Case
• 63yo M /c PMH of HLD/HTN, s/p TBI &
subsequent temporal lobectomy for persistent
seizures
• Presents with severe 9/...
Case
• Additional PMHx/PSHx: LBP/HNP L4-5 with
broad bulge & mild NF impingement on MRI
2012
• FSHx: Occasional Etoh; 10 P...
Case
• PE:
–
–
–
–

VSS, AOx3, NAD
HS RRR /s M, Lungs CTAB
Left Chest Wall TTP, L-Spine paraspinal TTP
No edema, or focal ...
Case
• Cardiac Diagnostics:
– EKG no acute changes compared to previous
studies
– GXT 2007 Full Bruce Protocol /s evidence...
Treadmill Test: You’re doing it wrong

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
Case
• GXT Performed:
– Modified Bruce 13:30, 9.2 METS, max effort
– RHR 55 achieved MHR 148 (94% predicted)
– No BP drop,...
Exercise Stress Testing for CAD
• Graded Exercise Stress Test
– Simple/Cheap/Effective (if used properly)
– Evaluates Exer...
Exercise Stress Testing for CAD

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
DFM Compared To DCS

Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9.
Madiga...
How do we prevent a GXT “Fail”?

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
CRITICALLY APPRAISED TOPIC

Evaluation of Pre-Test
Probability of CAD
Mike Moore, R1

Madigan Army Medical Center IM Oral ...
Objectives

•
•
•
•

Review case
Clinical question formulation
Literature review methods
Conclusions from literature revie...
Clinical Question
• Population
– Primary Care population at risk of CAD

• Intervention
– Improve diagnostic efficiency fo...
Utilized Resources

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
In case you still can’t find Ovid…

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
COMBINED PREDICTIVE MODELS
BMJ 2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012)

Madigan Army Medical Center...
Major Studies
• Prediction model to estimate presence of
coronary artery disease: retrospective pooled
analysis of existin...
Clinical Question - Background

• Determination of the Pretest Probability of
CAD
– Diamond and Forrester method (DFM)
• A...
Which Method is Best?
• DFM:
– 18% low, 65% intermediate, 17% high risk

• DCS: 53% of patients had a reclassification of
...
Outline for Conducting Pooled Analyses
• Search strategy
• Study inclusion criteria
• Obtain primary data
• Prepare data f...
SORT
Strength of Recommendation Taxonomy (SORT)

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
SORT
Strength of Recommendation Taxonomy (SORT)

Madigan Army Medical Center IM Oral Exam Workgroup

5 APR 2013
Summary of Evidence
• Use the DCS:
Duke Chest Pain - CAD Risk Calculator
• Consider use of
COURAGE
calculator (patients
wi...
Bottom Line
• Routinely use a Combined Prediction Model
(DCS or CAD Consortium) for Predicting the
Pretest Probability of ...
Current Research
• Ongoing Research
– Evaluate new modalities of CV Non-Invasive
Diagnostics
– Health System Utilization

...
Effect on Patient Case
• In this case:
– The patient was reassessed
– GXT was performed
– Critical LAD lesion identified a...
References
(in addition to those already cited)
• Up To Date:
– “Exercise ECG testing to determine prognosis of
coronary h...
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Cat using gxt to screen for cad moore 10 30-13 (final)

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  • AHLTA Bx showed multiple presentations to PCM for L arm, chest wall, and back pain. Indeed working dx for this admission was costrochondritis.
  • Change slide titleClearly, in retrospect, the patient probably did not have recurrent arm, chest wall, or back pain, he probably had atypical angina over the past 2-3 years. How do we make that decision to call pain “nonanginal.”
  • Cat using gxt to screen for cad moore 10 30-13 (final)

    1. 1. Case • 63yo M /c PMH of HLD/HTN, s/p TBI & subsequent temporal lobectomy for persistent seizures • Presents with severe 9/10 back pain starting 24 hours ago, evaluated in ED – CTPA/cTnT x1 negative, required IV opioids for pain control in ED – Further Hx: CP 1-2/10 associated with dyspnea/cough while walking on treadmill at home for 20-30 minutes Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    2. 2. Case • Additional PMHx/PSHx: LBP/HNP L4-5 with broad bulge & mild NF impingement on MRI 2012 • FSHx: Occasional Etoh; 10 PY smoking hx, quit 10 years ago; Mother SCD/ACS 42 years of age (heavy smoker) • Meds: ASA, ACEI, B-blocker, Vytorin; Topamax/Clonazepam for seizures. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    3. 3. Case • PE: – – – – VSS, AOx3, NAD HS RRR /s M, Lungs CTAB Left Chest Wall TTP, L-Spine paraspinal TTP No edema, or focal neuro findings • Labs/Imaging: – CMP/CBC WNL, cTnT negative, Last Lipids Jul 13 LDL 57, HDL/TG WNL – CT Head NAIP, CTPA NEOD, pCXR NACPD Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    4. 4. Case • Cardiac Diagnostics: – EKG no acute changes compared to previous studies – GXT 2007 Full Bruce Protocol /s evidence of ischemia, low risk study. Baseline chest wall pain 2/10 before and after study. • Seen in ED, or ED follow up: What Now? – 63 yo M with back & atypical CP, also with multiple cardiac RF (age, lipids, smoking, FH) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    5. 5. Treadmill Test: You’re doing it wrong Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    6. 6. Case • GXT Performed: – Modified Bruce 13:30, 9.2 METS, max effort – RHR 55 achieved MHR 148 (94% predicted) – No BP drop, ST depression 1mm at peak & all 5 minutes of recovery • LHC /c CA: 70-80% obstruction midLAD, subsequent PTCA /c stenting of same Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    7. 7. Exercise Stress Testing for CAD • Graded Exercise Stress Test – Simple/Cheap/Effective (if used properly) – Evaluates Exercise Tolerance & ECG Changes related to CAD – Highly dependent on determination of pretest probability of CAD • Pretest Probability – Age/Gender/Pain Character (DFM) – DM/Smoking/HLD/Q-waves (Duke) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    8. 8. Exercise Stress Testing for CAD Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    9. 9. DFM Compared To DCS Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    10. 10. How do we prevent a GXT “Fail”? Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    11. 11. CRITICALLY APPRAISED TOPIC Evaluation of Pre-Test Probability of CAD Mike Moore, R1 Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    12. 12. Objectives • • • • Review case Clinical question formulation Literature review methods Conclusions from literature review Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    13. 13. Clinical Question • Population – Primary Care population at risk of CAD • Intervention – Improve diagnostic efficiency for CAD • Comparison – Evaluate DF vs. DCS estimation of rick of CAD • Outcome – Reduce unnecessary testing “What is the best way to determine the pretest probability of CAD” Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    14. 14. Utilized Resources Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    15. 15. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    16. 16. In case you still can’t find Ovid… Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    17. 17. COMBINED PREDICTIVE MODELS BMJ 2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    18. 18. Major Studies • Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts – BMJ 2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012) • Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography – Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    19. 19. Clinical Question - Background • Determination of the Pretest Probability of CAD – Diamond and Forrester method (DFM) • Age, Gender, Character of Pain – Duke Clinical Score (DCS) • DFM + Smoking, DM, HLD, Q-waves on EKG Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    20. 20. Which Method is Best? • DFM: – 18% low, 65% intermediate, 17% high risk • DCS: 53% of patients had a reclassification of their risk (most changed from intermediate to low or high risk) – 50% low, 19% intermediate, 35% high risk • Net reclassification improvement for the prediction of obstructive CAD was 51% Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    21. 21. Outline for Conducting Pooled Analyses • Search strategy • Study inclusion criteria • Obtain primary data • Prepare data for pooled analysis • Estimate study-specific effects • Examine whether results are heterogeneous • Estimate pooled result • Conduct sensitivity analyses Friedenreich CM, Methods for pooled analyses of epidemiologic studies. Epidemiology; 1993; 4:295-302. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    22. 22. SORT Strength of Recommendation Taxonomy (SORT) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    23. 23. SORT Strength of Recommendation Taxonomy (SORT) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    24. 24. Summary of Evidence • Use the DCS: Duke Chest Pain - CAD Risk Calculator • Consider use of COURAGE calculator (patients with known CAD for clinical guidance) Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    25. 25. Bottom Line • Routinely use a Combined Prediction Model (DCS or CAD Consortium) for Predicting the Pretest Probability of CAD – Rational to use FH, Smoking, HLD, HTN for adjustment of pretest probability – Timing of pain is important • Reassess Risk of CAD (Frequency?) – Every 2-3 years is rational Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    26. 26. Current Research • Ongoing Research – Evaluate new modalities of CV Non-Invasive Diagnostics – Health System Utilization • Future Directions – Reassessment of risk/disease – Evaluation after medical treatment Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    27. 27. Effect on Patient Case • In this case: – The patient was reassessed – GXT was performed – Critical LAD lesion identified and stented • Outcome was excellent • Key Point: Use of the “Cardiac 4” – ASA, ACEI, BB, Statin Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
    28. 28. References (in addition to those already cited) • Up To Date: – “Exercise ECG testing to determine prognosis of coronary heart disease“ – “Stress testing for the diagnosis of coronary heart disease“ • Diamond GA, Forester JS. Analysis of probability as an aid in the clinical diagnosis of coronaryartery disease. NEJM 1979;300:1350-8 • Pryor DB et al (from Duke University) Estimating the likelihood of significant coronary artery disease Am J Med 1983;75:771-80. Madigan Army Medical Center IM Oral Exam Workgroup 5 APR 2013
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