1 / 87

To Stress or not to stress ?

To Stress or not to stress ?. Karam Paul MS, MD, MBA, FACC Community Heart and Vascular. Cardiac stress testing - learning objectives. ►Know why to undertake a stress test ►Know who should have one ►Know how it is performed ►Understand the limitations ►Understand which to choose

ofira
Télécharger la présentation

To Stress or not to stress ?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. To Stress or not to stress ? Karam Paul MS, MD, MBA, FACC Community Heart and Vascular

  2. Cardiac stress testing - learning objectives ►Know why to undertake a stress test ►Know who should have one ►Know how it is performed ►Understand the limitations ►Understand which to choose ►Know what to do with the result

  3. Cardiac stress testing • Why do a stress test?

  4. Aims of stress testing ►Elicit abnormalities not present at rest ►Estimate functional capacity ►Estimate prognosis ►Likelihood of coronary artery disease ►Extent of coronary artery disease ►Effect of treatment

  5. Cardiac stress testing • Who should have one?

  6. Diagnostic test ►Bayes’ Theorem ►Consider the ‘pre-test risk’ ►Sensitivity & specificity of the test ►Post-test probability of CAD ►Diagnostic power of EST is maximal when the pre-test probability is intermediate.

  7. Risk assessment ►Pre-existing coronary artery disease ►Diabetes ►Hypertension ►Smoking history ►Family history ►Renal disease

  8. Consider other risk factors Pre-existing coronary artery disease ►Diabetes ►Hypertension ►Hyperlipidemia ►Smoking history ►Family history ►Renal disease

  9. Consider other risk factors ►Pre-existing coronary artery disease ►Diabetes ►Hypertension ►Hyperlipidemia ►Smoking history ►Family history ►Renal disease

  10. Valvularheart disease

  11. Rhythm disorders

  12. Contraindications

  13. Cardiac Stress Testing How is it done?

  14. Exercise protocol

  15. Positive!

  16. Measurements ►ECG ►Exercise capacity (METS – metabolic equivalent) ►Symptoms ►Blood pressure ►Heart rate response & recovery

  17. ECG  1mm planar ST depression  3 consecutive beats

  18. ► The normal and rapid upsloping ST segment responses are normal responses to exercise. ► Minor ST depression can occur occasionally at submaximal workloads in patients with coronary disease. ► The slow upsloping ST segment pattern often demonstrates an ischemic response in patients with known coronary disease or those with a high pretest clinical risk of coronary disease. ► Downsloping ST segment depression represents a severe ischemic response. ► ST segment elevation in an infarct territory (Q wave lead) indicates a severe wall motion abnormality and, in most cases, is not considered an ischemic response. (From Chaitman BR: Exercise electrocardiographic stress testing. In Beller GA [ed]: Chronic Ischemic Heart Disease. In Braunwald E [series ed]: Atlas of Heart Diseases. Vol 5. Chronic Ischemic Heart Disease. Philadelphia, Current Medicine, 1995, pp 2.1-2.30

  19. T wave changes ► Influenced by:  Body position  Respiration  Hyperventilation  Drug Rx  Myocardial ischemia  Necrosis ► Pseudonormalisation:  Usually non-diagnostic  Consider ancillary imaging

  20. METs

  21. Heart rate response ►Peak HR > 85% of maximal predicted for age ►HR recovery >12 bpm (erect) ►HR recovery >18 bpm (supine)

  22. Heart rate response

  23. Prognostic value of stress testing Parameters associated with adverse prognosis or multi-vessel disease ► Duration of symptom-limiting exercise <5 METs ► Failure to increase sBP ≥120mmHg, or a sustained decreased ≥ 10mmHg, or below rest levels, during progressive exercise ► ST segment depression ≥2mm, downsloping ST segment, starting at <5 METs, involving ≥5 leads, persisting ≥5 min into recovery ► Exercise-induced ST segment elevation (aVR excluded) ► Angina pectoris at low exercise workloads ► Reproducible sustained (>30 sec) or symptomatic ventricular tachycardia

  24. Limitations of treadmill stress test ► Non-diagnostic ECG changes ► False positives/false negatives ► Women – false positives ► Elderly – more sensitive/less specific ► Diabetics – autonomic dysfunction ► Hypertension ► Inability to exercise ► Drugs – digoxin; anti-anginals

  25. Non-coronary causes of ST segment depression ► Anemia ► Cardiomyopathy ► Digoxin ► Glucose load ► Hyperventilation ► Hypokalemia ► Intraventricular conduction disturbance ► Mitral valve prolapse ► Pre-excitation syndrome ► Severe aortic stenosis ► Severe hypertension ► Severe hypoxia ► Severe volume overload (aortic or mitral regurgitation) ► Sudden excessive exercise ► Supraventricular tachycardia's

  26. Limitations of treadmill stress test  Sensitivity 68%  Specificity 77%

  27. Ancillary techniques to enhance content  Echocardiography  Radionuclide imaging

  28. Stress echocardiography

  29. Stress echocardiography Compares pre & post:  Regional contractility  Overall systolic function  Volumes  Pressure gradients  Filling pressures  Pulmonary pressures  Valvular function

  30. Dobutamine stress echo

  31. Stress echo - limitations Factors which effect image quality:  Body habitus  Lung disease  Breast implants

  32. Normal stress echocardiogram

  33. Case 1 ►54 year old bank project manager ►Exertional chest pain & dyspnea ►Ex-smoker ►TC = 6.7mmol/L ►Stress ECG – 2mm ST segment depression in 5 leads

  34. Stress echocardiogram

  35. Coronary angiogram

  36. Case 2 ►62 year old female ►Chest pain & dyspnea ►Treadmill exercise test – non-diagnostic  sub-maximal  Hypertension  No ECG changes

  37. Case 2 ►Exercised 7½ minutes (9.4 METS) ►No chest pain ►ECG changes

  38. Case 2

  39. Case 2

  40. Case 3 ►24 year old female engineer ►Exertionaldyspnea ►Palpitations

  41. Case 3 Inducible dyspnea ►ECG  partial right bundle branch block  no ischemic changes

  42. Case 3

More Related