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Stress Testing: which test, which patient? Adam Wolfe, DO Program Director, IM Residency Metro Health - University of Michigan Health Conflicts of Interest NONE Goals Review indications and contraindications for stress testing Review common modalities for stress evaluation of our patients in the primary care setting Understand the concern around unnecessary testing

Highlight specific patient populations we commonly encounter Symptomatic patients Asymptomatic patients with risk factors Pre-operative evaluation of non-cardiac surgery Patients with DM Cases Questions and experiences

The answers I dont have all of the answers. Stress testing is not indicated in our patients with low CV risk and those without symptoms. Stress testing is best utilized for our patients with intermediate probability of CVD based on symptoms. Male gender, older age, DM, and dyslipidemia were independent predictors. Make sure that medical management (GDMT) is optimized likely this is more effective than stress testing at improving patient outcomes. Continue to fight the good fight against therapeutic inertia. Pre-operative stress testing is almost never indicated in our patients with good exercise capacity (>4 METS). When evaluating surgical patients use a validated guideline (RCRI, Gupta, ACS), be consistent about using it, and, trust the one that you use.

At the end of the day, its about practicing good medicine. Our clinical dilemma in primary care Asked to evaluate patients on a daily basis for CV evaluation Pre-operative assessment Patients presenting with chest pain (typical or atypical) Abnormal ECG results Patients who want more data to estimate their risk What data is there for our DM patients and CV screening?

Over the next 30 years, the number of procedures in Medicare patients is expected to double (6 12 million annually) Studies show that a conservative estimate of overutilization of stress testing in Medicare patients is at 4% Cardiac complications are the leading cause of death peri-operatively and extend length of stay by an average of 11 days after an event. The mortality rate of patients with perioperative MI is substantial, ranging from 30% to 50% Ann Surg. 2013 Jan; 257(1): 7380. Initiatives Consultative management may increase unnecessary testing and

complications with primary care patients. Ann Intern Med. 2010;152(1):47-51. Choosing the right test Review of testing available to us in primary care Indications Patients with symptoms suggesting angina Patients with acute chest pain (after relief of symptoms) Patients with recent ACS (treated conservatively) 3 months Patients with known CHD and new or worsening symptoms For the pre-operative evaluation of the non-cardiac surgery patient

Highest risk surgeries (maybe some intermediate) Patients with chronic LV dysfunction and CHD who are candidates for revascularization Evaluate severity and symptoms of valvular or congenital heart disease or evaluate arrhythmic therapy (non CAD related) Asymptomatic patients with multiple risk factors??? Contraindications Acute myocardial infarction (MI; within 2 days) Unstable angina not previously stabilized by medical therapy Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure

Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Acute aortic dissection Gibbons et al., J. Am. Coll. Cardiol. 40;1531, 2002 Modalities for Patient Evaluation Which test? Stress Modalities Inc HR or Dec Resistance Exercise (always better, if possible) Treadmill, Recumbent Bike, Arm Bike 85% max predicted HR is the goal for maximal information Usual Bruce Protocol starts at 1.7mph at a 10% grade and increases in speed and grade every 3 minutes (4 METS) - Stress test warranty: if you go

10 minutes on a Bruce, you are pretty much guaranteed not to have an event in the next year 3.5 ml/Kg/min O2 consumption = 1 MET Dobutamine Positive inotrope and chronotrope (B1) and some vasodilation (B2) Variable patient response Increased arrhythmia risk, caution with severe AS Fewer false positives (vascular sx literature)

Hold Beta blockers/ Diltiazem/Verapamil (48hrs before) Stress Modalities Inc HR or Dec Resistance Vasodilator (if your patient cant exercise) Adenosine / Dipyridamole Requires infusion Regadenoson (Lexiscan) No infusion needed Preferred with patients who cannot exercise or who do have LBBB Contraindication in patients with COPD (caution), hypotension, sick sinus syndrome, high-degree AVB, critical carotid occlusive disease, or oral dypyridamole therapy

Does not rely on regional wall motion abnormalities, as it looks at perfusion Hold Theophylline, Pentoxifylline (Trental), and Dipyridamole 48 hrs before Hold all caffeine 12 hrs before Viagra / Levitra (24hrs before), Cialis (72hrs before), Nitrates (48 hrs before), CCBs (48hrs before) Imaging Modalities Myocardial imaging evaluation is critical for many patients Females have significantly increased false + stress ECG results (40-80%) Echocardiogram Hemodynamics with stress, wall motion abnormalities, and valve / structural information Challenging with certain patients

Obesity COPD or increased AP diameter chest wall False negatives at times due to decreased afterload Visual estimation of EF vs calculated EF Thallium or Sestamibi Calculated EF based on end systole and end diastole (what if MR or AI) Provides evidence of under-perfusion False negatives from left main disease, equal flow limiting obstructions, caffeine consumption

False positive results with hyperventilating or increased soft tissue (breast or abdominal / diaphragm attenuation) usually inferior territory How do they all compare? Comparison of all modalities available are similar Lets explore some clinical questions! 3 illustrative cases Sharon A 45 year old woman with moderate RA affecting hands primarily and mild resting pulmonary hypertension who complaints of chest pain and dyspnea on exertion? Which stress test is most appropriate?

a) b) c) d) e) f) g) Exercise EKG Exercise stress echo Exercise nuclear Dobutamine stress echo Dobutamine nuclear Vasodilator nuclear Curbside the cardiologist

Pre-test probability test questions Can the patient exercise to a satisfactory workload? Does the patient have an abnormal baseline ECG? Does the patient need an

assessment of myocardial viability? Revascularization strategy Does the patient have a large body habitus or lung disease? What is the pre-test likelihood of disease based on the chest pain

quality? What are the costs and effects on health outcomes of each test? Are there contraindications to the test? Our responsibility Holy grail: identify patients who are at risk and provide appropriate care and medical optimization

Stress testing identifies patient riskbut pre-test probability is imperative! Bayes Theorem ACC National Cardiovascular Data Registry patients who underwent coronary angiography: male gender, older age, diabetes mellitus, and hyperlipidemia were independent predictors of the likelihood of CHD Coronary Artery Surgery Study (CASS), 1465 men and 580 women with complaints of chest pain Definite angina Substernal chest discomfort characterized by all of the following characteristics: a typical quality and duration, provocation by exertion or emotional stress, and relief by rest (3/3) Probable or atypical angina (2/3) Non-angina or non-ischemic chest pain (0-1/3)

Could other variables help us in our assessment Coronary calcium scoring has been shown to improve PreTP N Engl J Med. 2010;362(10):886 N Engl J Med. 1979;301(5):230 BMJ 2012;344:e3485 Pre-test probability for our patients Historically Duke Clinical Score and Diamond and Forrester tools tend to overestimate a patients pre-test probability for CAD, but still are used widely for estimation of a patients risk. Useful tool for estimation was published by the CAD

consortium: https:// www.qxmd.com/calculate/calculator_287/pre-test-probability-of-cadcad-consortium Validated and easy to use on a rapid basis by you or your MA/RN 8 variables to predict risk low, intermediate, or high Extended risk model includes CAC, which isnt universally performed BMJ. 2012 June 12, 344: e3485 Into the OR Evaluation of patient risk pre-operatively with stress testing Vinnie A 60yo man is evaluated for a pre-operative

evaluation prior to a left total knee replacement. He does recently have the complaint of chest pain of 4 months duration. He describes the pain as sharp, located in the left chest, with no radiation or associated symptoms, that occurred with walking one to two blocks and resolves with rest. Occasionally, the pain improves with continued walking or occurs during the evening hours. He has hypertension. Family history does not include cardiovascular disease in any first-degree relatives. His only medication is amlodipine. On physical examination, he is afebrile, blood pressure is 130/80mHg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No carotid bruits are present, and a normal S1 and S2 with no murmurs

are heard. Lung fields are clear, and distal pulses are normal. EKG showed normal sinus rhythm. Is a stress test indicated for Vinnie pre-operatively? Pre-operative evaluation of our patients JACC 2014 we have reviewed this before Evaluate MACE risk for procedure and for patient (using validated tool). RCRI (Revised Goldman) 6 indicators Gupta (NSQIP MICA data) 5 indicators ACS (NSQIP data) 21 indicators Estimate the functional capacity of the patient.

Will further testing impact decision making or perioperative care? Estimating risk in the office Key piece to consider with our surgical patients To test or not to test, that is the question! Seven specialty societies recommend against the use of preoperative stress testing in patients scheduled to undergo low- and/or intermediate-risk non-cardiac surgery. A paradigm shift has occurred for management of most stable

CAD with medical therapy first rather than routine PCI. Significant cost and harm is associated with unnecessary testing, false positives, and additional procedures. Information from stress testing should be meaningful to direct management To answer this question, we need to continue to talk with our patients! Determine functional capacity and risk, and focus on the patients GDMT and optimize their therapy. CARP trial high risk surgical patients show no benefit with revascularization, even with known 70% stenosis. N Engl J Med 2004;351:2795-804

What about diabetes? Do we have data available to help us with our DM patients in our practice? James A 66 yr old male with diabetes, on dialysis and s/p BKA, admitted with chest pain, and ruled out for MI by EKG and cardiac enzymes, and following up in the office after discharge. Which stress test is most appropriate? a) Exercise EKG b) Exercise stress echo c) Exercise nuclear d) Dobutamine stress echo e) Dobutamine nuclear f) Vasodilator nuclear

g) Curbside the cardiologist What data do we have for our DM patients? CV equivalency of DM has been questioned after initial trial data when looking back at meta-analysis LOOK-AHEAD 5,783 overweight/obese asymptomatic middle-aged men and women with type 2 diabetes Only age was a separate determinant of CAD DADDY-D (Does coronary Atherosclerosis Deserve to be Diagnosed and treated early in Diabetics?) trial. 520 DM patients They found silent ischemia in 7.6% of patients Failed to demonstrate a significant reduction in cardiac events and HF episodes

CAC (Coronary Artery Calcium) seems to show significant promise in the risk stratification of DM patients The yield of MPI can be improved by selecting a higher-risk group of patients with symptoms, peripheral vascular disease, CKD, an abnormal ECG, or a high CAC score (e.g., >400) if +, think stress testing N Engl J Med 339:229234. 1998 Diabet Med 26:142148. 2008 Diabetes Care 33:901907, What data do we have for our DM patients? CFR (Coronary Flow Reserve) or FFR (Fractional Flow Reserve) is possibly

more representative of CAD risk and mortality in our DM patients. Equivalent (low) cardiac mortality risk between diabetic patients without known CAD (prior revascularization or MI) but with CFR >1.6 and those without diabetes. In contrast, the subgroup of diabetic patients without known CAD but with CFR <1.6 had essentially the same risk as patients without diabetes but with CAD.

Circulation 126:18581868. 2012 Evaluation of DM patients for CAD Stress testing in DM patients continues to be an option, with * CAC seems to be continuing to hold promise as a marker for risk CACTI (Coronary Artery Calcification in Type 1 Diabetes) Better when compared with the Framingham risk score and the UKPDS (United Kingdom Prospective Diabetes Study) (area under the curve 0.76, 0.70, and 0.69, respectively; all p < 0.05) Cardiac CTA has started to provide some evidence for asymptomatic patients with DM However, coronary CTA is currently not recommended and is not

considered appropriate as a risk stratification tool in this population. Diabetes Care 26:29232928. J Am Coll Cardiol 43:16631669. Cardiac MR is still investigational, but is gaining some traction, especially in the DM population. Rick A 48 year old 450 lb morbidly obese man with OSA on CPAP and h/o prior DVT, who complaints of atypical chest pain that is relieved with nitroglycerin. He is not very mobile and cannot lie completely flat. Which stress test is most appropriate?

Exercise EKG Exercise stress echo Exercise nuclear Dobutamine stress echo Dobutamine nuclear Vasodilator nuclear Curbside the cardiologist

Final Thoughts I still dont have all of the answers. Stress testing is not indicated in our patients with low CV risk and those without symptoms. Stress testing is best utilized for our patients with intermediate probability of CVD based on symptoms. Male gender, older age, DM, and dyslipidemia were independent predictors of risk. Make sure that medical management (GDMT) is optimized likely this is more effective than stress testing at improving patient outcomes. Continue to fight the good fight against therapeutic inertia. Pre-operative stress testing is almost never indicated in our patients with good exercise capacity (>4 METS). When evaluating surgical patients use a validated guideline (RCRI, Gupta, ACS), be consistent about using it, and, trust the one that you use.

At the end of the day, its about practicing good medicine. Thanks! Questions or Experiences?

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