5. • A 45 yrs old female patient known hypertensive for 2yrs presented in
emergneny department with complaint of severe chest pain radiating
to left arm for 45min associated with diaphoresis.
• Ecg: T- wave inversion in v1-4
• Trop I raised
• After giving GDMT she became asymptomatic.
6. • Ischemia guided strategy
• TIMI score 1
• Observed
• Non-invasive testing plan
• She is unable to exercise due to right foot deformity
• Asthmatic
7. 4.5. Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS:
Recommendations
CLASS I
1. Noninvasive stress testing is recommended in low- and intermediate-risk patients who have been free of ischemia at rest or with low-level
activity for a minimum of 12 to 24 hours . (Level of Evidence: B)
2. Treadmill exercise testing is useful in patients able to exercise in whom the ECG is free of resting ST changes that may interfere with
interpretation (Level of Evidence: C)
3. Stress testing with an imaging modality should be used in patients who are able to exercise but have ST changes on resting ECG that may
interfere with interpretation. In patients undergoing a low-level exercise test, an imaging modality can add prognostic information (349–352).
(Level of Evidence: B)
4. Pharmacological stress testing with imaging is recommended when physical limitations preclude adequate exercise stress.
(Level of Evidence: C)
5. A noninvasive imaging test is recommended to evaluate LV function in patients with definite ACS (349–352). (Level of Evidence: C)
11. • A 59 yrs old male diabetic, smoker,presented in opd with complaints
of chest pain after walking 1km for last 6months. Pain relived with
rest within 5min. His Ecg shows LBBB.
Diagnosis?
Which test and method
14. CLASS I
• Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who
have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)
CLASS IIa
• Exercise stress with nuclear MPI or echocardiography is reasonable for patients with an intermediate to high pretest probability of obstructive
IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)
• Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive IHD who have an
uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Level of Evidence: B)
CLASS III: No Benefit
• Pharmacological stress with nuclear MPI, echocardiography, or CMR is not recommended for patients who have an interpretable ECG and at
least moderate physical functioning or no disabling comorbidity (Level of Evidence: C)
• Exercise stress with nuclear MPI is not recommended as an initial test in low-risk patients who have an interpretable ECG and at least
moderate physical functioning or no disabling comorbidity. (Level of Evidence: C)
15. UNABLE TO EXERCISE CLASS I
• Pharmacological stress with nuclear MPI or echocardiography is recommended for
patients with an intermediate to high pretest probability of IHD who are incapable of at least
moderate physicalfunctioning or have disabling comorbidity (Level of Evidence: B)
20. Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment:
PATIENTS ABLE TO EXERCISE
CLASS I
The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in
patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to LBBB or
ventricular pacing (Level of Evidence: B)
CLASS IIa
The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in
patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG (Level of Evidence: B)
CLASS III: No Benefit
• Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in
patientswith SIHD who are able to exercise to an adequate workload and have an interpretable ECG. (Level of Evidence: C)
RISK ASSESSMENT IN PATIENTS UNABLE TO EXERCISE
CLASS I
Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD
who are unable to exercise to an adequate workload regardless of interpretability of ECG (Level of Evidence: B)
21. RISK ASSESSMENT REGARDLESS OF PATIENTS’ ABILITY TO EXERCISE
CLASS I
1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in
patients with SIHD who have LBBB on ECG, regardless of ability to exercise to an adequate workload
(Level of Evidence: B)
2. Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is
recommended for risk assessment in patients with SIHD who are being considered for revascularization of
known coronary stenosis of unclear physiological significance (Level of Evidence: B)
CLASS III: No Benefit
A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the
same time is notrecommended for risk assessment in patients with SIHD. (Level ofEvidence C)
23. High risk- Multivessel
Moderate to severe abnormalities, such as abnormal wall
motion in 4 segments or multivessel abnormalities,
indicate an increased risk (range: 6- to 10-fold) over that of
patients with a normal stress imaging study.
24. Follow-Up Noninvasive Testing in Patients With Known SIHD: New,
Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina:
• PATIENTS ABLE TO EXERCISE
CLASS I
Exercise with nuclear MPI or echocardiography is recommended in patients with known SIHD who have new or
worsening symptoms not consistent with UA and who have a) at least moderate physical functioning or no disabling
comorbidity but b) an uninterpretable ECG (Level of Evidence: B)
CLASS IIa
Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or
worsening symptoms not consistent with UA and who have a) at least moderate physical functioning and no disabling
comorbidity, b) previously required imaging with exercise stress, or c) known multivessel disease or high risk for
multivessel disease (Level of Evidence: B)
CLASS III: No Benefit
Pharmacological stress imaging with nuclear MPI, echocardiography, or CMR is not recommended in patients with
known SIHD who have new or worsening symptoms not consistent with UA and who are capable of at least moderate
physical functioning or have no disabling comorbidity (Level of Evidence: C)
25. PATIENTS UNABLE TO EXERCISE
CLASS I
Pharmacological stress imaging with nuclear MPI or echocardiography is
recommended in patients with known SIHD who have new or worsening
symptoms not consistent with UA and who are incapable of at least
moderate physical functioning or have disabling comorbidity (Level of
Evidence: B)
26.
27. Noninvasive Testing in Known SIHD—Asymptomatic (or Stable Symptoms)
CLASS IIa
Nuclear MPI, echocardiography, or CMR with either exercise or pharmacological stress can be useful
for follow-up assessment at2-year or longer intervals in patients with SIHD with prior evidence ofsilent
ischemia or who are at high risk for a recurrent cardiac event and a) are unable to exercise to an
adequate workload, b) have an uninterpretable ECG, or c) have a history of incomplete coronary
revascularization (Level of Evidence: C)
CLASS III: No Benefit
Nuclear MPI, echocardiography, or CMR, with either exercise or pharmacological stress or CCTA, is
not recommended for follow-upassessment in patients with SIHD, if performed more frequentlythan at
a) 5-year intervals after CABG or b) 2-year intervals after PCI (Level of Evidence: C)
34. • A 30 yrs old male with signifant family history of pcad presented to some
local hospital with chest pain of 2hrs associated with sweating. His Ecg
showed ST segment elevation in inferior leads. He was successfully
thrombolyzed with sk over there. Due to lack of cath lab facilities patient
was referred to us after 2days. Patient is asymptomatic and vitally stable
now?
I-B
36. • A 60 yrs old male diabetic and hypertensive patient presented to er
with chest pain of 4hrs associated with sweating and palpitation. His
Ecg showed ST segment elevation in anterior leads. Patient
immediately shifted to cath lab. His cor angio shows mild to moderate
proximal stenosis in LAD. Rest are normal.
• We lacK IVUS or FFR
38. • A 50 yrs old male diabetic and hypertensive patient presented to er
with chest pain of 3hrs associated with sweating and palpitation. His
Ecg showed ST segment elevation in anterior leads. Patient
immediately shifted to cath lab.
• LAD- TIGT PROX STENOSIS- PCI done
• LCX- moderate prox
• RCA- moderate mid
IIB-B
39. Use of Noninvasive Testing for Ischemia
Before Discharge:
CLASS I
Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of
inducibleischemia in patients with STEMI who have not had coronaryangiography and do not have high-risk
clinical features forwhich coronary angiography would be warranted (577–579).(Level of Evidence: B)
CLASS IIb
1. Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance
of a noninfarct artery stenosis previously identified at angiography. (Level of Evidence: C)
2. Noninvasive testing for ischemia might be considered before discharge to guide the postdischarge exercise
prescription.(Level of Evidence: C)
40. Risk Assessment After STEMI
• Additional risk assessment should be used to guide decisions about performance of
coronary angiography in patients who did not undergo an invasive evaluation as part
of their initial treatment strategy and to guide consideration of interventions to
reduce the risk of SCD due to arrhythmia.
• Exercise testing early after STEMI may also be performed to 1) assess functional
capacity and the ability to perform tasks at home and at work, 2) evaluate the efficacy
of medical therapy, and 3) assess the risk of a subsequent cardiac event.
• It is the consensus of the writing committee that patients without complications who
have not undergone coronary angiography and who might be potential candidates for
revascularization should undergo provocative testing before hospital discharge.
Inpatients with noninfarct artery disease who have undergone successful PCI of the
infarct artery and have an uncomplicated course, it is reasonable to proceed with
discharge and plans for close clinical follow-up with stress imaging within3 to 6 weeks.
42. • A 30 yrs old male withsignifant family history of pcad and diabetic
presented with chest pain of 2hrs associated with sweating. His Ecg
showed ST segment elevation in anterior leads. He was thrombolyzed
with sk. His echo shows akinetic whole of IVS and ANTERIOR wall.
