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Getting the Most Out of Exercise Tests

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Title: Clinical Utility of Stress Testing Author: EGervino Last modified by: egervino Created Date: 5/27/2004 6:07:11 PM Document presentation format – PowerPoint PPT presentation

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Title: Getting the Most Out of Exercise Tests


1
Getting the Most Out of Exercise Tests
  • Ernest V. Gervino, Sc.D., FACSM
  • Assistant Professor of Medicine
  • Harvard Medical School
  • Chief, Clinical Physiology Laboratory
  • Beth Israel Deaconess Medical Center

2
Utility of Stress Testing
  • Detection of Ischemia
  • Sx ST r BP response
  • Prognosis of Coronary Disease
  • MET capacity Magnitude of STr
  • Extent of myocardial involvement
  • Efficacy of Rx
  • Risk Stratification
  • Exercise Rx
  • Arrhythmia detection/assessment

Gervino et al. Textbook of Cardiothoracic
Anesthesiology pp 203-232 2001
3
Stress Testing Asymptomatic Pts
  • No definite indications
  • Possible indications
  • Special Occupations
  • Pilots
  • Police Officers
  • Bus Drivers
  • Patients gt 40 years of age
  • 2 or more cardiac risk factors
  • Sedentary patients beginning exercise

ICSI 2007 Feb 20
4
Interpreting Stress ECG
Darrow, MD. Am. Fam. Phy. 59(2), 1999
5
Interpreting Stress ECG
Gervino et.al. Textbook of Cardiothoracic
Anesthesiology p 212 2001
6
Key Parameters of Test Results ST
Segments and Beyond
  • Exercise duration
  • Onset/Resolution of Sx
  • Onset/Resolution of ST r
  • Magnitude of ST r
  • Impaired HR response (chronotropic
    incompetence)
  • iSBP with h workloads
  • High-grade arrhythmias e.g., prolonged VT
    paroxysmal atrial fibrillation/flutter high
    grade AV block

ICSI, guidelines 2007
7
Findings Associated with Poor Prognosis
  • Low Workload
  • lt 6.5 METS
  • lt 6 minutes of Bruce protocol
  • Low Peak Heart Rate
  • HR lt 120 bpm (not on Beta blocker)
  • Decrease or blunted systolic BP response
  • Remains under 130 mmHg
  • ST Segment Depression gt 2 mm
  • Multiple Leads
  • Prolonged recovery gt 6 minutes
  • ST Segment Elevation non-Q wave leads
  • Increase in complex ventricular ectopy
  • Exercise-induced angina

ICSI 2007, Feb 20
8
Duke Prognostic Treadmill Score
  • Determining Score
  • Duke Score Ex time (min) - (5 X ST dep in
    mm) (4 X angina score on treadmill)
  • Angina Score
  • No angina 0
  • Non-limiting angina 1
  • Limiting angina 2

9
Prognostic Value of Duke TM Score
  • Score gt 5
  • Low Risk 4 yr survival 99
  • Score of -10 to 4
  • Intermediate Risk 4 yr survival 95
  • Score gt -10
  • High Risk 4 yr survival 79

ICSI 2007 Feb 20
10
Principles Regarding Stress Tests
  • Order only if results will likely alter your
    management, e.g., NOT
  • 25 y/o with vague sx most likely normal
  • 85 y/o typical angina while walking
  • Goal to identify patients at high risk of major
    cardiac morbidity or mortality
  • Esp. Left main, 3VD or SCD risk

11
Assessment of Myocardium at Risk Anatomy vs.
Physiology
  • Presence of an anatomic lesion(s) at coronary
    angiography may not reflect the amount of
    myocardium at risk
  • Amount of myocardium at risk may be minimal and a
    physiologic study (with or without imaging) may
    be more useful

12
Treadmill
13
Cycle Ergometer
14
Pharmacologic Stress Test
15
Pacing Stress Test
16
Independent Reasons for Terminating Exercise
Stress Test
  • Patients request
  • ST segment depression gt 3 mm
  • ST segment elevation gt 2 mm in a non-Q wave lead
  • Progressive angina (or equivalent) of 8/10
  • Drop in SBP with increasing workloads
  • VEA or AEA with hemodynamic compromise
  • Patient appears pale or clammy
  • SBP/DBP response to exercise gt 230/110 mmHg
  • Development of 2nd or 3rd degree heart block
  • Fatigue/exhaustion (RPE gt 17 Borg Scale)

Gibbons et al., Circulation, 106 1883-1889 2002
17
Major Contraindications
  • Acute MI lt 3 days
  • Unstable angina pectoris
  • Acute myocarditis or pericarditis
  • Uncontrolled ventricular or atrial arrhythmias
  • Symptomatic 2nd or 3rd degree AV heart block
  • Acute illness
  • Acute aortic dissection
  • Acute PE / pulmonary infarction
  • Inability to give informed consent

Based on Gibbons et al., J. Am. Coll. Cardiol.
401531, 2002
18
ACC/AHA Classifications
  • Class I Evidence and/or general agreement that
    procedure is useful and effective
  • Class II Conflicting evidence and/or divergence
    of opinion in usefulness/efficacy
  • Class IIa Weight of evidence/opinion in favor of
    usefulness/efficacy
  • Class IIb Usefulness/efficacy less well
    established by evidence/opinion
  • Class III Evidence or general agreement that
    procedure/treatment is not useful or effective
    and in some cases may be harmful

Based on Gibbons et al., J. Am. Coll. Cardiol.
401532, 2002
19
ETT Recommendations
  • Class I
  • Pts initial evaluation of suspected or known CAD
  • RBBB, lt 1 mm ST depression at rest
  • Pts with suspected or known CAD with significant
    change in clinical status
  • Low risk crescendo angina
  • Free of active ischemic or CHF sx for 8-12 hours
  • Intermediate risk crescendo angina
  • Free of active ischemic or CHF sx for 48-72 hours

Based on Gibbons et al., J. Am. Coll. Cardiol.
401533, 2002
20
ETT Recommendations (Cont.)
  • Class IIa Intermediate risk of crescendo angina
  • Negative initial cardiac markers
  • Serial EKG without significant change
  • Negative cardiac markers 6-12 hours from onset of
    sx
  • No other evidence of ischemia during observation
  • Class IIb Following EKG abnormalities
  • WPW
  • V-paced rhythm
  • gt 1 mm resting ST depression
  • LBBB or IVCD with QRS gt 120 ms
  • Pt with stable course with periodic monitoring to
    guide treatment

Based on Gibbons et al., J. Am. Coll. Cardiol.
401533, 2002
21
ETT Recommendations (Cont.)
  • Class III
  • Severe comorbidity likely to limit life
    expectancy or candidacy for revascularization
  • High risk for unstable angina

Based on Gibbons et al., J. Am. Coll. Cardiol.
401533, 2002
22
Terminating Stress Tests
  • Patients request
  • ST segment depression gt 3 mm
  • ST segment elevation gt 2 mm in a non-Q wave lead
  • Progressive angina (or equivalent) of gt 8/10
  • Drop in SBP with increasing workloads
  • Arrhythmia with hemodynamic compromise
  • Palor or clamminess
  • SBP/DBP response to exercise gt 230/110 mmHg
  • Development of 2nd or 3rd degree AV heart block
  • Fatigue/exhaustion (RPE gt 17 Borg Scale)

Rating of Perceived Exhaustion where 20 is
tops
Gibbons et al., J. Am. Coll.
Cardiol. 401531, 2002
23
Reported Average Sensitivity Specificity of
Stress Tests
  • Test modality Sensitivity Specificity
  • Non-Imaging ETT 65 85
  • Nuclear ETT
  • Quantitative 87 87
  • Qualitative 87 77
  • Dipyridamole 90 90
  • RVG 87 75
  • Echo ETT 80 87

24
Determining Pre-Test Probability for Myocardial
Ischemic Syndrome vs. Obstructive CAD
  • Symptoms
  • Angina, Atypical Angina, Non-Angina, None
  • Risk factors
  • HTN, Lipids, Smoking, Activity,
  • Fam. Hx, DM, Obesity, Age, PVD
  • Activity pattern
  • Bed rest, Inactive, Active, Exercise
  • Reason for test
  • CP, known CAD, MI, Arrhythmia, Pre-Op testing

Adapted from Han et al., Ann Emerg. Med . 2007
25
Symptoms of Non-Obstructive Myocardial Ischemic
Syndrome
  • Occurs with exertion
  • Usually located in the anterior chest wall (but
    not always)
  • Increases in intensity with increased myocardial
    demand
  • Relieved with rest within 5 minutes
  • Symptom is similar on repeated bouts of exertion

Gervino et.al. Textbook of Cardiothoracic
Anesthesiology 203-232 2001
26
Post-Test Probability of CAD Based on Pre-Test
Symptoms - Women
Diamond and Forrester. N. Engl. J. Med. 1350-7,
1979
27
Post-Test Probability of CAD Based on Pre-Test
Symptoms - Men
Diamond and Forrester. N. Engl. J. Med. 1350-7,
1979
28
Major Indications for Imaging ETT
  • LVH by ECG
  • LBBB (consider vasodilator)
  • Digoxin Rx
  • Abnormal ST-T on resting ECG
  • Localization of region(s) of ischemia
  • Increased sensitivity in selected populations

Hendel et.al. J Nucl Card, 13 (6) E152-E1562006
29
ECG Requiring Imaging ETT
  • LVH with ST-T changes and LAA

30
Advantages of Imaging Studies
  • Stress Echo
  • hspecificity
  • Versatility
  • Eval cardiac anatomy function
  • Convenience
  • itest duration
  • icost
  • Nuclear Perfusion
  • htechnical success rate
  • hsensitivity for 1VD
  • haccuracy for multiple wall motion abnormalities
  • hpublished data

31
Limitations of Imaging Studies
  • Obesity
  • Breast Attenuation
  • Excess infra-diaphragmatic uptake
  • Cost (may require prior 3rd party approval!)

Gibbons et al., J. Am. Coll. Cardiol. 401531,
2002
32
Indications for Pharmacologic Stress Testing
  • Advanced peripheral vascular disease
  • Inability to ambulate
  • Evaluation of stunned or hibernating
    myocardium with dobutamine

Gervino et.al. Textbook of Cardiothoracic
Anesthesiology pp 203-232 2001
33
Contraindications to Dipyridamole/Adenosine
Stress Testing
  • Unprotected 2nd or 3rd degree heart block
  • Unstable angina
  • Asthma with active wheezing
  • Use of theophylline (last 24 hours), caffeine,
    xanthines, colas, chocolate (last 6-12 hours)
  • LVEF lt 15
  • Severe/critical outflow obstruction
  • Resting hypotension (SBP lt 100 mmHg)

Hendel et.al. J Nucl Cardiol 2006 13 E152.
34
Contraindications to Dobutamine Stress Testing
  • High grade tachyarrhythmia
  • Resting hypertension (BP gt 190/110 mmHg)
  • Critical valvular heart disease
  • Unstable angina
  • History of severe anxiety/panic attacks

Cheitlin et al., Circulation, 3-88 2003
35
Summary for Evaluation of Myocardial Ischemic
Syndrome
36
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37
Conclusion
  • Study should add incremental information
  • Functional test preferred
  • Pre-test probability conditions post-test
    likelihood of ischemic syndrome (Bayesian
    analysis)
  • Magnitude, onset/resolution of changes (sx and/or
    ST segments) help determine severity of ischemia

38
Selected References
  • Gibbons RJ, Antman EM, Albert JS, et al. ACC/AHA
    2002 guideline update for exercise testing. J.
    Am. Coll. Cardiol. 2002401531-1540.
  • Eagle KA, Gibbons RJ, Antman EM, Gregoratos G, et
    al. ACC/AHA 2002 guideline update on
    perioperative cardiovascular evaluation for
    noncardiac surgery. J. Am. Coll. Cardiol. 2002
    www.acc.org, 1-38.
  • Maslow A, Gervino EV, Lowenstein E. Textbook of
    Cardiothoracic Anesthesiology. Ed DM Thys. Ch.
    9 Stress testing. pp 203-232. McGraw Hill , NY,
    2001.
  • Rodgers GP, Ayanian JZ, Balady G, Beasley JW,
    Brown KA, Gervino EV, et al. ACC/AHA Clinical
    Competence Statement on Stress Testing.
    Circulation 20001021726-1738.
  • Miller T, McBride J, Basset J, Haranath S,
    Evenson AM. Cardiac stress test supplement.
    Institute for Clinical System Improvement 2007,
    Feb 20. www.icsi.org
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