Stress testing and outpatient workup of chest pain 2019

1. Stress testing and outpatient
evaluation of chest pain
Drew Baldwin, MD
Virginia Mason
13 February 2019

2. Overview
• What are the causes of chest pain?
• How do we choose the best test for diagnosis and risk assessment?
• What tools and resources are available to help us?

3. Causes of chest pain
• Cardiac causes
• Myocardial ischemia
• Aortic dissection
• Decompensated heart failure
• Pericarditis or myopericarditis
• Stress (takotsubo) cardiomyopathy
• Mitral stenosis
• Pulmonary causes
• Pulmonary embolism
• Pneumothorax
• Pneumonia
• Malignancy
• Asthma or COPD
• Pleuritis
• Sarcoidosis
• Sickle cell disease/acute chest syndrome
• Pulmonary hypertension
• Gastrointestinal
• Esophageal reflux
• Esophageal spasm
• Esophagitis
• Eosinophilic esophagitis
• Hiatal hernia
• Esophageal rupture
• Biliary colic
• Cholangitis/cholecystitis
• Pancreatitis
• Peptic ulcer
• Psychiatric
• Panic attacks/anxiety disorder
• Domestic violence with panic disorder
• Depression
• Somatization
• Factitious disorder
• Musculoskeletal
• Musculoskeletal chest pain syndromes
• Costochondritis
• Sternoclavicular arthritis
• Xiphoidalgia
• Spontaneous sternoclavicular
subluxation
• Lower rib pain syndromes
• Posterior chest wall syndromes
• Cervical disc disease with referred pain
• Rheumatic diseases
• Rib fracture
• Trauma
• Other
• Cocaine use
• Methamphetamine intoxication
• Herpes zoster

4. Management of noncardiac chest pain
Suspected diagnosis Diagnosis/treatment approach
Pulmonary embolism CT angiogram chest
Esophageal reflex Diet/medications (endoscopy if high-risk)
Musculoskeletal pain Rest, physical therapy, acetaminophen, NSAIDs
Anxiety disorder/panic attacks Stress management, cognitive-behavioral therapy,
antidepressant medications

5. History – symptoms consistent with
myocardial ischemia
• Provoked by exertion, stress, cold, meals, sexual intercourse
• Relieved with rest
• Poorly-localized chest pressure or discomfort
• Radiation to neck, jaw, throat, teeth, one arm, or both arms
• Onset is gradual, not usually abrupt
• Symptoms associated with diaphoresis, nausea, or vomiting
• Similarity to previous episodes of chest pain
• Severity of pain is not predictive

6. Swap C, Nagurney J. Value and limitations of chest pain history in the evaluation of patients
with suspected acute coronary syndromes. JAMA 2005; 294:2623.

7. https://www.mdcalc.com/framingham-
coronary-heart-disease-risk-score

8. ECG
• Can indicate acute coronary syndrome.
• Cannot exclude myocardial ischemia as a cause of chest pain.

9. Cardiac enzymes
• Almost never appropriate in the office.
• Troponin should be measured in the emergency department.

10. Choosing the optimal diagnostic test
• Functional testing:
• Treadmill ECG stress test
• Exercise stress echocardiogram
• Exercise stress testing with myocardial perfusion imaging
• Dobutamine stress echocardiogram
• Vasodilator testing with myocardial perfusion imaging
• Anatomic testing:
• CT coronary angiogram
• Cardiac catheterization with coronary angiogram

11. Sensitivity and specificity of stress testing for
detecting significant coronary artery stenosis
Sensitivity Specificity
Exercise ECG ~ 70% ~ 75%
Exercise stress echocardiography ~ 85% ~ 80%
Dobutamine stress
echocardiography
~ 80% ~ 85%
Pharmacologic myocardial
perfusion imaging
~ 80% ~ 85%
Coronary CT angiography ~ 95% ~ 85%

12. Meta-analysis: anatomic vs. functional testing
• Thirteen trials with 20,092 patients followed for a mean of 18 months
• CCTA vs functional stress testing
• Risk for death: 1.0% vs 1.1%; RR 0.93; 95% CI, 0.71-1.21
• Risk for cardiac hospitalization 2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21
• Risk for myocardial infarction* 0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96
• Risk for coronary angiography 11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59
• Risk for revascularization 7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43
Foy AJ, et al. Coronary Computed Tomography Angiography vs Function Stress
Testing for Patient With Suspected Coronary Artery Disease: A Systematic Review
and Meta-analysis. JAMA Internal Med. Published online October 2, 2017.

13. Risk for myocardial infarction
* SCOT-HEART trial: 85%
of patients in CCTA arm
also had functional stress
testing
Foy AJ, et al. JAMA Internal
Med. 2017

14. Risk for revascularization

15. Choosing the optimal functional test
• Can the patient exercise?
• Exercise is preferred.
• Is an exercise ECG interpretable?
• LBBB and ventricular pacing make the exercise ECG uninterpretable.
• Testing availability
• Risk for radiation exposure

16. Askew JW, et al. Selecting the optimal
cardiac stress test.

17. Exercise ECG only vs. exercise ECG with imaging
• Advantages of exercise only:
• Lower cost
• Less technically-challenging
• Advantages of exercise with imaging:
• Higher sensitivity
• Better prognostic value
• Ability to localize ischemia
• Additional information on cardiac structure and function
• Reasons to choose exercise with imaging first:
• Resting ECG has baseline ST or T wave abnormalities or LVH
• Patient is on digoxin therapy
• History of revascularization
• Need additional information about location of ischemia or myocardial viability

18. Stress echo vs. DSE vs. Lexiscan MPI
• LBBB or ventricular pacing  ? might choose Lexiscan MPI
• Able to exercise  Usually choose treadmill stress echo
• Unable to exercise  Usually choose dobutamine stress echo
Contraindications to dobutamine: ventricular arrhythmias, unstable angina, LVOT
obstruction, aortic dissection, severe hypertension.
Contraindications to Lexiscan (regadenoson): bronchospastic airway disease,
hypotension, sick sinus syndrome, high-degree atrioventricular block.

19. Advantages of DSE over MPI
• Lower cost
• Shorter test
• May be more accurate with improvements in DSE imaging
• No radiation exposure
• Less environmental impact

20. Atomic bomb survivors 200 mSv
LD50 5000 mSv

21. Radiation risk
Nonemergent cardiac imaging using CT, radiopharmaceuticals, or
fluoroscopy should be performed on the basis of shared decision
making, through which the patient is made aware of the clinical
justification and expected benefit of the test, its potential risks,
including radiation-related risk, and the risks and benefits of the
alternatives, including not having the test performed. (Class I; Level of
Evidence C).
Fazel R, et al. Approaches to Enhancing Radiation Safety in Cardiovascular
Imaging: A Scientific Statement From the American Heart Association.
Circulation 2014; 130: 1730-1748.

22. Molybdenum mine near
Prince George, BC

24. 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment
of Stable Ischemic Heart Disease

25. Thank you
drew.baldwin@virginiamason.org