STRESS ECG AND STRESS ECHOCARDIOGRAPHY Giuseppe Biondi Zoccai
STRESS ECG AND STRESS ECHOCARDIOGRAPHY Giuseppe Biondi Zoccai Division of Cardiology, University of Turin, Italy Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy www. metcardio. org
LEARNING GOALS • • Scope of the problem Stress ECG Stress echocardiography Reconciling the evidence www. metcardio. org
LEARNING GOALS • • Scope of the problem Stress ECG Stress echocardiography Reconciling the evidence www. metcardio. org
FINDING AN APPROPRIATE DIAGNOSTIC LEVEL www. metcardio. org
FINDING AN APPROPRIATE PROGNOSTIC LEVEL www. metcardio. org
DIAGNOSTIC AND PROGNOSTIC WORK-UP OF SUSPECTED CORONARY HEART DISEASE • • • Clinical history Physical examination Resting ECG Resting echocardiography Stress ECG Stress echocardiography Stress nuclear scan Coronary CT Coronary angiography …. www. metcardio. org
EFFECTIVE RADIATION DOSES Picano, Am J Med 2003 www. metcardio. org
CORONARY STEAL PHENOMENON Picano, Circ 1998 www. metcardio. org
CORONARY STEAL PHENOMENON Picano, Circ 1998 www. metcardio. org
THREE STATES OF THE SODIUM CHANNEL AND THE NORMAL SODIUM CURRENT (INa) 0 Sodium Current Late Na+ Peak Na+ Resting Closed Na+ Activated Inactivated out [Na] 140 m. M Na+ ~ 10 m. M in out in Na+ Na+ Ca++ ++ Ca Ca++ Na+/Ca++ Exchanger Na+ Ca++ www. metcardio. org
ISCHEMIA INDUCED EFFECTS ON LATE INa AND INTRACELLULAR CALCIUM 0 Sodium Current Excess Calcium: Late • Electrical instability • Contractile dysfunction • ECG changes Na+ Impaired Inactivation Peak Na+ + + Na Na+Na Na+ Na+ Na+ Ca++ in out Na+ Ca++ Ca in Ca++ ++ Ca Ca++++Ca++ ++ Ca Ca Ca++ Na+/Ca++ Exchanger Na+ Ca++ www. metcardio. org
THE ISCHEMIC CASCADE www. metcardio. org
LEARNING GOALS • • Scope of the problem Stress ECG Stress echocardiography Reconciling the evidence www. metcardio. org
TREADMILL STRESS TEST www. metcardio. org
KEY ACCESSORY www. metcardio. org
EQUIPMENT FOR STRESS TESTING • • Treadmill or bicycle or steps ECG machine Blood pressure cuff Computer is a ‘nice to have’ ACLS certification Defibrillation/intubation cart Exit strategy Good help* (it takes two to test) www. metcardio. org
PROTOCOLS www. metcardio. org
TYPICAL BRUCE OR RAMP STRESS WORK TIME www. metcardio. org
WHY USE A BIKE ERGOMETER? 1. Accurate measurement of POWER. 2. Ramping protocols allow for assessment of physiologic function across all work levels. 3. Independent of patient’s weight. 4. Less danger of fall and injury to patient. 5. Easier to take accurate B/P at high work rates. 6. Patient can stop at anytime. 7. Holding handle bars does not effect test (Holding treadmill handrails can significantly effect results). 8. Fits into smaller space and is portable. 9. Patients with knee or hip problems tend to perform better and report being more comfortable on the bike. www. metcardio. org
WHY USE A BIKE ERGOMETER? 10. Bike ramp protocols are designed to last 6 -10 minutes, resulting in less fatigue (yet peak work is maximized). 11. HR, Work, and VO 2 (Cardiac Output) are linearly related. Bike ramp protocols produce linear increases in Work, thereby mimicking the expected physiologic response in health and disease. 12. Determination of the Anaerobic Threshold (AT) by the most popular methods (V-slope and VE/VO 2 nadir) were developed and proven through the use of bike ramp protocols. To use another method means to lose AT detection accuracy. 13. Bike ramp protocols are used by many of the leading clinical and research cardiopulmonary exercise testing labs (UCLA, Duke, Mayo, Stanford, Bowman. Gray, Johns Hopkins, UAB, Temple to name a few). Recently, treadmills capable of performing ramp protocols have been developed. www. metcardio. org
MY VIEW: TREADMILL IS BEST www. metcardio. org
INDICATIONS TO STRESS TEST • • • Diagnosis of coronary artery disease Risk-stratification in cardiac valve disease Appraisal of rate response Appraisal of pressure response to stress Appraisal of functional capacity www. metcardio. org
INFORMATION OBTAINED FROM EXERCISE STRESS BUT NOT AVAILABLE WITH PHARMACOLOGICAL TEST • • Exercise duration/tolerance Reproducibility of symptoms with activity Heart rate response to exercise Blood Pressure response Detection of stress induced arrhythmias Assess control of angina with medical therapy Prognosis www. metcardio. org
KEY ASPECTS • Exercise duration and work-load (minutes, METs, Watts) • Maximum blood pressure • Maximum heart rate (given that predicted for age) • Rate-pressure product • Baseline ECG • ST-segment changes • • T-wave changes Q waves Duke treadmill score Heart rate recovery www. metcardio. org
ABNORMAL RESPONSE TO STRESS TESTING 1) Heart rate fails to rise above 120 or unable to attain target heart rate of 85% of max 2) Blood pressure shows a drop in systolic 3) Patient physically unable to complete test 4) Marked hypertension, >260/115 5) Chest Pain and/or unusual shortness of breath www. metcardio. org
NORMAL RESPONSE OF ECG TO STRESS TESTING ECG Changes 1) QRS complex decreases in size 2) J point depresses, resulting in up sloping of ST segment 3) ST segment returns to baseline by 80 milliseconds 4) PR segment may down slope – thus baseline is defined as PQ junction 5) R amplitude may decrease at rates that go above 130 6) T wave decreases www. metcardio. org
ABNORMAL RESPONSE OF ECG TO STRESS TESTING ECG Changes – Horizontal or down sloping ST segments – ST segment depressed or elevated – ST segment does not return to baseline by 80 milliseconds – U or T wave inversion – Dysrhythmias – rate dependent blocks above first degree, WPW appears, Atrial fib/flutter, multiform and/or increasing PVC’s, V-tach occurs www. metcardio. org
ECG CHANGES www. metcardio. org
ECG CHANGES www. metcardio. org
RISK www. metcardio. org
CRITERIA DIAGNOSTIC FOR ISCHEMIA • Horizontal or down sloping ST segment with depression of 1 or greater mm. • Horizontal, up or down sloping ST segment with elevation of 1 or greater mm. • Up sloping ST depression greater than 1. 5 mm at J+80 msec. www. metcardio. org
CRITERIA DIAGNOSTIC FOR ISCHEMIA • Horizontal or down sloping ST segment with depression of 1 or greater mm. • Horizontal, up or down sloping ST segment with elevation of 1 or greater mm. • Up sloping ST depression greater than 1. 5 mm at J+80 msec. www. metcardio. org
CRITERIA SUGGESTIVE FOR ISCHEMIA • Horizontal or down sloping ST segment with depression greater than 0. 5 mm but <1 mm. • Up sloping ST depression between 0. 7 and 1. 5 mm at J+80 msec. • Chest pain or fall in Blood pressure or persistent HTN in recovery or new S 3 or murmur at peak exercise. (<1 mm) www. metcardio. org
SYMPTOM-SIGN LIMITED TESTING ENDPOINTS – WHEN TO STOP! Dyspnea, fatigue, chest pain Systolic blood pressure drop ECG--ST changes, arrhythmias Physician Assessment Borg Scale (17 or greater) www. metcardio. org
PREDICTED MAXIMUM HEART RATE www. metcardio. org
WHAT IS A MET? Metabolic Equivalent Term 1 MET = "Basal" aerobic oxygen consumption to stay alive = 3. 5 ml O 2 /Kg/min Actually differs with thyroid status, post exercise, obesity, disease states But by convention just divide ml O 2/Kg/min by 3. 5 www. metcardio. org
MAJOR DETERMINANTS OF MYOCARDIAL OXYGEN CONSUMPTION Picano, Circ 1998 www. metcardio. org
PROGNOSTIC ROLE OF METs Myers et al, New Engl J Med 2002 www. metcardio. org
PREDICTING CARDIAC DEATH Marcus et al, Chest 1995 www. metcardio. org
DUKE TREADMILL SCORE www. metcardio. org
BAYES THEOREM If P(B) ≠ ), then P(A/B) = “ P(B/A)P(A) + P(B/not A)P (not A) www. metcardio. org
CONTINUOUS OF RISK www. metcardio. org
TYPICAL REPORT Treadmill stress test stopped at the end of the 3 rd standard Bruce stage for fatigue (max BP 200/100 mm Hg, max HR 140 bpm, RPP 28, 000). No symptoms. No arrhythmias. No abnormalities in the baseline ECG. In the 2 nd stage development of ST depression, which becomes diagnostic in the 3 rd stage (max 1. 5 mm in V 5 at the peak), with quick recovery after the stress. Duke treadmill score: 1 (<-11 high risk; >4 low risk). Heart rate recovery: 10 (valore di riferimento >12). Positive stress test for myocardial ischemia at mid-to-high work -load. www. metcardio. org
GUIDELINES Gibbons et al, Circ 2002 www. metcardio. org
GUIDELINES: RECOMMENDATIONS Gibbons et al, Circ 2002 www. metcardio. org
GUIDELINES: RECOMMENDATIONS Gibbons et al, Circ 2002 www. metcardio. org
STRESS EKG IS NOT A SLAM DUNK 5/10, 000 result in serious cardiovascular event 1/10, 000 result in death Results are based on Bayes Theorem Requires proper selection, preparation, and execution • Not the GOLD standard • • www. metcardio. org
LEARNING GOALS • • Scope of the problem Stress ECG Stress echocardiography Reconciling the evidence www. metcardio. org
STRESS ECHOCARDIOGRAPHY www. metcardio. org
BASIC PRINCIPLE OF STRESS ECHO www. metcardio. org
BASIC PRINCIPLE OF STRESS ECHO www. metcardio. org
WALL MOTION RESPONSES Sicari et al, Eur Heart J 2009 www. metcardio. org
CARDIAC SEGMENTS www. metcardio. org
WALL SEGMENTS AND CORONARY DISTRIBUTION www. metcardio. org
CURRENT STRESS PROTOCOLS Exercise: Pharmacologic: Catecholamines: Vasodilators: Vasospastic: Adjuncts: ECG ECHO NUCLEAR Tread Bicycle Post-Tread Bicycle Tread Dobutamine Dipyridamole Adenosine Ergonovine Atropine Handgrip Dobutamine Dipyridamole Adenosine Dipyridamole Ergonovine www. metcardio. org
INDICATIONS TO STRESS ECHOCARDIOGRAPHY • • • Diagnosis of coronary artery disease Risk-stratification in cardiac valve disease Appraisal of myocardial viability Patients unable to ambulate www. metcardio. org
PREPARATION • Avoid smoking • Avoid food/beverages • Take all medications unless instructed otherwise • Wear comfortable clothes and shoes www. metcardio. org
KEY PHARMACOLOGICAL TESTS Picano, Circ 1998 www. metcardio. org
DOBUTAMINE PROTOCOL Sicari et al, Eur Heart J 2009 www. metcardio. org
DIPYRIDAMOLE PROTOCOL Sicari et al, Eur Heart J 2009 www. metcardio. org
FURTHER APPLICATIONS Sicari et al, Eur Heart J 2009 www. metcardio. org
LEARNING GOALS • • Scope of the problem Stress ECG Stress echocardiography Reconciling the evidence www. metcardio. org
PATIENTS APPROPRIATE FOR ROUTINE ECG STRESS TEST WITHOUT IMAGING • • • Patient can exercise for 6 or more minutes Normal baseline ECG No history of diabetes No history of coronary revascularization No history of myocardial infarction www. metcardio. org
ABSOLUTE CONTRAINDICATIONS • Within 24 hours of troponin positive ACS • Within 7 days for high dose DSE after STEMI • Left ventricular failure with symptoms at rest (in tertiary centres viability may be assessed using low dose dobutamine stress). • Recent history (within the last week) of life threatening arrhythmias. • Severe dynamic or fixed left ventricular outflow tract obstruction although low dose DSE may be useful. • BP >220/120 • Recent pulmonary embolism or infarction. • Thrombophlebitis or active deep vein thrombosis. • Known hypokalaemia (particularly for Dobutamine stress) • Active endocarditis, myocarditis, or pericarditis. www. metcardio. org
POSSIBLE CONTRAINDICATIONS TO STRESS TESTING BASED ON RESTING ECG • ST-segment changes 1 mm or greater, either depression or elevation • Ventricular strain patterns or hypertrophy • T-wave inversions • Left bundle branch block • Right bundle branch block, if significant • Prolonged QT interval www. metcardio. org
ABSOLUTE CONTRAINDICATIONS TO DOBUTAMINE STRESS ECHO • • • Suspected or known severe bronchospasm 2 nd or 3 rd degree AV block without pacemaker Sick sinus syndrome without pacemaker BP <90 mm. Hg systolic Xanthines taken in the last 12 hours, or dipyridamole use in the last 24 hours www. metcardio. org
FIRST THINGS FIRST: DIAGNOSTIC PERFORMACE OF DIFFERENT TESTS www. metcardio. org
CHOOSING YOUR TEST Heijenbrok-Kal et al, Am Heart J 2007 www. metcardio. org
CHOOSING YOUR TEST Froelicher et al, Chest 1999 www. metcardio. org
CARDIAC STRESS IMAGING Picano, Am J Med 2003 www. metcardio. org
ADVANTAGES OF STRESS ECHOCARDIOGRAPHY COMPARED TO NUCLEAR STRESS TESTING • • Higher Specificity Visualization of cardiac valves Evaluate for presence of pericardial effusion Ability to measure RV Systolic Pressure More accurate assessment of LV ejection fraction Doppler interrogation to determine Diastolic Function Lower Cost Lack of Radiation Exposure www. metcardio. org
TAKE HOME MESSAGES • Stress testing, by either stress ECG, stress nuclear scan, dipyrididamol/dobutamine nuclear scan, stress echocardiography, dipyrididamol/dobutamine echocardiography, is crucial in the diagnostic workup of patients with suspected coronary heart disease • These tests are also useful in the prognostic work-up of patients with established coronary heart disease • Given financial and logistic constraints, stress ECG should be performed in most suitable subjects as 1 st line test, followed/substituted by imaging tests in all the other cases www. metcardio. org
Thank you for your attention For any correspondence: gbiondizoccai@gmail. com For these and further slides on these topics feel free to visit the metcardio. org website: http: //www. metcardio. org/slides. html www. metcardio. org
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