Cardiac Stress Testing

Info

🌱 來自: Huppert’s Notes

Cardiac Stress Testing🚧 施工中

Cardiac Stress Testing

•   Indications:

-   Assessment for a new diagnosis of coronary artery disease (CAD) in patients with chest pain who have been ruled out for acute coronary syndrome (ACS)

•   Helpful in patients who have INTERMEDIATE pre-test probability of CAD (Table 1.3)

TABLE 1.3 • Pre-Test Probability of CAD Based on Age and Features of Chest Pain

-   If low pre-test probability of CAD, stress testing is not specific enough (positive results are often false positives)

-   If high pre-test probability of CAD, stress testing is not sensitive enough (negative results are often false negatives); instead proceed to coronary angiogram, which is more sensitive/specific

•   Chest pain quality and age together determine the probability of underlying CAD (Table 1.3)

-   Features of chest pain concerning for CAD:

•   Substernal location

•   Provoked by exertion or emotion

•   Improved by rest or with nitroglycerin

-   All features = Typical angina; 2–3 features = atypical angina; 0–1 features = nonanginal

•   Also adjust assessment of CAD risk using the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Calculator and additional factors:

-   Very high risk: History of MI, stroke, TIA, peripheral arterial disease

-   High risk: Familial hypercholesterolemia, prior CABG or PCI, DM, HTN, CKD (eGFR 15–59), current smoker, LDL-C persistently ≥100 mg/dL despite treatment, heart failure

-   Other risk enhancers: Low HDL, LDL >160 mg/dL, family history of premature ASCVD (<55 yr in male first degree relative; <65 yr in female first degree relative), metabolic syndrome (TG >150 mg/dL, HTN, DM, low HDL-C, increased weight circumference), inflammatory conditions (especially RA, psoriasis, HIV), menopause before 40 yr, pregnancy complications (e.g., preeclampsia), high-risk ethnicity (e.g., South Asian)

•   Contraindications: Recent MI or active ACS, decompensated heart failure, uncontrolled arrhythmias; severe hypertension may preclude testing or affect the validity of the results

•   Pre-stress test patient instructions:

-   Instruct patients to take all medications as usual with the exception of beta blockers

-   Patients are allowed to eat, but cannot consume caffeine prior to vasodilator testing

•   Types of stress tests: Can vary the combination of stressor and detector (Table 1.4)

TABLE 1.4 • Types of Cardiac Stress Tests

-   Possible stressors:

•   Exercise – Treadmill or bike

•   Pharmacologic – Coronary vasodilators (adenosine derivatives, e.g., regadenoson) or β1 agonist (dobutamine)

-   Possible detectors:

•   ECG

•   ECHO

•   Nuclear (PET vs. SPECT such as 99m Tc-sestamibi)

•   Cardiac MR (new technology, only available in select centers)