1. CURRENT STATUS OF STRESS TESTING JOHN HAMATY D.O.

2. INTRODUCTION  Form of imprisonment in 1818  Edward Smith’s observations

3. TECHNIQUE  Heart rate  Blood pressure  ECG parameters  Physical appearance

5. INDICATIONS  Ischemic heart disease  Medical efficacy  Baseline post procedure  Culprit vessel  Hypertension management

6. COMPLICATIONS  Cardiac arrhythmias  Sudden death  Myocardial infarction  Fatigue  Heart failure  hypotension

9. DIAGNOSTIC VALUE OF STRESS TESTING (SENSITIVITY & SPECIFICITY)  Designed to test how effectively a test separates subjects with disease from healthy individuals  ST segment depression has 84% specificity for angiographically significant CAD(assumes 85% heart rate)

10. Prognostic Value of Testing  Post MI  Stable CAD  Post CABG(3 mos.)  Post intervention(6 mos.)  High Risk(Diabetics*******)  Hypertension

11. ASSESSING THE APPROPRIATE TEST FOR THE APPROPRIATE PATIENT  Treadmill  Treadmill with imaging  Pharmacologic  Echocardiography

12. PHARMACOLOGIC Indications  Patients unable to exercise  Preoperative risk stratification  Early postinfarct risk stratification  Left bundle branch block  Fixed-rate pacemakers

13. PHARMACOLOGIC TESTING Persantine/Adenosine Persantine/Adenosine  Needs nuclear augmentation  Coronary vasodilation  Bronchospastic  Not for acute asthmatic’s or severe COPD Dobutamine Dobutamine  Inotrope  Vasodilator  Afterload reducer  Increase heart rate  May require atropine  No bronchospastic component(COPD)

14. PERSANTINE  IV dosing of.56ml/kg over 4 minutes  5 fold increase in coronary blood flow velocity  Acts by indirectly increasing intravascular adenosine levels  Precursor to adenosine  Reverse effects with Aminophylline(dosing from 50-250mg iv injection

15. ADENOSINE  Actively transported across cell to activate the A1 and A2 receptors, stimulates adenocine cyclase in smooth muscle and produces vasodilatation  Leads to increase in cAMP, causes increase in Ca levels leading to smooth muscle relaxation

16. PERSANTINE/ADENOSINE- CONTRAINDICATIONS  Bronchospasm- active lung disease  AV block  Taking caffine or methalxanthines  Hypotention- <90mm hg

17. DOBUTAMINE  Dobutamine is a synthetic catecholamine, which directly stimulates both beta-1 and beta-2 receptors. A dose-related increase in heart rate, blood pressure, and myocardial contractility occurs.

18. DOBUTAMINE  increases regional myocardial blood flow based on physiological principles of coronary flow reserve. A similar dose-related increase in subepicardial and subendocardial blood flow occurs within vascular beds supplied by significantly stenosed arteries, with most of the increase occurring within the subepicardium rather than the subendocardium. Thus, perfusion abnormalities are induced by the development of regional myocardial ischemia.

19. DOBUTAMINE- CONTRAINDICATIONS  Patients with recent (1 wk) myocardial infarction; unstable angina; significant aortic stenosis or obstructive cardiomyopathy; atrial tachyarrhythmias with uncontrolled ventricular response; history of ventricular tachycardia, uncontrolled hypertension, or thoracic aortic aneurysm; or left bundle branch block should not undergo dobutamine stress testing.

20. Treadmill Stress Testing  Must be able to walk!!  Can be used alone for low risk cases  Augmentation can be with nuclear or echo  Physiologic response  Blood pressure response to exercise  Exercise prescription

21. STRESS ECHO  Can be done with treadmill or dobutamine  Assesses wall motion  Evaluates regional and global wall motion  Fast answers  No radiation exposure

22. STRESS ECHO STRESS NUCLEAR  Cardiac function  Real-time imaging  Additional information (LVH, valves)  Patient convenience  Cost  Relative perfusion  More objective interpret.  Quantitation of extent of perfusion abnorm. of perfusion abnorm.  More extensive literature on prognosis