Noninvasive Cardiac Testing. Testing. Noninvasive Cardiac Testing. Noninvasive Cardiac Testing. A Practical Guide to Selecting Cardiac Stress Testing

Noninvasive Cardiac Testing A Practical Guide to Selecting Cardiac Stress Testing Andrew C. Chiu, MD, FACC Noninvasive Cardiovascular Laboratory Essen...
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Noninvasive Cardiac Testing A Practical Guide to Selecting Cardiac Stress Testing Andrew C. Chiu, MD, FACC Noninvasive Cardiovascular Laboratory Essentia Health Heart & Vascular Center

Noninvasive Cardiac Testing Clinical Context for Exercise Testing

Test Selection Algorithm

Test Outcome Decision Pathways

From: ACC/AHA 2002 Guideline Update for Exercise Testing

Noninvasive Cardiac Testing Clinical Context for Exercise Testing

From: ACC/AHA 2002 Guideline Update for Exercise Testing

Noninvasive Cardiac Testing Contraindication to exercise testing

From: ACC/AHA 2002 Guideline Update for Exercise Testing

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing 2005 Heart Conference Guideline Advantages •Workable •Fairly simple

Shortcomings At initial branch point: •Not intuitive •Not oriented towards primary clinical question

7

Noninvasive Cardiac Testing Diagnostic/Prognostic test to localize ischemia or assess viability?

NO

Abnormal EKG ≥ intermediate risk structural disease digoxin

Able to exercise?

YES

NO

NO

YES

Able to exercise?

YES

Able to exercise?

YES

NO

Standard GXT

YES

Pharmacologic Stress Imaging

Exercise Stress Imaging

Pharmacologic Stress Imaging

NO

Exercise Stress Imaging

Pharmacologic Stress Imaging

8

Noninvasive Cardiac Testing Diagnostic/Prognostic test to localize ischemia or assess viability?

NO

Abnormal EKG ≥ intermediate risk structural disease digoxin

YES

Standard GXT

9

RE

YES

Able to exercise?

NO

Pharmacologic Stress Imaging

TI

YES

AR UL C S VA

Exercise Stress Imaging

Exercise Stress Imaging NO

Pharmacologic Stress Imaging

O

N

A Able to exercise? IZ

YES

NO

Able to exercise?

YES

NO

Pharmacologic Stress Imaging

Noninvasive Cardiac Testing Diagnostic/Prognostic test to localize ischemia or assess viability?

NO

Abnormal EKG ≥ intermediate risk structural disease digoxin NO

Able to exercise?

YES

NO

OM PT

Standard GXT

&

EM CH IS

M SYPharmacologic Stress Imaging

IA

AT UYES AL V E

N IO

Exercise Stress Imaging

Able to exercise?

YES

Able to exercise?

YES

YES

Exercise Stress Imaging

NO

Pharmacologic Stress Imaging

NO

Pharmacologic Stress Imaging

10

Noninvasive Cardiac Testing • Reordered sequence of questions • Step 1: Can patient exercise? – Majority of symptom & ischemia evaluations addressed

• Step 2: Which Pharmacologic Imaging Test? – Asks if significant reactive airway disease present – Notes exception of LBBB • Step 3: Which Exercise Imaging Test? – Asks if factors present limiting to stress echo

Noninvasive Cardiac Testing

Noninvasive Cardiac Testing

Noninvasive Cardiac Testing Step 1: 1: Can Patient Exercise? Yes

No

Treadmill Stress Test

Pharmacologic Imaging Test

Step 2

•Abnormal EKG •LVH •Digoxin, Beta Blockers, Calcium Channel Blockers •Pre-menopausal women •Prior equivocal stress tests •Prior stents, CABG, MI

Yes

No

Exercise Imaging Test

Graded Exercise Test

Step 3

Noninvasive Cardiac Testing Step 2: Which Pharmacologic Imaging Test? Does patient have Reactive Airway Disease (Asthma or Inhaler/Steroid Dependant)?

Yes

No**

Dobutamine Echo

Nuclear

Vasodilator MRI

Nuclear

**LBBB: Recommend Vasodilator Nuclear unless evaluating exertional symptoms

Dobutamine MRI Stress Test can provide additional information about viability. Can also detect associated structural abnormalities, pericarditis, myocarditis, presence of previous non-transmural infarcts (may not be detected by Nuclear stress in 50% of patients with previous infarcts).

Noninvasive Cardiac Testing Step 3: Which Exercise Imaging Test? Does patient have any of the following: •COPD •Technically Difficult Echo •Resting Wall Abnormality

Yes Nuclear Stress*

No Stress Echo

* Stress contrast echo may be utilized in select circumstances

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing Exercise stress: stress:

• Treadmill – Protocols:

• Bruce & Modified Bruce • Naughton • UW branching

– Sensitivity: 66% for ASCAD • (40% for single vessel, 90% for multivessel disease)

– Specificity: 84% of patients without significant disease had negative GXT

• Bicycle

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Noninvasive Cardiac Testing • Adequacy of stress Often defined as: 85% MPHR MPHR = 220-age

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Noninvasive Cardiac Testing • Adequacy of stress Rate Pressure Product (or Double Product) Product)

= BP x HR (at peak exercise)

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Noninvasive Cardiac Testing • Adequacy of stress Rate Pressure Product (or Double Product) Product) best approximation of myocardial oxygen demand generated by exercise

21

Noninvasive Cardiac Testing • Adequacy of stress Rate Pressure Product (or Double Product) Product)

≥ 25,000 level of stress at which test has best negative predictive value for obstructive CAD

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Noninvasive Cardiac Testing • Advantage of stress

Symptom Limited Endpoint (SLEP) achieved during exercise stress better correlates symptoms to objective findings than do pharmacologic tests

23

Noninvasive Cardiac Testing • Advantage of stress A wealth of data with clinical and prognostic value

From: ACC/AHA 2002 Guideline Update for Exercise Testing 24

Noninvasive Cardiac Testing Comparison of test modalities by sensitivity and specificity: Test Modality

Sensitivity

Exercise Stress

Specificit y

66%

84%

82-85%

84%

Exercise Stress Cardiolite

90%

81%

Dobutamine Stress Echocardiography

80%

84%

Dobutamine Stress Contrast Echocardiography

79%

76%

Dobutamine Stress Cardiolite

82%

75%

Dobutamine Stress Cardiac MRI

86%

86%

Vasodilator Cardiolite

89%

65%

Exercise Stress Echocardiography

25

Noninvasive Cardiac Testing • Exercise Stress

– Regular Graded Exercise Test (GXT) appropriate for low risk patients with low pretest probability by clinical history

– Sensitivity too low for moderate to high risk patients with moderate to high pretest probability by clinical history

Noninvasive Cardiac Testing • Exercise Stress

From: ACC/AHA 2002 Guideline Update for Exercise Testing

Noninvasive Cardiac Testing Exercise stress imaging • Why imaging? 

Greater sensitivity and specificity

28

Noninvasive Cardiac Testing Exercise stress imaging • Why exercise over pharmacologic? 

Provides physiologic assessment of: Ischemia Hemodynamic performance Functional capacity Correlation to symptoms Prognosis Greater sensitivity and specificity 











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Noninvasive Cardiac Testing Comparison of test modalities by sensitivity and specificity: Test Modality Exercise Stress

Specificit y

66%

84%

82-85%

84%

Exercise Stress Cardiolite

90%

81%

Dobutamine Stress Echocardiography

80%

84%

Dobutamine Stress Contrast Echocardiography

81%

76%

Dobutamine Stress Cardiolite

82%

75%

Dobutamine Stress Cardiac MRI

86%

86%

Vasodilator Cardiolite

89%

65%

Exercise Stress Echocardiography (± Contrast)

30

Sensitivity

Noninvasive Cardiac Testing Comparison of test modalities by sensitivity and specificity: specificity: Test Modality

Sensitivity

Exercise Stress

Specificit y

66%

84%

82-85%

84%

Exercise Stress Cardiolite

90%

81%

Dobutamine Stress Echocardiography

80%

84%

Dobutamine Stress Contrast Echocardiography

81%

76%

Dobutamine Stress Cardiolite

82%

75%

Dobutamine Stress Cardiac MRI

86%

86%

Vasodilator Cardiolite

89%

65%

Exercise Stress Echocardiography

31

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Echocardiography

– advantages: faster, cheaper, more structural information, higher specificity than Cardiolite® – disadvantages: limited by acoustic factors, less sensitive with pre-existing wall motion abnormalities

32

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Echocardiography

– For detection of CAD by exercise induced wall motion abnormalities in normal hearts: • Sensitivity: 78% • Specificity: 100%

33

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Contrast Echocardiography – Definity® (synthetic perflurocarbon microspheres IV)

34

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Contrast Echocardiography • improves sensitivity • enhances subendocardial border • 10-20% of patients with suboptimal echocardiogram can undergo SCE with results comparable to SE in patients with adequate echocardiograms • SCE approaches capabilities of nuclear myocardial stress perfusion imaging

35

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Contrast Echocardiography – contrast contraindicated in: • severe hepatic or pulmonary disease • known major intracardiac shunt • severe allergic reaction – adverse events extremely rare (1:10,000)

36

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Contrast Echocardiography – contrast well tolerated – side effects in clinical trial (N=279) • headache (5.4%) • nausea/vomiting (4.3%) • flushing (3.6%) • dizziness (2.5%) • hypersensitivity in one patient (0.3%) 37

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Nuclear Myocardial Perfusion Imaging

– IV injections of radiopharmaceutical tracer – image acquisition with gamma camera

38

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Nuclear Myocardial Perfusion Imaging

Cardiolite® Cardiolite® (99mTc - sestimibi)

– Less scatter – More counts – Faster image acquisition

39

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Nuclear Myocardial Perfusion Imaging Thallium (201Tl)

– Viability assessment – Cheap – Logistical challenges – Image quality

40

Noninvasive Cardiac Testing Exercise Stress Imaging: Imaging:

• Stress Nuclear Myocardial Perfusion Imaging

– Comparing rest and post-stress images for inducible perfusion defects as indication of flow limiting coronary artery disease Two head gamma camera

41

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing Pharmacologic stress agents:

• Dobutamine

– positive inotrope and chronotrope – induces ischemia when obstructive CAD present – beta blockers attenuates effects; reduces sensitivity – reversed by beta blockers

43

Noninvasive Cardiac Testing Pharmacologic stress agents:

• Dobutamine

– contraindications: severe hypertension, hypotension, uncontrolled arrhythmia. – side effects: palpitations, paresthesias, nausea, sensation of urinary urgency, may precipitate ectopy, hyper/hypotension – may be used in conjunction with atropine to achieve target heart rate* *unless contraindicated with glaucoma or obstructive uropathy present

44

Noninvasive Cardiac Testing

Pharmacologic vasodilator agents:

• Persantine (dipyridamole) • Adenoscan (adenosine) • Lexiscan (rogadenoson)

– coronary vasodilators revealing underlying obstruction through relative perfusion defects – caffeine within 24 hours attenuates sensitivity – xanthine containing drugs with 3 days may reduce sensitivity

45

Noninvasive Cardiac Testing Pharmacologic vasodilator agents:

• Lexiscan (rogadenoson)

– A2A adenosine receptor agonist – coronary vasodilator – produces and maintains maximal hyperemia quickly for optimal duration practical for radionuclide myocardial perfusion imaging – 2-3 minute half life allows single bolus

46

Noninvasive Cardiac Testing Pharmacologic vasodilator agents:

• Lexiscan (rogadenoson) – Contraindications: • 2° or 3° AV block • sinus node dysfunction

unless these patients have a functioning artificial pacemaker

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Noninvasive Cardiac Testing Pharmacologic vasodilator agents:

• Lexiscan (rogadenoson) – Warnings/Precautions • myocardial ischemia • SA and AV Nodal Block • hypotension • bronchoconstriction

48

Noninvasive Cardiac Testing Pharmacologic vasodilator agents:

• Lexiscan (rogadenoson)

– LBBB recommendation: • When preexisting LBBB or paced rhythm, vasodilator nuclear myocardial perfusion imaging is preferred • Dobutamine may be substituted – validation: single small study data

49

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing •Alternate modalities – Cardiac Magnetic Resonance

• MRI using dobutamine stress • alternative to nuclear and echo stress imaging

51

Noninvasive Cardiac Testing • Alternate modalities

– Cardiac Magnetic Resonance

52

Noninvasive Cardiac Testing • CMR Indications – Dobutamine stress testing where nuclear or echo imaging problematic – LV volumes, mass & EF – Myocardial infarction & viability – Arrhythmogenic Right Ventricular Dysplasia – Evaluation of cardiac masses, thrombus – Congenital heart disease, anomalous coronaries – Aortic pathology – Pericardial pathology 53

Noninvasive Cardiac Testing • CMR Limitations – – – – –

Time consuming Dobutamine stress only Prior authorization requirement Claustrophobia No ferrous metal

54

Noninvasive Cardiac Testing • Alternate modalities – Cardiac CT angiography

• permits definition of cardiac structures including coronary arteries

55

Noninvasive Cardiac Testing • Alternate modalities – Cardiac CT angiography

• Example of a proximal right coronary artery high grade lesion

56

Noninvasive Cardiac Testing • Cardiac CT Indications – Patients with an equivocal or a possible false positive or false negative stress test – Prior positive stress test or known disease where a repeat stress test would remain abnormal (limiting sensitivity for disease in another coronary distribution)

57

Noninvasive Cardiac Testing • Cardiac CT Indications – Risk assessment in the elderly or those reluctant to undergo coronary angiography – Follow-up on old CABG – New left main stent or early post-stent chest pain

58

Noninvasive Cardiac Testing • Cardiac CT Contraindications – atrial fibrillation – renal insufficiency with other test options – young women with other test options (avoid extra radiation) – highly calcified arteries – asymptomatic screening

59

Noninvasive Cardiac Testing • Cardiac CT Limitations – – – –

radiation contrast anatomic rather than physiologic assessment if significantly abnormal, may still need additional cath

60

Noninvasive Cardiac Testing CT Coronary Angiography

Images courtesy of Dr. Glenn Albin 61

Noninvasive Cardiac Testing CT Coronary Angiography

Images courtesy of Dr. Glenn Albin 62

Noninvasive Cardiac Testing • Test selection

– Algorithms: old and new – Choosing stress & imaging modalities • Why exercise over pharmacologic? – Exercise stress – Exercise stress imaging • Why pharmacologic over exercise? – Pharmacologic stress imaging – Pharmacologic vasodilator imaging – Alternative modalities – Clinical pearls

• Case presentations

Noninvasive Cardiac Testing Conditions precluding stress testing • • • •

unstable angina/ACS MI < 72 hrs without revascularization and/or risk factors for myocardial free-wall rupture. decompensated CHF unstable rhythm: VT / VF

Consider consultation

64

Noninvasive Cardiac Testing Conditions precluding stress testing • • • • • •

unstable medical condition uncontrolled HTN neurologic injury outflow obstruction: HOCM, severe/critical AS pericardial disease: pericarditis, cysts, tumors cardiac vegetations/endocarditis Consider consultation

65

Noninvasive Cardiac Testing Limitations to exercise • • • • •

morbid obesity severe limiting pulmonary disease neuromuscular limitation orthopedic limitation gait instability or vertigo



limiting claudication Pharmacologic Test

66

Noninvasive Cardiac Testing Clinical Pitfalls to Avoid • • • •

lack of consent NPO less than four hours Nitroglycerin IV within last four hours lack IV access for pharmacological or nuclear imaging test

67

Noninvasive Cardiac Testing Clinical Pitfalls to Avoid in vasodilator nuclear MPI •

caffeine < 24 hours of vasodilator nuclear Soft drinks, coffee, chocolate, Anacin, Excedrin, NoDoz, Darvon, Caffregot or Fiorinal



xanthine < 3 days of a vasodilator nuclear – Theodur, Theophylline, Slo-bid, Respid or Trental

68

Noninvasive Cardiac Testing Clinical Pitfalls to Avoid in vasodilator nuclear MPI • • • •

severe brochospastic disease on dipyridamole, theophylline, aminophylline known cerebral aneurysm hypotension

69

Noninvasive Cardiac Testing Clinical Pitfalls to Avoid in dobutamine stress testing • • • •

on dobutamine on beta blockers (should be held) susceptible rhythm derangements MI

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