Common Clinical Problems CHEST PAIN. Chest Pain Evaluation 9/25/2014. Southeast Regional Heart and Vascular Symposium for Primary Care Providers

Transcription

1 Southeast Regional Heart and Vascular Symposium for Primary Care Providers Imaging: Which Test is Best? William P. Warren, MD, FACC Common Clinical Problems Atrial Fibrillation Congestive Heart Failure Valvular Heart Disease CHEST PAIN Chest Pain Evaluation Cardiac PET Treadmill Only Stress Coronary Calcium Score Stress Echo Cardiac MRI Stress MPI Coronary CTA Pharm MPI Dobutamine Echo 1

2 MedSolutions OR Order a Treadmill Only Stress and avoid MedSolutions GOOD Imaging is GOOD Patient Care How to Choose the Best Imaging Test for the Patient with Suspected Ischemic Heart Disease 2012 ACC/AHA Guidelines for Stable Ischemic Heart Disease 2

3 Possible Imaging Tests for Patients with Chest Pain TEST COST ADVANTAGES DISADVANTAGES TMO $ Widely Available False +, Inability to reach target HR Coronary Calcium $ risk factor Not for symptomatic pts. Stress ECHO $$ No radiation Limited by obesity, COPD, LBBB, Pacing, WMA Dobutamine ECHO $$ Same as Stress ECHO Same as Stress ECHO Stress MPI $$$ Widely Available, streamlined process Pharmacologic MPI $$$ Regadenoson well tolerated vs. older drugs Coronary CTA $$$ High Negative Predictive Value Radiation exposure, attenuation artifacts Radiation exposure, attenuation artifacts Insurance coverage, overestimate CAD Cardiac PET $$$$ Best sens/specificity, Pharmacologic stress only Lower radiation than MPI Cardiac MRI $$$$ No radiation Limited availability, complicated logistics How to Choose? Consider: Exercise Capacity Baseline EKG Pretest Probability of Disease Other Patient Specific Factors Exercise Capacity Ability to Perform ADL s and Moderate Household Work (~4-5 METS) Exercise is the best single predictor of cardiovascular outcome Memorial/CHI able to do 65% of outpatient MPI tests as exercise tests 3

4 EKG Factors: Left Bundle Branch Block Ventricular Pacing at Baseline Resting ST depressions >0.5mm (ie. LVH with strain pattern or digoxin effect) Pretest Probability of Disease Clinical Assessment of Cardiac Risk Diamond and Foster (age, sex, typical symptoms) Other Patient Specific Factors Obesity: technically limited ECHO images (Definity contrast may help) Obesity: attenuation artifact for MPI (2 day imaging protocols may help) Obesity: May favor PET imaging (less attenuation artifact) COPD/lung disease: technically limited ECHO images COPD/asthma: may lead to bronchspasm with adenosine (less with regadenoson) Orthopedic or age factors limiting exercise may dictate a pharmacologic test 4

5 Evaluation of Patients with Chest Pain: Low Pretest Probability of Disease EKG Able to Exercise (4METS) Best Test Normal Yes TMO Normal No Pharm MPI or Dob ECHO Abnormal Yes Stress MPI or Stress ECHO Abnormal No Pharm MPI or Dob ECHO LBBB, Ventricular Pacing, Resting WMA, Obesity, or Lung Disease favor Pharm MPI over Dob ECHO Evaluation of Patients with Chest Pain: Intermediate or High Pretest Probability of Disease favors Stress ECHO or Stress MPI over TMO regardless of EKG or ability to exercise Stress ECHO or Stress MPI is indicated if a prior TMO is equivocal or uninterpretable (2008/2009 ACC/AHA Guidelines appropriateness score 7-9 out of 9) Suspected Ischemic Heart Disease: Patient Focused Summary Young person with some risk factors. Normal EKG. Able to exercise. TMO Same young patient who can exercise, but abnormal EKG. Stress ECHO LBBB or Ventricular pacing. Pharm MPI Intermediate or High clinical risk. Normal EKG. Able to exercise. Stress ECHO or Stress MPI 5

6 Suspected Ischemic Heart Disease: Patient Focused Summary Obesity, unable to exercise Pharm MPI COPD, unable to exercise Pharm MPI Older, general debility Pharm MPI Suspected Ischemic Heart Disease: Patient Focused Summary Anxious Young Person with Family History of CAD Risk factor assessment +/ Calcium Score Intermediate Risk ASYMPTOMATIC patient concerned about statin use? Calcium Score Patient you think had a false positive TMO or other stress Medical treatment or Coronary CTA Anxious executive willing to pay for the best test to look for CAD = Medical Rx or Coronary CTA Medical treatment or Coronary CTA The Future of Imaging for Ischemic Coronary Disease ECHO: strain imaging for better wall motion assessment MPI: new camera technology allows shorter imaging time and/or lower radiation dose MPI: stress only protocols lower radiation dose PET: high energy photons with short half life allow more accurate images with lower total radiation dose PET: simplified unit dosing (flurpiridaz) Coronary CT: new camera/detector arrays and combination of perfusion or infarct/viability imaging with anatomical images 6

7 Thank you. William P. Warren, MD, FACC 7