Wail Hashimi M.D., FACC Cardiology Associates

Transcription

1 Wail Hashimi M.D., FACC Cardiology Associates

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3 38 year old female with mild obesity She is planning an exercise program to loose weight. She has no other known risk factors for CAD. You recommend: A. Exercise stress echo. B. Exercise SPECT. C. Exercise treadmill test. D. Proceed to exercise program no further testing.

4 38 year old female with mild obesity She is planning an exercise program to loose weight. She has no other known risk factors for CAD. You recommend: A. Exercise stress echo. B. Exercise SPECT. C. Exercise treadmill test. D. Proceed to exercise program no further testing.

5 38 year old female with mild obesity and Diabetes She is planning an exercise program to loose weight. She has no other known risk factors for CAD. You recommend: A. Exercise stress echo. B. Exercise SPECT. C. Exercise treadmill test. D. Proceed to exercise program no further testing.

6 38 year old female with mild obesity and Diabetes She is planning an exercise program to loose weight. She has no other known risk factors for CAD. You recommend: A. Exercise stress echo. B. Exercise SPECT. C. Exercise treadmill test. D. Proceed to exercise program no further testing.

7 any constellation of signs or symptoms that the physician believes may represent a complaint consistent with obstructive CAD. *chest pain *chest tightness *burning *dyspnea *shoulder pain *jaw pain *new ECG abnormality American Society of Nuclear Cardiology review of the ACCF/ASNC appropriateness criteria for single-photon emission computed tomagraphy myocardial perfusion imaging (SPECT MPI)

8 Classification of Stable Angina Substernal chest pain Brought on by exertion and or emotional stress Relieved with rest and or NTG Typical/definite Angina: All 3 features Atypical/probable angina: 2 features Non-anginal chest pain : 1 or less features.

9 Coronary Heart Disease Equivalent Diabetes Peripheral Vascular disease CVA/ symptomatic Carotid disease Aortic aneurysm 10 year Framingham risk greater than 20%

10 Age (y) Gender Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Nonanginal Chest Pain Asymptomatic Men Intermediate Intermediate Low Very low Women Intermediate Very low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Intermediate Low Very low Men High Intermediate Intermediate Low Women High Intermediate Intermediate Low

11 Age (y) Gender Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Nonanginal Chest Pain Asymptomatic Men Intermediate Intermediate Low Very low Women Intermediate Very low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Intermediate Low Very low Men High Intermediate Intermediate Low Women High Intermediate Intermediate Low

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13 Clinical context for exercise testing for patients with suspected ischemic heart disease. *Electrocardiogram interpretable unless preexcitation, electronically paced rhythm, left bundle branch block, or resting ST-segment depression >1 mm. Gibbons R J et al. Circulation. 1997;96: Copyright American Heart Association, Inc. All rights reserved.

14 For the initial diagnosis of patients with suspected Coronary artery Disease VS Risk assessment of patient with known CAD

15 Stress Testing as a Screening Test is generally not indicated. (Class III) Stress testing with imaging is not Recommended in very low and low risk individuals. (Class III) Stress testing in intermediate probability individuals is a Class II indication at best Surveillance testing is allowed every 5 years for CABG patients and 2 years for prior Stents. Any sooner it is Class III to proceed

16 If patient is able to exercise, exercise stress testing is preferred I patient has an interpretable ECG, exercise ECG is recommended, but exercise echo/mpi is reasonable if pretest probability is intermediate to high If patient is unable to exercise or has an un-interpretable ECG, pharmacologic stress imaging is recommended.

17 LBBB Digoxin effect Pre-excitation LVH with baseline ST changes Abnormal ECG with greater than 1 mm ST changes at baseline Paced rhythm RBBB is an interpretable ECG LVH with out reporlarization abnormalities is interpretable

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19 Stress Testing/Advanced Imaging for Diagnosis and risk Assessment Patients with known or suspected* Coronary Artery Disease who are able to exercise and have an interpretable ECG (*intermediate or greater pretest probability or one or more coronary equivalent) Class 1 : Exercise ECG Class IIa: Exercise Echo or MPI Class IIb: coronary CT angiogram Class III: Pharmacologic stress imaging

20 Exercise induce VT/Vfib Exercise induced ST elevation ST depression at low work load and persisting into recovery Hypertensive BP response If any of these findings then Cath would be indicated as the next step

21 DTS= Treadmill time(bruce) 5 x ST deviation - 4 x Angina index (0,1,2) Low risk score > 5 Intermediate risk -10 to 4 High risk < -11

22 Duke Treadmill Score 4 year CV survival Avg. Annual CV mortality Low risk 99% 0.25% Treat medically Intermediate risk 95% 1.25% Stress imaging High risk 79% 5% Cath

23 Stress Testing/Advanced Imaging for Diagnosis and risk Assessment Patients with known or suspected* coronary equivalent) Coronary Artery Disease who are able to exercise and have an uninterruptable ECG. (*intermediate or greater pretest probability or one or more coronary equivalent) Class 1 : Exercise Echo of MPI Class IIa: Pharmacologic stress CMR Class IIb: Coronary CT angiography Class III: Exercise Stress test

24 Stress Testing/Advanced Imaging for Diagnosis and risk Assessment Patients with known or suspected* Coronary Artery Disease who are unable to exercise. *(intermediate or greater pretest probability or one or more coronary equivalent) Class 1 : Pharm. Stress echo or MPI Class IIa: Pharmacologic stress MRI Class IIb: Coronary CT angiography Class III: Exercise Stress test

25 Stress Testing/Advanced Imaging for Diagnosis and risk Assessment Patients with known or suspected* Coronary Artery Disease who have LBBB or Paced rhythm, regardless of ability to exercise. *(intermediate or greater pretest probability or one or more coronary equivalent) Class 1 : Pharmacologic stress echo or MPI

26 Stress Testing/Advanced Imaging for Diagnosis and risk Assessment in a patient with known CAD Patient with IHD who have a change in symptoms and prior revascularization Or Patients with coronary stenosis of unclear physiologic significance Class 1 : Exercise/Pharmacologic stress echo or MPI/echo/MRI

27 Normal EF Normal perfusion Good exercise tolerance. (greater than 10 mets)

28 EF 40 49% Moderate stress-induce perfusion defect without lv dilatation or increase lung uptake Mild to moderate stress-induced RWMA by echo (1-4 segments)

29 Significant LV dysfunction (EF <35% at rest or 40%with exercise) Stress-induce perfusion defect of >10% (MPI) or extensive RWM<A (>5 wall segments on Echo) Transient ischemic dilatation (TID) Increase lung uptake (TL-201) Low ischemic threshold.

30 Global Risk Sore (FRS) Framingham Risk calculator. HTN Diabetes Intermediate Risk Urinalysis ECG echo Urinalysis Ecg CACS Exercise ECG (MPI) CACS CRP Carotid IMT ABI Exercise ECG

31 Low risk : < 10 Intermediate Risk High Risk >20 Calcium scoring can help better define those individual that are intermediate risk to low risk.

32 % % 1.3% CACS <100 CACS CACS >400 0 Category 1

33 Decision based on 4 Variables Symptoms Resting ECG Ability to exercise Pre-test likelihood for CAD

34 Asymptomatic Assess Framingham Risk Score +/_ Coronary Calcium score. Stress Testing for High FRS or High Calcium score Stress Testing could be considered If an Abnormal ECG is present or There is a coronary artery disease equivalent,

35 Symptomatic Low pre-test probability => No testing, Bruce GXT Intermediate or High pre-test probablility Normal ECG, can exercise => Bruce GXT (intermediate), MPI High pre-test probability Abnormal ECG or unable to exercise => MPI (pharmacologic if unable to exercise)

36 Know and provide Symptoms ECG Pre-test likelihood Exercise ability

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38 Asymptomatic Screening: Class III (No indication) Asymptomatic Diabetic: MPI (Class II indication) Asymptomatic Intermediate Risk: CACS is indicated with MPI for high Risk Score (>400) Asymptomatic High Framingham score: MPI (class ll) Symptomatic Low Pre-test probability: Bruce GXT Symptomatic Intermediate Risk probability : Bruce GXT or MPI or CACS with MPI for intermediate or high calcium score Symptomatic High pre-test probability: MPI (Cath depending on circumstances clinical setting)

39 Symptomatic Low Pre-test probability with an interpretable GXT : Bruce GXT (class II) Symptomatic Intermediate Risk probability with an interpretable ECG : Bruce GXT( class I) or MPI or CACS with MPI for intermediate or high calcium score (classii) Symptomatic High pre-test probability with an interpretable ECG: MPI (Cath depending on circumstances clinical setting) (classi)

40 Follow up testing is appropriate in high risk situations, a matter of clinical judgment in intermediate risk situations and not required in low-risk situations. Class III : Stress testing in asymptomatic individuals less than 5 years post CABG and less than 2 year post PTCA