Chronic Stable Angina Diagnosis and Assessment Dr Magdy Rashwan Professor of Cardiology University of Alexandria Egypt
Stable Angina Diagnostic Approach Clinical presentation Clinical chemistry ElectroCardioGraphy None invasive Imaging Invasive investigations CDT 2010
Stable Angina The Clinical Presentation
Heberden s angina Some account of a disorder of the breast Royal College Of Physicians London, 1767 Julius Who are afflicted with it, are seized while they are walking (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast but the moment they stand still, all this uneasiness vanishes. the pain is situated in the upper part, sometimes in the middle, sometimes in the bottom of the os sterni.
. Clinical Chemistry Laboratory Values LDL-C (mg/dl) 110 HDL-C (mg/dl) 38 Total-C (mg/dl) 220 TG (mg/dl) 180 Creatinine 1.1 Fasting glucose (mg/dl) 103 A1c (%) 5.8 Hb ( g/dl) 12
Stable Angina Evaluation of LV Function Physical exam CXR Echocardiogram
Stable Angina Evaluation of Ischemia History of ACS Baseline Electrocardiogram Exercise Testing with or without Imaging N.A.N 2009
Baseline ECG The resting ECG may be normal between attacks however it may show old MI, heart block or LVH
ECG ST segment depression with or without T wave inversion that reverse after ischemia disappears.
ECG Elevation of ST segment in prinzmental s angina.
Indications for Stress Testing Objective confirmation of ischaemia Assessing extent of ischaemia Documenting exercise capacity Functional assessment of known CAD Determining risk and prognosis Determining need for angiography Assessing response to treatment
Exercise Testing Contraindications MI impending or acute Unstable angina Acute myocarditis/pericarditis Acute systemic illness Severe aortic stenosis Congestive heart failure Severe hypertension Uncontrolled cardiac arrhythmias
Common Types of Stress Tests Routine Treadmill (ECG only) Exercise Echocardiography Exercise Nuclear Stress Dobutamine Echocardiography Dobutamine Nuclear Stress Adenosine Nuclear Stress Dipyridamole Nuclear Stress
Exercise ECG stress testing Treadmill or bicycle ergometer Protocols vary - symptom limited Bruce most popular 8 stages Incline and speed increment every 3 minutes Target 85-100% maximum age predicted HR Achieve at least 6 METS for diagnostic accuracy
How good is exercise ECG testing? 78 76 Meta-analysis of 147 consecutive studies involving 24,074 patients 74 72 70 68 66 64 62 SENSITIVITY SPECIFICITY
DUKE TREADMILL SCORE Duration of exercise on treadmill (in minutes) Amount of ST segment depression (in millimeters) Treadmill Angina index: 0 = No Angina 1 = Non-limiting Angina 2 = Limiting Angina
PROGNOSIS: DUKE TREADMILL SCORE
Angina: Exercise Testing Low Risk Group Less than 1 mm ST depression in Stage III of Bruce Protocol Annual mortality: 1.3% 7 year survival
Angina: Exercise Testing High Risk Patients Significant ST-segment depression at low levels of exercise and/or heart rate<130 Fall in systolic blood pressure Diminished exercise capacity Complex ventricular ectopy at low level of exercise
Stable Angina Non invasive diagnostic Imaging tests Stress Echocardiography Myocardial perfusion scintigraphy CT angiography MRI
Stable Angina Stress Echo Ischemia may cause wall motion abnormalities
Stable Angina Guidelines for Nuclear stress Imaging Diagnosis/prognosis for CAD Non-diagnostic EST Abnormal resting ECG Negative EST with continued chest pain Intermediate probability of disease
Myocardial Perfusion Performed at rest & stress Stress study options treadmill exercise pharmacologic stress agents adenosine persantine (dipyridamole) dobutamine
Myocardial Perfusion Radiopharmaceuticals Thallium-201 chloride Tc-99m Sestamibi Tc-99m Tetrofosmin SPECT acquisition provides cross-sectional images of the myocardium in the short axis, horizontal long axis and vertical long axis planes
How do MPI images look like? - Summed Perfusion Images Stress Rest SA Stress Rest SA Stress Rest VLA Stress Rest HLA
Single-photon emission computed tomography perfusion images in two patients with stable anginal symptoms.
Stress Echo vs. Nuclear Stress
Sensitivity Comparison of Different Testing Modalities
SPECIFICITY OF DIFFERENT STRESS TESTING MODALITIES
Exercise Testing in Patients With Chest Pain >6 Months After Revascularization Exercise Testing After CABG chest pain is often atypical after surgery rest ECG abnormalities are frequent stress imaging tests are preferred 30% have an abnormal ECG response on treadmill exercise testing early after bypass surgery 1/00 32
Exercise Testing in Patients With Chest Pain >6 Months After Revascularization Exercise Testing After PTCA exercise ECG is an insensitive (40% to 55%) predictor of restenosis; stress imaging tests are preferred insufficient data to justify a particular frequency of testing after angioplasty 1/00 medslides.com 33
ECG Treadmill EST in Women Higher false-positive rate Reduces procedures without loss of diagnostic accuracy Only 30% of women need be referred for further testing
Comparison of Non-invasive Modalities in the Diagnosis of CAD in Women Sensitivity % Specificity % TMT 61 70 Stress Thallium 78 64 SPECT MIBI 86 80 Stress Echo 86 70 Dobutamine Echo 80 (SVD) 91 (MVD) Rubidium PET 91 90 Meta-analysis of exercise testing to detect coronary artery disease in women Kwok Y. Kim C. et al Am J Cardiol 1999. Mar 1:83(5); 660-6. 79
Information obtained from Exercise Stress but not available with Pharmacological Test Exercise Duration/Tolerance Reproducibility of Symptoms with Activity Heart rate response to exercise Blood Pressure response Detection of Stress Induced Arrhythmias Assess control of angina with medical therapy
Patients Appropriate for Routine ECG Stress Test without Imaging Patient can exercise for 6 or more minutes Normal baseline ECG No history of diabetes No history of coronary revascularization No history of myocardial infarction
Situations Where Nuclear Imaging Preferred Diabetics Previous Myocardial Infarction Reduced LV ejection fraction Left Bundle Branch Block (with Adenosine) Significant COPD Hospitalized patient with positive enzymes
Situations Where Stress ECHO Preferred Women Younger patients with lower likelihood of symptomatic coronary artery disease Valvular heart disease needs to also be evaluated Evaluate for pulmonary hypertension Exertional dyspnea is the predominant complaint
Adenosine is Preferred over Dobutamine except in the following situations Patient taking dipyridamole Patient who cannot exercise and are prone to pulmonary bronchospasm Patient with more than first degree heart block
Stable Angina invasive diagnostic tests Coronary Angiography
Indications for Coronary Angiography High risk stress test ECG Hemodynamic High risk perfusion study Multiple defects Severe perfusion defects TID Ongoing symptoms Post MI angina CHF Vocational indication Pilots Truck/bus drivers Diagnostic uncertainty
Direct Referral For Diagnostic Coronary Angiography When Noninvasive Testing Is Contraindicated Or Unlikely To Be Adequate Due To Illness, Disability Or Physical Characteristics. For Example: coexisting chronic obstructive pulmonary disease noninvasive testing is abnormal but not clearly diagnostic a high clinical probability of severe CAD diabetics with paucity of symptoms of myocardial ischemia due to autonomic and sensory neuropathy 1/00 43
Stable Angina Vs Stable Plaque
Noninvasive Plaque Imaging Computed Tomography Magnetic Resonance Imaging Nuclear imaging (PET)
Invasive Techniques for Assessing Plaques Optical coherence tomography (OCT) Near-infrared (NIR) spectroscopy Intravascular MRI Intravascular ultrasound (IVUS) Virtual histology Palpography
Calcium Volume Scoring Area = 15 mm 2 Peak CT = 450 Score = 15 x 4 = 60 Area = 8 mm 2 Peak CT = 290 Score = 8 x 2 = 16 Hn x-factor (Agatston Scoring) 130-199 1 200-299 2 300-399 3 >400 4
Corresponding Images of OCT and Coronary Angioscopy Kubo, T. et al. J Am Coll Cardiol Intv 2008;1:74-80
PROSPECT: Conclusions From this trial, the first prospective, natural history study of atherosclerosis using multimodality imaging to characterize the coronary tree, we can conclude that: Approximately 20% of pts with ACS successfully treated with stents and contemporary medical Rx develop MACE within 3 years, with adverse events equally attributable to recurrence at originally treated culprit lesions (treatment failure) and to previously untreated non culprit coronary segments Approximately 12% of pts develop MACE from non culprit lesions during 3 years of follow-up Patients treated with contemporary medical therapy who develop non culprit lesion events present most commonly with progressive or unstable angina, and rarely with cardiac death, cardiac arrest or MI
When to Consider MSCT Equivocal stress test or persistent symptoms despite negative stress test Prior to non-coronary cardiac surgery (valve or congenital repair) Patients with difficult access or on therapeutic warfarin Suspected coronary anomalies
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina I. Test Laboratory tests For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence Full blood count, creatinine I C I B Fasting glucose I B I B Fasting lipid profile I B I B hs CRP, homocysteine, Ip(a), apoa, apob IIb B IIb B ECG Initial evaluation I C I B During episode of angina I B Routine periodic ECG on successive visits IIb C IIb C
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina II. Test Ambulatory ECG monitoring For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence Suspected arrhythmia I B Suspected vasopastic angina IIa C In suspected angina with normal exercise test IIa C Chest X-ray Suspected heart failure, or abnormal cardiac auscultation I B I B Suspected significant pulmonary disease I B
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina III. Test For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence Echocardiogram Suspected heart failure, abnormal auscultation, abnormal ECG, Q waves, I B I B BBB, marked ST changes Previous MI I B Hypertension or Diabetes Mellitus I C I B/C Intermediate or low risk patient not due to have alternative assessment of LV function IIa C
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina IV. Test Exercise ECG First line for initial evaluation, unless unable to exercise/ecg not evaluable Patients with known CAD and significant deterioration in symptoms Routine periodic testing once angina controlled For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence I B I B IIb C IIb C I B
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina V. Test Exercise imaging technique For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence (echo or radionuclide) Initial evaluation in patients with uninterpretable ECG I B I B Patients with non-conclusive exercise test (but adequate exercise tolerance) I B I B For Angina post revascularization IIa B IIa B To identify location of ischaemia in planning revascularization IIa B Assesment of functional severity of intermediate lesions on arteriography IIa C
Summary of recommendations for routine non-invasive investigations in evaluation of stable angina VI. Test For Diagnosis Class of Indication Level of Evidence For Prognosis Class of Indication Level of Evidence Pharmacological stress imaging technique Patients unable to exercise I B I B Patients with non-conclusive exercise test due to poor exercise tolerance I B I B To evaluate myocardial viability IIa B Other indications as for exercise imaging where local facilities favour IIa B IIa B pharmacological rather than exercise stress Non-invasive CT arteriography Patients with low probability of disease and non-conclusive or positive stress test IIb C
Algorithm for Chest Pain Evaluation in Women Low Probability of CAD (< 20 %) Consider no test High likelihood false + result Intermediate Probability of CAD (20-80%) Perfusion imaging or stress echo High Risk Probability of CAD (> 80%) Perfusion imaging or stress echo Consider direct angiography Continuing Medical Implementation...bridging the care gap
Questions to Ask When Picking a Test Can the patient exercise on the treadmill or is pharmacological stress testing needed? Can the patient have a routine stress ECG treadmill test or is adjunctive imaging (Nuclear or ECHO) needed? If imaging needed, which one should be used? If pharmacological stress needed instead of exercise, which agent to use?
ACC/AHA guidelines Initiating testing modality for patient with an intermediate probability of CAD? 1. Exercise ECG stress test without imaging 2. Stress test with imaging Myocardial perfusion imaging Dobutamine echocardiography 3. Women 4. Coronary angiography 6
CardioAlex Magdy Rashwan, MD 2010 Professor of Cardiology University of Alexandria Egypt Alexandria Faculty of Medicine, EGYPT.