The document discusses cardiac stress testing. It describes indications for cardiac stress testing as symptoms of angina and an intermediate risk for myocardial infarction (10-20% 10-year risk). It reviews different diagnostic testing options for coronary artery disease including exercise stress tests (ECG, echocardiogram, nuclear imaging) and pharmacologic stress tests (dobutamine echocardiogram/nuclear imaging, vasodilator nuclear imaging, PET/CT). It provides details on the pros and cons of each test.

1. CARDIAC STRESS TESTING

2. INDICATION FOR CARDIAC STRESS TESTING:
SYMPTOMS OF ANGINA AND AN INTERMEDIATE RISK
FOR MI
• INTERMEDIATE RISK OFTEN ESTABLISHED AS 10YR
RISK OF 10-20% FOR MI.
• SEVERAL RISK ASSESSMENT TOOLS AVAILABLE,
MKSAP CALLS OUT THE FRAMINGHAM RISK SCORE
SPECIFICALLY.

3. DIAGNOSTIC TESTING FOR CAD
EXERCISE STRESS
TESTING
• EXERCISE ECG
• STRESS ECHO
• NUCLEAR SPECT
PERFUSION
PHARMACOLOGIC
STRESS TESTING
• DOBUTAMINE ECHO
• DOBUTAMINE
NUCLEAR PERFUSION
• VASODILATOR
NUCLEAR PERFUSION
• PET/CT

4. EXERCISE STRESS TESTING
ECG
INITIAL TEST FOR MOST
PATIENTS
DATA ON EXERCISE
CAPACITY, BP AND HR
RESPONSE, AND
PROVOKED SYMPTOMS
NOT USEFUL WHEN
BASELINE ECG IS
ABNORMAL (LVH, LBBB,
PACER, ST DEPRESSION)
ECHO
WHEN ABNORMAL ECG
OR INFO ON SPECIFIC
AREA OF MYOCARDIUM
IS DESIRED
EXERCISE DATA + WALL
MOTION
ABNORMALITIES
IMAGE QUALITY IS A
CONCERN
BASELINE WALL MOTION
ABNORMALITIES
COMPLICATE
ASSESSMENT
ACCURACY DIMINISHED
IN LESS SIGNIFICANT
DISEASE.
NUCLEAR
WHEN ABNORMAL ECG
OR INFO ON SPECIFIC
AREA OF MYOCARDIUM
IS DESIRED
TECHNETIUM VS.
THALLIUM
LBBB MAY CAUSE FALSE
POSITIVE DUE TO
CONDUCTION DEL AY IN
THE SEPTUM
ATTENUATION
ARTIFACTS FROM
BREAST TISSUE OR
DIAPHRAGM

5. PHARMACOLOGIC STRESS TESTING
DOBUTAMINE
ECHO
RECOMMENDED FOR
PATIENTS WHO CANNOT
EXERCISE
IMAGES ACQUIRED
CONTINUOUSLY
CONTRAINDICATIONS
TO DOBUTAMINE IN
SEVERE BASELINE HTN
AND ARRHYTHMIAS
BETA-BLOCKERS MUST
BE WITHHELD PRIOR TO
TESTING
DOBUTAMINE
NUCLEAR
DIAGNOSTIC ACCURACY
EQUIVALENT TO ECHO
PREFERRED WHEN ECHO
IMAGE QUALITY IS
SUBOPTIMAL
CONTRAINDICATIONS
TO DOBUTAMINE IN
SEVERE BASELINE HTN
AND ARRHYTHMIAS
BETA-BLOCKERS MUST
BE WITHHELD PRIOR TO
TESTING
VASODILATOR
NUCLEAR
ADENOSINE OR
DIPYRIDAMOLE OR
REGADENOSON
L ATE PERFUSION
IMAGING ALLOWS FOR
EVAL OF VIABILITY
CONTRAINDICATED IN
BRONCHOSPASTIC
AIRWAY DISEASE AND
THEOPHYLLINE USE
HOLD CAFFEINE FOR 24
HOURS PRIOR
ADENOSINE
CONTRAINDICATED IN
SSS AND HIGH AV
BLOCK

6. PHARMACOLOGIC STRESS TESTING
PET/CT
BEST PERFUSION IMAGES IN L ARGER
PATIENTS
DATA ON BOTH PERFUSION AND
FUNCTION
SHORTER STUDY DURATION WITH
LOWER RADIATION DOSE THAN
CONVENTIONAL NUCLEAR PERFUSION
IMAGING
CAN MEASURE ABSOLUTE MYOCARDIAL
BLOOD FLOW
CAN BE COMBINED WITH CAC SCORING
AVAIL ABILITY IS LIMITED, EXPENSIVE,
PHARMACOLOGIC STRESS PROTOCOL
ONLY
A NOTE ON CAC TESTING
NOT RECOMMENDED FOR ROUTINE
SCREENING IN ALL RISK GROUPS
REASONABLE IN ASYMPTOMATIC
PATIENTS AT INTERMEDIATE RISK FOR
CAD
CAC SCORES ARE PREDICTIVE OF
CARDIOVASCUL AR RISK IN SELECTED
PATIENTS
DOES NOT PROVIDE DATA ON
CORONARY LUMINAL NARROWING
RADIATION EXPOSURE

7. A 60 Y.O. MAN IS EVALUATED FOR 4 MONTHS OF INTERMITTENT, BURNING,
LEFT SIDED CHEST PAIN THAT IS NON-RADIATING, OCCURS WITH ACTIVITY,
AND RESOLVES WITH REST. ADDITIONALLY HE NOTES OCCASIONALLY HAVIN G
SIMILAR PAIN IN THE EVENING AFTER EATING DINNER. OTHER THAN THE
OCCASIONAL CHEST PAIN WITH EXERTION, HE CAN WALK WITHOUT
LIMITATION. HISTORY OF HTN ON HCTZ, NO OTHER MEDS.
VS: T36.8, BP140/80, HR80, RR14, BMI 30
PE: UNREMARKABLE
ECG: NSR, RATE 70, NONSPECIFIC 1MM ST CHANGES IN THE ANTERIOR AND
LATERAL LEADS, LA ENLARGEMENT, LVH
WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE DIAGNOSTIC TEST
TO PERFORM NEXT?
(A) CORONARY ARTERY CALCIUM SCORE
(B) EXERCISE ELECTROCARDIOGRAPHIC STRESS TEST
(C) EXERCISE PERFUSION STRESS TEST
(D) PHARMACOLOGIC STRESS TEST
MKSAP 16, CARDIOVASCULAR MED, #115

8. A 68 Y.O. WOMAN IS EVALUATED FOR 3 WEEKS OF INTERMITTENT
EXERTIONAL CHEST PAIN. SHE WALKS SEVERAL DAYS PER WEEK. SHE HAS DM
TYPE 2 AND HTN. HER FATHER DIED OF MI AT 54.
MEDS: ASA, METFORMIN, GLYBURIDE, LISINOPRIL
VS: AFEBRILE, BP128/90, HR83, RR18, BMI35
PE: CARDIAC SOUNDS ARE DISTANT, OTHERWISE UNREMARKABLE
SEE ECG ON NEXT SLIDE
WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE DIAGNOSTIC TEST
TO PERFORM NEXT?
(A) CARDIAC MAGNETIC RESONANCE (CMR) WITH GADOLINIUM
ENHANCEMENT
(B) EXERCISE ECG STRESS TEST
(C) EXERCISE STRESS ECHOCARDIOGRAPHY
(D) PHARMACOLOGIC PERFUSION IMAGING STUDY
MKSAP 16, CARDIOVASCULAR MED, #92

9. MKSAP 16, CARDIOVASCULAR MED, #92