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CAD 2014 - Introduction to Stress testing
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CAD 2014 - Introduction to Stress testing

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Stress Testing

Stress Testing

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  • 1. Exercise ECG Stress Testing for Internists Salah Abusin, MD, MRCP, ABIM, ABIM (Card) Interventional Cardiologist Dubuque, IA, USA
  • 2. Stress Testing for Internists • Principles & Purpose • Patient Preparation • Understanding the report • When NOT to do it – Contraindications • When to do it - Indications
  • 3. Exercise ECG Stress Testing Principles • Elicit cardiovascular & ECG abnormalities not present at rest and to determine the adequacy of cardiac function.
  • 4. Exercise ECG Stress Testing Purpose • estimate prognosis/determine functional capacity • the likelihood and extent of coronary artery disease (CAD)
  • 5. Procedure 1. Patient is connected to ECG monitor in treadmill 2. Check Baseline BP & 12 lead ECG 3. Start treadmill 4. Monitor patient for symptoms 5. Check BP every 3 minutes 6. Treadmill ECG machine records 12 lead ECG periodically
  • 6. When to stop • Symptoms – Patient develops exercise limiting symptoms • BP changes – Drop in BP or rise above 250/115 • ECG Changes – Significant arrhythmias – Pronounced ST changes from baseline
  • 7. Patient Preparation • Patients should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 hours of testing. • Patients should be rested for the assessment, avoiding significant exertion or exercise on the day of the assessment. • Patients should wear clothing that allows freedom of movement, including walking or running shoes, and a loose-fitting shirt with short sleeves that buttons down the front. They should not wear restrictive undergarments during the test.
  • 8. Understanding the Report Duration of Exercise • The most important prognostic information from the ECG Stress Test
  • 9. Understanding the Report Target HR achieved? • The target HR is measured as follows – 220 – Age • HR with exercise should rise to > 85% of target HR to consider this sufficient exercise • If the test is stopped early (in the absence of evidence of ischemia) before >85% of target HR is achieved then the test is considered inconclusive
  • 10. Understanding the Report Did the patient develop any symptoms? • Development of chest pain (with hemodynamic/ECG changes) suggested an increased likelihood of CAD • Chest pain at low workload is considered a poor prognostic sign
  • 11. Understanding the Report BP changes during exercise • SBP should rise with exercise • A drop in SBP with exercise is considered a poor prognostic sign (indication to stop the test)
  • 12. Understanding the Report ST segment changes with Exercise • Development of significant ST depression during Exercise increases the likelihood of significant CAD • Development of ST Elevation is considered a poor prognostic sign (indication to stop the test)
  • 13. Understanding the Report Arrhythmias during Exercise • Development of VT is considered a poor prognostic sign (indication to stop the test)
  • 14. When not to do it? When it is not safe • ACS – Acute Phase • Uncontrolled arrhythmia • Uncontrolled HF, uncontrolled HTN • Symptomatic Severe Ao stenosis • Acute PE • Suspected or known dissecting aneurysm • Active or suspected myocarditis, pericarditis, or endocarditis • Acute noncardiac disorder that may affect exercise performance or be aggravated by exercise
  • 15. When not to do it? When the ECG cannot be interpreted • ACS • Uncontrolled arrhythmia • Uncontrolled HF, uncontrolled HTN • Symptomatic Severe Ao stenosis • Acute PE • Suspected or known dissecting aneurysm • Active or suspected myocarditis, pericarditis, or endocarditis • Acute noncardiac disorder that may affect exercise performance or be aggravated by exercise
  • 16. Indications - Stable Angina • Diagnosis of Obstructive CAD – Highest Yield in patients with intermediate probability – When used in patients with low probability, increases likelihood of false positive (especially in women) • Risk Stratification in patients high probability of CAD
  • 17. Indications – Unstable Angina • Risk Stratification for Low risk Unstable Angina (negative troponin) after 8-12 hours
  • 18. Indications – STEMI • Before discharge for patients who underwent successful thrombolysis and did NOT undergo diagnostic coronary angiography • Before discharge in patients who came with late presenting STEMI and did NOT undergo diagnostic coronary angiography
  • 19. • Thanks