Cardiac Stress Testing

Dr Lisa Walters MBBS FRACP

Senior Lecturer in Medicine
University of Queensland
Queensland Cardiology Annual Scientific
Conference 2009
October 11 2009
Cardiac stress testing - learning objectives
Know why to undertake a stress test
Know who should have one
Know how it is performed
Understand the limitations
Understand which to choose
Know what to do with the result
Holy Spirit
Northside
QC
Cardiac stress testing
Why do a stress test?
Aims of stress testing
Elicit abnormalities not present at rest
Estimate functional capacity
Estimate prognosis
Likelihood of coronary artery disease
Extent of coronary artery disease
Effect of treatment
Cardiac stress testing
Who should have one?
Diagnostic test
Bayes Theorem
Consider the pre-test risk
Sensitivity & specificity of the test
Post-test probability of CAD
Diagnostic power of EST is maximal when the
pre-test probability is intermediate.
Risk assessment
Pre-existing coronary artery disease
Diabetes
Hypertension
Smoking history
Family history
Renal disease
Consider other risk factors
Pre-existing coronary artery disease
Diabetes
Hypertension
Hyperlipidaemia
Smoking history
Family history
Renal disease
Consider other risk factors
Pre-existing coronary artery disease
Diabetes
Hypertension
Hyperlipidaemia
Smoking history
Family history
Renal disease
Valvular heart disease
Rhythm disorders
Contraindications
Cardiac Stress Testing
How is it done?
Exercise protocol
Measurements
ECG
Exercise capacity (METS metabolic
equivalent)
Symptoms
Blood pressure
Heart rate response & recovery
ECG
1mm planar ST
depression
3 consecutive beats
The normal and rapid upsloping ST segment
responses are normal responses to exercise.
Minor ST depression can occur occasionally at
submaximal workloads in patients with coronary
disease.
The slow upsloping ST segment pattern often
demonstrates an ischemic response in patients
with known coronary disease or those with a high
pretest clinical risk of coronary disease.
Downsloping ST segment depression represents a
severe ischemic response.
ST segment elevation in an infarct territory (Q
wave lead) indicates a severe wall motion
abnormality and, in most cases, is not considered
an ischemic response.
(From Chaitman BR: Exercise electrocardiographic stress testing. In Beller GA [ed]: Chronic Ischemic Heart Disease. In
Braunwald E [series ed]: Atlas of Heart Diseases. Vol 5. Chronic Ischemic Heart Disease. Philadelphia, Current
Medicine, 1995, pp 2.1-2.30.)
T wave changes
Influenced by:
Body position
Respiration
Hyperventilation
Drug Rx
Myocardial ischaemia
Necrosis
Pseudonormalisation:
Usually non-diagnostic
Consider ancillary imaging
METs
Heart rate response
Peak HR > 85% of maximal predicted for age
HR recovery >12 bpm (erect)
HR recovery >18 bpm (supine)
Heart rate response
Prognostic value of stress testing
Parameters associated with adverse prognosis
or multi-vessel disease
Duration of symptom-limiting exercise <5 METs
Failure to increase sBP 120mmHg, or a sustained decreased
10mmHg, or below rest levels, during progressive exercise
ST segment depression 2mm, downsloping ST segment, starting at
<5 METs, involving 5 leads, persisting 5 min into recovery
Exercise-induced ST segment elevation (aVR excluded)
Angina pectoris at low exercise workloads
Reproducible sustained (>30 sec) or symptomatic ventricular
tachycardia
Limitations of treadmill stress test
Non-diagnostic ECG changes
False positives/false negatives
Women false positives
Elderly more sensitive/less specific
Diabetics autonomic dysfunction
Hypertension
Inability to exercise
Drugs digoxin; anti-anginals
Non-coronary causes of ST segment
depression
Anaemia
Cardiomyopathy
Digoxin
Glucose load
Hyperventilation
Hypokalaemia
Intraventricular conduction disturbance
Mitral valve prolapse
Pre-excitation syndrome
Severe aortic stenosis
Severe hypertension
Severe hypoxia
Severe volume overload (aortic or mitral rgurgitation)
Sudden excessive exercise
Supraventricular tachycardias
Non-coronary causes of ST segment
depression
Anaemia
Cardiomyopathy
Digoxin
Glucose load
Hyperventilation
Hypokalaemia
Intraventricular conduction disturbance
Mitral valve prolapse
Pre-excitation syndrome
Severe aortic stenosis
Severe hypertension
Severe hypoxia
Severe volume overload (aortic or mitral rgurgitation)
Sudden excessive exercise
Supraventricular tachycardias
Limitations of treadmill stress test
Sensitivity 68%
Specificity 77%
Ancillary techniques to enhance content
Echocardiography
Radionuclide imaging
Stress echocardiography
Stress echocardiography
Compares pre & post:
Regional contractility
Overall systolic function
Volumes
Pressure gradients
Filling pressures
Pulmonary pressures
Valvular function
Dobutamine stress echo
Stress echo - limitations
Factors which effect image quality:
Body habitus
Lung disease
Breast implants
Normal stress echocardiogram
Case 1
54 year old bank project manager
Exertional chest pain & dyspnoea
Ex-smoker
TC = 6.7mmol/L
Stress ECG 2mm ST segment depression in
5 leads
Stress echocardiogram
Coronary angiogram
Case 2
62 year old female
Chest pain & dyspnoea
Treadmill exercise test non-diagnostic
sub-maximal
Hypertension
No ECG changes
Case 2
Exercised 7 minutes (9.4 METS)
No chest pain
ECG changes
Case 2
Case 2
Case 3
24 year old female engineer
Exertional dyspnoea
Palpitations
Case 3
Inducible dyspnoea
ECG
partial right bundle branch block
no ischaemic changes
Case 3
Case 3
Case 3
Case 4
43 year old male - airline catering
Chest pain
Dyspnoea
Case 4
Inducible dyspnoea
Non-specific T wave changes
No ST segment shift
Global deterioration in left ventricular
function
Case 4
Case 4
Case 4
Nuclear SPECT imaging
Radio-tracer injection
Isotopes:
Thallium-201
Technetium 99m (sestamibi)
Myocardial uptake
Photon emission captured by gamma camera
Rest & redistribution phases
Pharmacologic protocols available
Digital presentation
Nuclear SPECT imaging
Nuclear SPECT imaging
Nuclear SPECT imaging
Nuclear SPECT imaging
Reversible inferior wall defect
Milder reversible inferior wall
defect
Limitations of nuclear SPECT imaging
Time-consuming
Artifacts
Balanced ischaemia
Radiation
Limitations of nuclear SPECT imaging
Normal apical thinning.
Limitations of nuclear SPECT imaging
A. Breast attenuation B. Anterior ischaemia
Limitations of nuclear SPECT imaging
Limitations of nuclear SPECT imaging
Risk of iatrogenic malignancy
Linear no-threshold model
Consider:
age
gender
background
Copyright 2007 American Heart Association
Einstein, A. J. et al. Circulation 2007;116:1290-1305
Limitations of nuclear SPECT imaging
MRI cardiac stress test
Useful for:
Patients unable to exercise
ECG uninterpretable
Unsuitable for DSE
And.
No radiation
But
Not currently available
MRI cardiac stress test
Cardiac stress testing
So.which one to choose?
Cardiac stress testing
TEST SENSITIVITY/SPECIFICITY TIME RADIATION COST SUPPLEMENTARY LIMITATIONS
Treadmill
68/77 30mins nil least Nil
BBB
Arrhythmias
*
Stress echo
85/88 45mins nil mid
Structural
Functional
Haemodynamic
viability
Body habitus
*
Nuclear stress
imaging
85/81 3-4hours 10 mS most LV function
viability
Artifact
Balanced ischemia
*
* no information regarding plaque vulnerability
What to do with the result?
Remember Bayes theorem
Consider the pre-test risk
Be aware of the sensitivity & specificity of the
test
Apply the post test probability
Question
45 year old diabetic man
Anterior chest discomfort with exertion
Exercised for 2 mins 30 secs (4.6 METs)
95% maximal predicted heart rate
Mild chest pain
BP increased from baseline to 180/80mmHg
1mm ST depression in leads II, III, aVF, V4-6
Which is true?
1. Pre-test risk is intermediate
2. Post-test probability for cardiac events is
high
3. The ECG changes are non-diagnostic
4. The ECG changes are false-positive in the
setting of hypertension
5. Chest pain is not a useful symptom in
diabetics
Which is true?
1. Pre-test risk is intermediate
2. Post-test probability for cardiac events is
high
3. The ECG changes are non-diagnostic
4. The ECG changes are false-positive in the
setting of hypertension
5. Chest pain is not a useful symptom in
diabetics
Remember
Remember
Parameters associated with adverse prognosis
or multi-vessel disease
Duration of symptom-limiting exercise <5 METs
Failure to increase sBP 120mmHg, or a sustained decreased
10mmHg, or below rest levels, during progressive exercise
ST segment depression 2mm, downsloping ST segment, starting at
<5 METs, involving 5 leads, persisting 5 min into recovery
Exercise-induced ST segment elevation (aVR excluded)
Angina pectoris at low exercise workloads
Reproducible sustained (>30 sec) or symptomatic ventricular
tachycardia
When ordering a stress test consider
Pre-test risk of disease
Sensitivity & specificity of the test
Value of supplementary data
AND JUST ONE MORE TIP..
CT Calcium score
Correlates with presence & extent of CAD
Strong negative predictive value
Cannot predict functional significance
Higher scores can predict events
Recommended for asymptomatic with
intermediate risk
CT Calcium score
Calcification of the left
anterior descending
coronary artery (large
arrow) and left
circumflex coronary
artery (small arrow).
CT Calcium score
Score description RR
0 nil
1 99 mild 1.9
100 399 moderate 4.3
400 999 severe 7.2
>1000 extensive 10.8
CT Calcium score
Indicated asymptomatic with intermediate risk
Not for low risk/population screening
High risk use current guidelines
Do not reduce Rx if intermediate risk & 0 score
CT coronary angiography
2-dimensional & 3-dimensional
reconstructions
Relies on slow, regular heart rate
High negative predictive value (rule out
ability)
CT coronary angiography - limitations
Lower positive predictive value (over-
estimation tendency)
Grading of stenosis limited
Does not evaluate functional significance
Radiation exposure
CT coronary angiography
Role not yet clearly defined
Potential for those with intermediate
likelihood of disease:
Where stress testing not possible
Stress test equivocal/uninterpretable
Acute chest pain/no ECG changes/normal
enzymes
Role in anomalous anatomy
CT coronary angiography