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NONINVASIVE TEST OF CAD

NONINVASIVE TEST OF CAD

anwerghanijaber
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NONINVASIVE TEST OF CAD

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  1. NONINVASIVE EVALUATION OF CAD POCKET medicine NOTES ANWER GHANI

  2. Stress testing • Indications: dx obstructive CAD, evaluate Δ in clinical status in Pt w/ known CAD, risk stratify after ACS, evaluate exercise tolerance, localize ischemia (imaging required) • Contraindications:  • Absolute: AMI w/in 48 h, high-risk UA, acute PE, severe AS, uncontrolled HF, uncontrolled arrhythmias, myopericarditis, acute aortic dissection • Relative : left main CAD, mod symptomatic valvular stenosis, severe HTN, HCMP, high-degree AVB, severe electrolyte abnl.

  3. Exercise tolerance test • Generally preferred if Pt can meaningfully exercise; ECG Δs w/ Se ~65%, Sp ~80% • Typically via treadmill w/ Bruce protocol (modified Bruce or submax if decond. or recent • MI) • Hold anti-isch. meds (eg, nitrates, βB) if dx’ing CAD but give to assess adequacy of meds

  4. Pharmacologic stress test • Use if unable to exercise, or recent MI. Se & Sp ≈ exercise. • Coronary vasodilator: diffuse vasodilation : Regadenoson (↓side effects), dipyridamole, adenosine. Side effects: flushing, ↓ HR, AVB, SOB, bronchospasm. • Dobuta.: longer test; may precip arrhythmia

  5. Imaging for stress test • Use if uninterpretable ECG  • Use when need to localize ischemia • Radionuclide myocardial perfusion imaging w/ images obtained at rest & w/ stress • Echo (exercise or dobuta): Se ~85%, Sp ~85%; no radiation; operator dependent • Cardiac MRI (w/ pharmacologic stress) another option with excellent Se & Sp

  6. Test results • HR (must achieve ≥85% of max pred HR [220-age] for exer. test to be dx) •  BP response, • peak double product (HR × BP; nl >20k) • HR recovery (HR peak – HR1 min later; nl >12)

  7. TEST RESULTS • ECG Δs: downsloping or horizontal ST ↓ (≥1 mm) 60–80 ms after QRS predictive of CAD (but does not localize ischemic territory); however, STE highly predictive & • localizes • Imaging: radionuclide defects or echocardiographic regional wall motion abnormalities • reversible defect = ischemia; fixed defect = infarct; transient isch dilation → Severe 3VD

  8. High-risk test results. consider coronary angio) • ECG: ST ↓ ≥2 mm or ≥1 mm in stage 1 or in ≥5 leads or ≥5 min in recovery; ST ↑; VT • Physiologic: ↓ or fail to ↑ BP, angina during exercise, Duke score ≤–11;↓EF • Radionuclide: reversible defects, transient LV cavity dilation, ↑ lung uptake

  9. Myocardial viability  • Goal: identify hibernating myocardium that could regain fxn after revascularization MRI (Se ~85%, Sp ~75%),  PET (Se ~90%, Sp ~65%) Dobutamine stress echo (Se ~80%, Sp ~80%)

  10. Coronary CT/MR angio • CCTA 100% Se, 54% Sp for ACS,  •  ↑ cath/PCI, radiation vs. fxnal study •  CCTA vs. fxnal testing → ↑ radiation, cath/PCI early; by 5 y, ↓ CHD death/MI • Unlike CCTA, MR does not require iodinated contrast or radiation, and can assess LV fxn

  11. Coronary artery calcium score • Quantifies extent of calcium; thus, estimates plaque burden (but not % coronary stenosis) • CAC sensitive (91%) but not specific (49%) for presence of CAD • ACC/AHA guidelines note CAC assessment is reasonable in asx Pts w/ intermed risk and selected borderline risk.

  12. THANKS • ANWER GHANI

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