Drihabsuliman

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STRESS PROTOCOLS

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  • Drihabsuliman

    1. 1. Dr. Ihab Suliman MBBS,MRCP,Diplomat CBNC
    2. 2. Basics of MPI( Myocardial Perfusion Imaging) <ul><li>Radionuclide injected at rest and/or stress </li></ul><ul><li>Radionuclide taken up by myocardium and gamma rays emitted </li></ul><ul><li>Rest images compared with stress images </li></ul><ul><li>Decreased perfusion stress and rest – MI </li></ul><ul><li>Decreased perfusion at stress, normal with rest – ischemia </li></ul><ul><ul><li>Area indicates the coronary artery, size correlates with severity of CAD </li></ul></ul>
    3. 3. MYOCARDIAL PERFUSION GATED SPECT-STRESS <ul><li>A pharmacological stress agent used in patients with asthma, COPD, and emphysema is: </li></ul><ul><li>A. adenosine </li></ul><ul><li>B. aminophylline </li></ul><ul><li>Dobutamine </li></ul>
    4. 4. <ul><li>Dobutamine </li></ul>
    5. 5. MYOCARDIAL PERFUSION GATED SPECT-STRESS <ul><li>3. Stress imaging may begin approximately _______ after 99mTc-cardiolite injection in an exercise patient. </li></ul><ul><li>A. Immediately </li></ul><ul><li>B. 15-45 minutes </li></ul><ul><li>next day </li></ul>
    6. 6. <ul><li>15- 45 Minutes. </li></ul><ul><li>10-30 Minutes true for Thallium </li></ul>
    7. 7. <ul><li>4. A patient that weighs 450 pounds who is claustrophobic would be a candidate for _______. </li></ul><ul><li>A. planar imaging </li></ul><ul><li>B. SPECT imaging </li></ul><ul><li>C. PET imaging </li></ul>
    8. 8. A-Planar Imaging
    9. 9. Stress Test Options <ul><li>ETT (EST / Regular) Bruce protocol </li></ul><ul><li>ETT with Myocardial Perfusion Imaging(TST) </li></ul><ul><li>Pharmacological Stress( Single day , 2-day protocol) </li></ul><ul><ul><li>Dipyridamole (Persantine ) </li></ul></ul><ul><ul><li>Adenosine </li></ul></ul><ul><ul><li>Dobutamine </li></ul></ul><ul><ul><li>Stress ECHO: Exercise </li></ul></ul><ul><ul><li> Dobutamine </li></ul></ul>
    10. 10. Case _ 1 <ul><li>60 years old male Diabetic HBA1C 12 %, Hypertensive , Dyslipidemic, came to the cardiology clinic with Exertional Chest Pain, which is Retrosternal , radiates to both arms , associated with SOB & Sweating, recently He is getting Chest Pain at Rest. What should be done? </li></ul><ul><li>Threadmill nuclear stress test. </li></ul><ul><li>Regular stress test. </li></ul><ul><li>Cardiac Cath. </li></ul>
    11. 11. <ul><li>Cardiac Cath </li></ul><ul><li>Cardiac Cath done , showed 50-60% lesion at Mid LAD which is small in Diameter, no other Coronary lesions, what should be done ? </li></ul><ul><li>Aggressive medical therapy with Persantin uclear stress test. </li></ul><ul><li>Stenting of LAD with BMS </li></ul><ul><li>Go for Bypass surgery LIMA to LAD </li></ul>
    12. 14. MYOCARDIAL PERFUSION SPECT-REST <ul><li>INDICATIONS </li></ul><ul><li>Detection and evaluation of Coronary Artery Disease </li></ul><ul><li>Evaluation of myocardial viability in patients who are candidates for surgery </li></ul><ul><li>Risk assessment in patients with Coronary Artery Disease </li></ul><ul><li>Evaluation of physical indicators: Myocardial Infarction, chest pain, shortness of breath, family history of heart disease </li></ul>
    13. 16. Absolute Contraindications <ul><li>Recent AMI (within 48 hrs) </li></ul><ul><li>Unstable Angina </li></ul><ul><li>Uncontrolled arrhythmias </li></ul><ul><li>Severe symptomatic aortic stenosis </li></ul><ul><li>Uncontrolled symptomatic CHF </li></ul><ul><li>Acute pulmonary embolus. </li></ul><ul><li>Acute aortic dissection/aneurysm </li></ul><ul><li>Uncontrolled HTN </li></ul>
    14. 17. Relative Contraindications <ul><li>Left main disease </li></ul><ul><li>Mod stenotic valve disease </li></ul><ul><li>Electrolyte abnormalities </li></ul><ul><li>Severe arterial HTN (sys BP>200mm Hg, dias >110mm Hg) </li></ul><ul><li>Tachy/Brady arrhythmias </li></ul><ul><li>HCM or LVOT obstruction </li></ul><ul><li>Acute DVT </li></ul><ul><li>CVA within 3 months </li></ul><ul><li>Inability to adequately exercise </li></ul><ul><li>Acute systemic illness (pneumonia, severe anemia, infections) </li></ul>
    15. 18. EKG Exclusion Criteria <ul><li>Resting EKG abnormalities which render interpretation inconclusive and nuclear stress would be indicated. </li></ul><ul><li>Baseline ST segment depressions > 1mm </li></ul><ul><li>Digoxin </li></ul><ul><li>WPW </li></ul><ul><li>Left Bundle Branch Block </li></ul><ul><li>PPM </li></ul><ul><li>EKG criteria for LVH </li></ul>
    16. 19. Exercise Procedure(Bruce Protocol) <ul><li>Goal 220-age= 100% MPHR, need 85% for diagnostic study. </li></ul><ul><li>Low-level or Modified Bruce: Goal 75% MPHR or symptom limited. </li></ul><ul><li>NPO for 3 hours </li></ul><ul><li>Must be able to walk treadmill </li></ul><ul><li>No smoking ( no nicotine patches) </li></ul><ul><li>Hold beta blockers, nitrates (check with MD) </li></ul><ul><li>Comfortable clothing/shoes </li></ul>
    17. 20. Bruce Protocol
    18. 21. <ul><li>Mets are defined as: </li></ul><ul><li>Metabolic equivalents + Multiples of 02 consumption of 3.5 ml/kg/min by a person in the sitting position. Describes functional capacity. </li></ul><ul><li>Rate pressure product = Max HR x Max SBP </li></ul><ul><li>(25,000 is a good effort) Useful if Hr is low and SBP is high. </li></ul>
    19. 22. Modified Bruce: 2 minute intervals ½ stages Speed is constant grade increases. Naughton Protocol: 2 minute interval at 2 mph with grade changes 0%, 3.5%, 7%, 10.5%, 14%, 17.5%, 20%. These protocols are important in a setting of Post-MI( 5 TH or 6 th day on discharge)
    20. 23. Indications for termination of test <ul><li>Absolute </li></ul><ul><li>Drop in sys BP of >10mm Hg from pre-test standing BP despite increase in workload with ischemic evidence </li></ul><ul><li>Moderate to severe angina </li></ul><ul><li>Sustained VT </li></ul><ul><li>ST elevation > 1mm in leads without diagnostic Q waves </li></ul><ul><li>Subjects desire to stop </li></ul><ul><li>Dizziness, near syncope, ataxia </li></ul><ul><li>Technical difficulties with EKG/BP </li></ul><ul><li>Signs of poor perfusion (pallor, cyanosis) </li></ul>
    21. 24. Relative <ul><li>Drop systolic BP > 10mm Hg despite increase workload without evidence of ischemia </li></ul><ul><li>ST depression ≥ 2mm horizontal/downsloping </li></ul><ul><li>Arrhythmias: multifocal PVC’s, triplets, tachy/brady arrhythmias </li></ul><ul><li>Fatigue, leg cramps, SOB, wheezing </li></ul><ul><li>New BBB or IVCD </li></ul><ul><li>HTN: sys > 250mm Hg, dias >115mm Hg </li></ul>
    22. 25. ST Depression - Represents subendocardial ischemia -Abnormal > 1mm horizontal/downsloping at .08sec past “J” point.
    23. 26. Myocardial Perfusion Imaging SPECT <ul><li>Indications </li></ul><ul><ul><li>Detects presence/location/extent of myocardial ischemia in patients with R/O ACS </li></ul></ul><ul><ul><li>Risk stratification after ACS </li></ul></ul><ul><ul><li>Identify fixed defects, evaluate EF and viability </li></ul></ul><ul><ul><li>CP with abnl EKG’s (LBBB, PPM, LVH, NSSTW changes) </li></ul></ul><ul><ul><li>Equivocal ETT </li></ul></ul><ul><ul><li>Inability to exercise (pharmacological stress ) </li></ul></ul>
    24. 27. MPI Radiopharmaceuticals <ul><li>Thallium 201 </li></ul><ul><li>Technetium–99m </li></ul><ul><ul><li>Sestamibi (Cardiolyte) </li></ul></ul><ul><ul><li>Tetrafosmin (Myoview) </li></ul></ul><ul><li>Dual Isotope </li></ul><ul><ul><li>Thallium injected for resting images </li></ul></ul><ul><ul><li>Tech -99m injected at peak stress </li></ul></ul><ul><li>Resting Thallium -utilized to assess viability(no stress) </li></ul>
    25. 28. Thallium MPI Prep MI ruled out by cardiac markers NPO 6-12 hrs, NO CAFFEINE 24 hrs Wgt. <350 lbs. Consent IV access (peripheral preferred) No nuclear scans 24 hrs.(V/Q, bone) Be able to lie flat with hands behind head for 15 mins. x 2 Must be able to walk treadmill Notify if ICD present Pregnancy test for premenopausal women
    26. 29. PHARMACOLOGICAL MPI <ul><li>Indications: inability to exercise, abnl EKG (LBBB, PPM/ICD), risk stratification </li></ul><ul><li>Dipyridamole(Persantine) -indirectly causes coronary dilatation by blocking adenosine receptor sites. </li></ul><ul><ul><li>Infused over 4 min, isotope at 7-9 min or hemodynamic response </li></ul></ul><ul><li>Adenosine- potent vasodilator </li></ul><ul><ul><li>Infused over 4 min, isotope at 2 min </li></ul></ul><ul><ul><li>Low level exercise diminishes side effects </li></ul></ul>
    27. 30. CONTRAINDICATIONS <ul><li>Asthma/Severe COPD (can induce bronchospasm) </li></ul><ul><li>Hypotension </li></ul><ul><li>Recent CVA (within 30 days) </li></ul><ul><li>NY HA Class IV CHF </li></ul><ul><li>SIDE EFFECTS </li></ul><ul><li>Chest Pain </li></ul><ul><li>Headache </li></ul><ul><li>Flushing </li></ul><ul><li>Nausea </li></ul><ul><li>Transient asystole & heart block(Adenosine) </li></ul>
    28. 31. Dipyridamole/Adenosine prep <ul><li>NPO 12 hours (No Caffeine for 24 hrs) </li></ul><ul><li>No methylxanthines(bronchodilators) </li></ul><ul><li>Actual wgt. (drugs are wgt. based!) </li></ul><ul><li>Systolic BP>95mm Hg </li></ul><ul><li>No oral dipyridamole </li></ul><ul><li>Hold beta blockers </li></ul><ul><li>Use with caution: migraines </li></ul>
    29. 33. DOBUTAMINE <ul><li>+ Inotropic effect, increases myocardial O2 demand </li></ul><ul><li>Prep: same as ETT (no beta blockers, ICD off, etc) </li></ul><ul><li>Infuse 5-40 mcg/kg/min over 15 min </li></ul><ul><li>Goal to achieve 85% MPHR (atropine given 35% time) </li></ul><ul><li>End points same as ETT( EKG changes, CP, HTN etc.) </li></ul><ul><li>SIDE EFFECTS </li></ul><ul><ul><li>HTN </li></ul></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Arrhythmias(PVC’s 15%, SVT/Atrial 8%, NSVT 4%) </li></ul></ul><ul><ul><li>Palpitations/Anxiety </li></ul></ul>

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