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Getting the Most Out of Exercise Tests Ernest V. Gervino, Sc.D., FACSM Assistant Professor of Medicine Harvard Medical School Chief, Clinical Physiology.

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Presentation on theme: "Getting the Most Out of Exercise Tests Ernest V. Gervino, Sc.D., FACSM Assistant Professor of Medicine Harvard Medical School Chief, Clinical Physiology."— Presentation transcript:

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 Detection of Ischemia  Sx; ST  ; BP response Prognosis of Coronary Disease Prognosis of Coronary Disease  MET capacity; Magnitude of ST   Extent of myocardial involvement Efficacy of Rx Efficacy of Rx Risk Stratification Risk Stratification Exercise Rx Exercise Rx Arrhythmia detection/assessment Arrhythmia detection/assessment Gervino et al. Textbook of Cardiothoracic Anesthesiology ; pp ; 2001

3 Stress Testing: Asymptomatic Pts No definite indications No definite indications Possible indications Possible indications  Special Occupations  Pilots  Police Officers  Bus Drivers  Patients > 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 Exercise duration Onset/Resolution of Sx Onset/Resolution of Sx Onset/Resolution of ST  Onset/Resolution of ST  Magnitude of ST  Magnitude of ST  Impaired HR response (“chronotropic incompetence”) Impaired HR response (“chronotropic incompetence”)  SBP with  workloads  SBP with  workloads High-grade arrhythmias; e.g., prolonged VT; paroxysmal atrial fibrillation/flutter; high grade AV block 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 Low Workload  < 6.5 METS  < 6 minutes of Bruce protocol Low Peak Heart Rate Low Peak Heart Rate  HR < 120 bpm (not on Beta blocker) Decrease or blunted systolic BP response Decrease or blunted systolic BP response  Remains under 130 mmHg ST Segment Depression > 2 mm ST Segment Depression > 2 mm  Multiple Leads  Prolonged recovery > 6 minutes ST Segment Elevation non-Q wave leads ST Segment Elevation non-Q wave leads Increase in complex ventricular ectopy Increase in complex ventricular ectopy Exercise-induced angina Exercise-induced angina ICSI 2007, Feb 20

8 Duke Prognostic Treadmill Score Determining Score: Determining Score: Duke Score = Ex time (min) - (5 X ST dep in mm) – (4 X angina score on treadmill) Angina Score: Angina Score: No angina = 0 Non-limiting angina = 1 Limiting angina = 2

9 Prognostic Value of Duke TM Score  Score > 5  Low Risk: 4 yr survival 99%  Score of -10 to +4  Intermediate Risk: 4 yr survival 95%  Score > -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 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 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 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 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 Patient’s request Patient’s request ST segment depression > 3 mm ST segment depression > 3 mm ST segment elevation > 2 mm in a non-Q wave lead ST segment elevation > 2 mm in a non-Q wave lead Progressive angina (or equivalent) of 8/10 Progressive angina (or equivalent) of 8/10 Drop in SBP with increasing workloads Drop in SBP with increasing workloads VEA or AEA with hemodynamic compromise VEA or AEA with hemodynamic compromise Patient appears pale or clammy Patient appears pale or clammy SBP/DBP response to exercise > 230/110 mmHg SBP/DBP response to exercise > 230/110 mmHg Development of 2 nd or 3 rd degree heart block Development of 2 nd or 3 rd degree heart block Fatigue/exhaustion (RPE > 17 Borg Scale) Fatigue/exhaustion (RPE > 17 Borg Scale) Gibbons et al., Circulation, 106: ; 2002

17 Major Contraindications Acute MI < 3 days Acute MI < 3 days Unstable angina pectoris Unstable angina pectoris Acute myocarditis or pericarditis Acute myocarditis or pericarditis Uncontrolled ventricular or atrial arrhythmias Uncontrolled ventricular or atrial arrhythmias Symptomatic 2 nd or 3 rd degree AV heart block Symptomatic 2 nd or 3 rd degree AV heart block Acute illness Acute illness Acute aortic dissection Acute aortic dissection Acute PE / pulmonary infarction Acute PE / pulmonary infarction Inability to give informed consent Inability to give informed consent Based on: Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002

18 ACC/AHA Classifications Class I: Evidence and/or general agreement that procedure is useful and effective 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 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 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. 40;1532, 2002

19 ETT Recommendations Class I: Class I:  Pts initial evaluation of suspected or known CAD  RBBB, < 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 hours Based on: Gibbons et al., J. Am. Coll. Cardiol. 40;1533, 2002

20 ETT Recommendations (Cont.) Class IIa: Intermediate risk of crescendo angina 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 Class IIb: Following EKG abnormalities  WPW  V-paced rhythm  > 1 mm resting ST depression  LBBB or IVCD with QRS > 120 ms  Pt with stable course with periodic monitoring to guide treatment Based on: Gibbons et al., J. Am. Coll. Cardiol. 40;1533, 2002

21 ETT Recommendations (Cont.) Class III: 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. 40;1533, 2002

22 Terminating Stress Tests Patient’s request Patient’s request ST segment depression > 3 mm ST segment depression > 3 mm ST segment elevation > 2 mm in a non-Q wave lead ST segment elevation > 2 mm in a non-Q wave lead Progressive angina (or equivalent) of > 8/10 Progressive angina (or equivalent) of > 8/10 Drop in SBP with increasing workloads Drop in SBP with increasing workloads Arrhythmia with hemodynamic compromise Arrhythmia with hemodynamic compromise Palor or clamminess Palor or clamminess SBP/DBP response to exercise > 230/110 mmHg SBP/DBP response to exercise > 230/110 mmHg Development of 2 nd or 3 rd degree AV heart block Development of 2 nd or 3 rd degree AV heart block Fatigue/exhaustion (RPE* > 17 Borg Scale) Fatigue/exhaustion (RPE* > 17 Borg Scale) Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002 *Rating of Perceived Exhaustion where 20 is tops

23 Reported Average Sensitivity & Specificity of Stress Tests Test modality Sensitivity Specificity Non-Imaging ETT 65% 85% Non-Imaging ETT 65% 85% Nuclear ETT Nuclear ETT  Quantitative 87% 87%  Qualitative 87% 77%  Dipyridamole 90% 90%  RVG 87% 75% Echo ETT 80% 87% Echo ETT 80% 87%

24 Determining Pre-Test Probability for “Myocardial Ischemic Syndrome” vs. Obstructive CAD Symptoms: Symptoms:  Angina, Atypical Angina, Non-Angina, None Risk factors: Risk factors:   HTN,  Lipids, Smoking,  Activity,  + Fam. Hx, DM, Obesity,  Age, PVD Activity pattern: Activity pattern:  Bed rest, Inactive, Active, Exercise Reason for test: 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 Occurs with exertion Usually located in the anterior chest wall (but not always) Usually located in the anterior chest wall (but not always) Increases in intensity with increased myocardial demand Increases in intensity with increased myocardial demand Relieved with rest within 5 minutes Relieved with rest within 5 minutes Symptom is similar on repeated bouts of exertion Symptom is similar on repeated bouts of exertion Gervino et.al. Textbook of Cardiothoracic Anesthesiology ; 2001

26 Post-Test Probability of CAD Based on Pre-Test Symptoms - Women Diamond and Forrester. N. Engl. J. Med , 1979

27 Post-Test Probability of CAD Based on Pre-Test Symptoms - Men Diamond and Forrester. N. Engl. J. Med , 1979

28 Major Indications for Imaging ETT LVH by ECG LVH by ECG LBBB (consider vasodilator) LBBB (consider vasodilator) Digoxin Rx Digoxin Rx Abnormal ST-T on resting ECG Abnormal ST-T on resting ECG Localization of region(s) of ischemia Localization of region(s) of ischemia Increased sensitivity in selected populations Increased sensitivity in selected populations Hendel et.al. J Nucl Card, 13 (6); E152-E156;2006

29 ECG Requiring Imaging ETT LVH with ST-T changes and LAA LVH with ST-T changes and LAA

30 Advantages of Imaging Studies Stress Echo: Stress Echo:   specificity  Versatility  Eval cardiac anatomy & function  Convenience   test duration   cost Nuclear Perfusion:   technical success rate   sensitivity for 1VD   accuracy for multiple wall motion abnormalities   published data

31 Limitations of Imaging Studies Obesity Obesity Breast Attenuation Breast Attenuation Excess infra-diaphragmatic uptake Excess infra-diaphragmatic uptake Cost (may require prior 3 rd party approval!) Cost (may require prior 3 rd party approval!) Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002

32 Indications for Pharmacologic Stress Testing Advanced peripheral vascular disease Advanced peripheral vascular disease Inability to ambulate Inability to ambulate Evaluation of “stunned” or “hibernating” myocardium with dobutamine Evaluation of “stunned” or “hibernating” myocardium with dobutamine Gervino et.al. Textbook of Cardiothoracic Anesthesiology pp ; 2001

33 Contraindications to Dipyridamole/Adenosine Stress Testing Unprotected 2 nd or 3 rd degree heart block Unprotected 2 nd or 3 rd degree heart block Unstable angina Unstable angina Asthma with active wheezing Asthma with active wheezing Use of theophylline (last 24 hours), caffeine, xanthines, colas, chocolate (last 6-12 hours) Use of theophylline (last 24 hours), caffeine, xanthines, colas, chocolate (last 6-12 hours) LVEF < 15% LVEF < 15% Severe/critical outflow obstruction Severe/critical outflow obstruction Resting hypotension (SBP < 100 mmHg) Resting hypotension (SBP < 100 mmHg) Hendel et.al. J Nucl Cardiol 2006: 13; E152.

34 Contraindications to Dobutamine Stress Testing High grade tachyarrhythmia High grade tachyarrhythmia Resting hypertension (BP > 190/110 mmHg) Resting hypertension (BP > 190/110 mmHg) Critical valvular heart disease Critical valvular heart disease Unstable angina Unstable angina History of severe anxiety/panic attacks History of severe anxiety/panic attacks Cheitlin et al., Circulation, 3-88; 2003

35 Summary for Evaluation of Myocardial Ischemic Syndrome

36

37 Conclusion: Study should add incremental information Study should add incremental information Functional test preferred Functional test preferred Pre-test probability conditions post-test likelihood of ischemic syndrome (Bayesian analysis) 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 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. 2002;40; Gibbons RJ, Antman EM, Albert JS, et al. ACC/AHA 2002 guideline update for exercise testing. J. Am. Coll. Cardiol. 2002;40; 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; 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 Maslow A, Gervino EV, Lowenstein E. Textbook of Cardiothoracic Anesthesiology. Ed: DM Thys. Ch. 9: Stress testing. pp McGraw Hill, NY, Maslow A, Gervino EV, Lowenstein E. Textbook of Cardiothoracic Anesthesiology. Ed: DM Thys. Ch. 9: Stress testing. pp McGraw Hill, NY, Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, et al. ACC/AHA Clinical Competence Statement on Stress Testing. Circulation 2000;102: Rodgers GP, Ayanian JZ, Balady G, Beasley JW, Brown KA, Gervino EV, et al. ACC/AHA Clinical Competence Statement on Stress Testing. Circulation 2000;102: Miller T, McBride J, Basset J, Haranath S, Evenson AM. Cardiac stress test supplement. Institute for Clinical System Improvement; 2007, Feb 20. Miller T, McBride J, Basset J, Haranath S, Evenson AM. Cardiac stress test supplement. Institute for Clinical System Improvement; 2007, Feb 20.


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