1/ Cardiac Stress Testing @CardioNerds
🔶Indications
🔶Types - Exercise vs. Pharmacological
🔶Compare & Contrast Modalities
Thanks to @SimratKaurMD, @AmitGoyalMD, @jholtzman3 for feedback on this infographic!
Follow🧵for a breakdown of the graphic⤵️
🔶Indications
🔶Types - Exercise vs. Pharmacological
🔶Compare & Contrast Modalities
Thanks to @SimratKaurMD, @AmitGoyalMD, @jholtzman3 for feedback on this infographic!
Follow🧵for a breakdown of the graphic⤵️
2/ Indications
Evaluate:
🔺Stable chest pain in pts w/ intermediate-high risk of CAD
🔺New onset symptoms in pt w/ known CAD
🔺Valvular heart disease & provocative testing in HCM
🔺Microvascular disease & CAV in transplant pts
🔺Hibernating myocardium in pts w/ known CAD
Evaluate:
🔺Stable chest pain in pts w/ intermediate-high risk of CAD
🔺New onset symptoms in pt w/ known CAD
🔺Valvular heart disease & provocative testing in HCM
🔺Microvascular disease & CAV in transplant pts
🔺Hibernating myocardium in pts w/ known CAD
3/ Types❓Exercise vs. Pharmacological
🏃♀️Exercise
What➡️Treadmill
Who➡️ Anyone who can exercise (achieve 4 METs) and get to 85% of max predicted HR (220-age)
When evaluating report, look for:
🌟Duration of exercise
🌟METs achieved
🌟% max HR
🌟HR/BP response
🏃♀️Exercise
What➡️Treadmill
Who➡️ Anyone who can exercise (achieve 4 METs) and get to 85% of max predicted HR (220-age)
When evaluating report, look for:
🌟Duration of exercise
🌟METs achieved
🌟% max HR
🌟HR/BP response
4/ 🌟If patient can exercise to satisfactory workload, choose exercise 🌟
💊Pharmacological Stress Test💊
Inotrope
What➡️Dobutamine
Who➡️Not in pts with ventricular arrythmias, recent MI, aortic dissection, severe HTN
💊Pharmacological Stress Test💊
Inotrope
What➡️Dobutamine
Who➡️Not in pts with ventricular arrythmias, recent MI, aortic dissection, severe HTN
5/ 💊Vasodilator Stress Test 💊
What➡️Adenosine, regadenoson, dipyridamole
Who ➡️ Not in pts with severe bronchoconstriction (COPD, asthma), hypotension, high degree AV block, severe AS
🌟No caffeine for at least 12-24 hours🌟
What➡️Adenosine, regadenoson, dipyridamole
Who ➡️ Not in pts with severe bronchoconstriction (COPD, asthma), hypotension, high degree AV block, severe AS
🌟No caffeine for at least 12-24 hours🌟
6/ EKG -only exercise
Who➡️Without known CAD; normal EKG at rest (no LBBB, LVH, pre-excitation, baseline ST changes >1mm, V-pacing, digoxin use)
➕Easy; accessible; no radiation
➖Does not always localize ischemia
Positive test❓
1-mm horizontal or down-sloping ST depression
Who➡️Without known CAD; normal EKG at rest (no LBBB, LVH, pre-excitation, baseline ST changes >1mm, V-pacing, digoxin use)
➕Easy; accessible; no radiation
➖Does not always localize ischemia
Positive test❓
1-mm horizontal or down-sloping ST depression
7/ Stress Echo
Who➡️Abnormal baseline EKG; evaluate for dynamic LVOT obstruction in HCM & LFLG AS
➕Evaluates wall motion abnormalities (WMA), pulmonary HTN, functional capacity in pts w/ VHD
➖Sonographer dependent image quality
Positive test❓
New WMA
Who➡️Abnormal baseline EKG; evaluate for dynamic LVOT obstruction in HCM & LFLG AS
➕Evaluates wall motion abnormalities (WMA), pulmonary HTN, functional capacity in pts w/ VHD
➖Sonographer dependent image quality
Positive test❓
New WMA
8/ SPECT
➕Functional assessment of ischemia
➖Balanced ischemia in mvCAD;🚫assess hibernating myocardium; attenuation artifact; limited assessment in BMI >40; radiation exposure
Positive test❓
Perfusion defects in coronary territory w/ rest/stress; transient ischemic dilation
➕Functional assessment of ischemia
➖Balanced ischemia in mvCAD;🚫assess hibernating myocardium; attenuation artifact; limited assessment in BMI >40; radiation exposure
Positive test❓
Perfusion defects in coronary territory w/ rest/stress; transient ischemic dilation
9/ Stress PET
➕Quantify MBF; assess viability (hibernation vs scar); identify microvascular disease/CAV
➖Limited availability; expensive; 🚫to assess functional capacity; radiation
Positive test❓
Perfusion defects in coronary territory w/ rest/stress; abnormal MBFR
➕Quantify MBF; assess viability (hibernation vs scar); identify microvascular disease/CAV
➖Limited availability; expensive; 🚫to assess functional capacity; radiation
Positive test❓
Perfusion defects in coronary territory w/ rest/stress; abnormal MBFR
10/ Stress MRI
➕Tissue characterization; assess myocardium & viability
➖Patient limitations (BMI>40, claustrophobia, metallic implants, renal dysfunction);🚫assess functional capacity
Positive test
Perfusion defects in coronary territory w/ rest/stress; abnormal MBFR; LGE
➕Tissue characterization; assess myocardium & viability
➖Patient limitations (BMI>40, claustrophobia, metallic implants, renal dysfunction);🚫assess functional capacity
Positive test
Perfusion defects in coronary territory w/ rest/stress; abnormal MBFR; LGE
11/ Check out this great @CardioNerds episode on nuclear and multimodality imaging for coronary ischemia with @erikahuttce, @aschenonegiugni, & Dr. Wael Jaber
cardionerds.com
cardionerds.com
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