The Role of NonInvasive Testing in CAD Teresa Daniele,M.D, FACC - - PDF document

The Role of Non‐Invasive Testing in CAD

Teresa Daniele,M.D, FACC Chief of Cardiology, UCSF‐Fresno Program Director, Adult Cardiovascular Fellowship Associate Professor of Clinical Medicine, UCSF

Disclosures

• I have no relationships to disclose

Do you ever get short of breath or tired while walking?

Indications for Stress testing

• Known or suspected CAD

– Diagnosis – Prognosis

• Known or suspected dysrhythmia

– Exercise‐induced arrythmias – Chronotropic incometence

• Structural Heart Disease

– Asymptomatic severe aortic stenosis – Hypertrophic cardiomyopathy

Goals of Testing

• Diagnosis of CAD (Obstructive)
• Estimate Prognosis
• Extent of CAD
• Effect of treatment
• Estimate Functional Capacity

CAD and Luminal Obstruction

Diagnostic Test

• Consider the “Pre‐test risk”
• Sensitivity and Specificity of the test
• Post‐test probability of CAD
• Diagnostic power of stress test is maximal

when the pre‐test probability is intermediate.

How is it done?

The Bruce protocol

• Developed in 1949 by

Robert A. Bruce, considered the “father of exercise physiology”.

• Published as a

standardized protocol in 1963.

• Remains the gold‐

standard for detection of myocardial ischemia when risk stratification is necessary.

How good is exercise ECG testing?

• Gianrossi R, Detrano R,

Mulvihill D, et al. Exercise‐ induced ST depression in the diagnosis of coronary artery

• disease. Circulation 1989;

80:87‐98.

• Meta‐analysis of 147

consecutive studies involving 24,074 patients

Sensitivity Comparison of Different Testing Modalities SPECIFICITY OF DIFFERENT STRESS TESTING MODALITIES

Not Negative or Positive!

Assessment

• EKG
• Exercise capacity (METS‐metabolic equivalent)
• Symptoms
• Blood pressure
• Heart rate respose and recovery

DUKE TREADMILL SCORE

• Duration of exercise on treadmill (in minutes)
• Amount of ST segment depression (in

millimeters)

• Treadmill Angina index:

0 = No Angina 1 = Non‐limiting Angina 2 = Limiting Angina

DUKE TREADMILL SCORE

• Duration of exercise on treadmill (in minutes)

minus 5x (millimeters of maximal ST segment depression) minus 4X (treadmill anginal index)

• Example: Patient walked on treadmill for 11

minutes without chest pain. ECG showed one mm of ST segment deviation.

• Duke Score: +6 = 11 minus 5x (1) minus 4x (0)

PROGNOSIS: DUKE TREADMILL SCORE