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Getting the Most Out of Exercise Tests

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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 ; 2001

3 Stress Testing: Asymptomatic Pts
No definite 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 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 < 6.5 METS < 6 minutes of Bruce protocol Low Peak Heart Rate HR < 120 bpm (not on Beta blocker) Decrease or blunted systolic BP response Remains under 130 mmHg ST Segment Depression > 2 mm Multiple Leads Prolonged recovery > 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
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 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
Patient’s request ST segment depression > 3 mm ST segment elevation > 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 > 230/110 mmHg Development of 2nd or 3rd degree heart block Fatigue/exhaustion (RPE > 17 Borg Scale) Gibbons et al., Circulation, 106: ; 2002

17 Major Contraindications
Acute MI < 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. 40;1531, 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. 40;1532, 2002

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

23 Reported Average Sensitivity & Specificity of Stress Tests
Test modality Sensitivity Specificity Non-Imaging ETT % % Nuclear ETT Quantitative % % Qualitative % % Dipyridamole % % RVG % % Echo ETT % %

24 Determining Pre-Test Probability for “Myocardial Ischemic Syndrome” vs
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

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 ; 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 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-E156;2006

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. 40;1531, 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 ; 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 < 15% Severe/critical outflow obstruction Resting hypotension (SBP < 100 mmHg) Hendel et.al. J Nucl Cardiol 2006: 13; E152.

34 Contraindications to Dobutamine Stress Testing
High grade tachyarrhythmia Resting hypertension (BP > 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

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. 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 ; Maslow A, Gervino EV, Lowenstein E. Textbook of Cardiothoracic Anesthesiology. Ed: DM Thys. Ch. 9: Stress testing. pp 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 2000;102: 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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