than two years after PCI****

Stress testing 2013

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