Transcript Diapositiva 1 - metcardio.org

STRESS ECG AND STRESS
ECHOCARDIOGRAPHY
Giuseppe Biondi Zoccai
Division of Cardiology, University of Turin, Turin, Italy
Meta-analysis and Evidence-based medicine Training in
Cardiology (METCARDIO), Ospedaletti, Italy
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LEARNING GOALS
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Scope of the problem
Stress ECG
Stress echocardiography
Reconciling the evidence
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LEARNING GOALS
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Scope of the problem
Stress ECG
Stress echocardiography
Reconciling the evidence
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FINDING AN APPROPRIATE
DIAGNOSTIC LEVEL
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FINDING AN APPROPRIATE
PROGNOSTIC LEVEL
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DIAGNOSTIC AND PROGNOSTIC
WORK-UP OF SUSPECTED
CORONARY HEART DISEASE
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Clinical history
Physical examination
Resting ECG
Resting echocardiography
Stress ECG
Stress echocardiography
Stress nuclear scan
Coronary CT
Coronary angiography
….
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EFFECTIVE RADIATION DOSES
Picano, Am J Med 2003
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CORONARY STEAL PHENOMENON
Picano, Circ 1998
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CORONARY STEAL PHENOMENON
Picano, Circ 1998
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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 mM
Na+ Na+
~ 10mM
in
Na+ Na+
Na+ Na+
Ca++
Ca++
++
Ca
Ca++ Ca++
Ca++
in
Na+
out
Na+/Ca++
Exchanger
Na+
Ca++
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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+
Na+ Na+
Na+
Na+
out
Ca++
in
Na+
out
Ca++
in
Ca++ ++
Ca
Ca++
++
Ca
Ca++Ca++ Ca++
Ca++++Ca++
++
Ca++
Ca Ca
Ca++
Na+/Ca++
Exchanger
Na+
Ca++
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THE ISCHEMIC CASCADE
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LEARNING GOALS
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Scope of the problem
Stress ECG
Stress echocardiography
Reconciling the evidence
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TREADMILL STRESS TEST
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KEY ACCESSORY
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EQUIPMENT FOR STRESS TESTING
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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)
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PROTOCOLS
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TYPICAL BRUCE OR RAMP STRESS
WORK
WORK
TIME
TIME
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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.
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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 VO2 (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/VO2 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, BowmanGray, Johns Hopkins, UAB, Temple to name a few). Recently, treadmills
capable of performing ramp protocols have been developed.
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MY VIEW: TREADMILL IS BEST
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INDICATIONS TO STRESS TEST
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Diagnosis of coronary artery disease
Risk-stratification of coronary artery disease
Risk-stratification in cardiac valve disease
Appraisal of rate response
Appraisal of pressure response to stress
Appraisal of functional capacity
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INFORMATION OBTAINED FROM EXERCISE STRESS BUT
NOT AVAILABLE WITH PHARMACOLOGICAL TEST
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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
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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
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T-wave changes
Q waves
Duke treadmill score
Heart rate recovery
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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
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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
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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
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ECG CHANGES
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ECG CHANGES
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RISK
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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.
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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.
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CRITERIA SUGGESTIVE FOR ISCHEMIA
• Horizontal or down sloping
ST segment with depression
greater than 0.5mm but <1
mm.
• Up sloping ST depression
between 0.7 and 1.5mm at
J+80 msec.
• Chest pain or fall in Blood
pressure or persistent HTN in
recovery or new S3 or
murmur at peak exercise.
(<1 mm)
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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)
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PREDICTED MAXIMUM HEART RATE
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WHAT IS A MET?
Metabolic Equivalent Term
1 MET = "Basal" aerobic oxygen consumption to
stay alive = 3.5 ml O2 /Kg/min
Actually differs with thyroid status, post exercise,
obesity, disease states
But by convention just divide ml O2/Kg/min by 3.5
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MAJOR DETERMINANTS OF
MYOCARDIAL OXYGEN CONSUMPTION
Picano, Circ 1998
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PROGNOSTIC ROLE OF METs
Myers et al, New Engl J Med 2002
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PREDICTING CARDIAC DEATH
Marcus et al, Chest 1995
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DUKE TREADMILL SCORE
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BAYES THEOREM
If P(B) ≠ ), then
P(A/B) = “
P(B/A)P(A)
“
P(B/A)P(A) + P(B/not A)P (not A)
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CONTINUOUS OF RISK
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TYPICAL REPORT
Treadmill stress test stopped at the end of the 3rd 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 2nd stage development of ST depression,
which becomes diagnostic in the 3rd stage (max 1.5 mm in V5
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.
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GUIDELINES
Gibbons et al, Circ 2002
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GUIDELINES: RECOMMENDATIONS
Gibbons et al, Circ 2002
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GUIDELINES: RECOMMENDATIONS
Gibbons et al, Circ 2002
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STRESS EKG IS NOT A SLAM DUNK
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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
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LEARNING GOALS
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Scope of the problem
Stress ECG
Stress echocardiography
Reconciling the evidence
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STRESS ECHOCARDIOGRAPHY
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BASIC PRINCIPLE OF STRESS ECHO
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BASIC PRINCIPLE OF STRESS ECHO
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WALL MOTION RESPONSES
Sicari et al, Eur Heart J 2009
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CARDIAC SEGMENTS
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WALL SEGMENTS AND
CORONARY DISTRIBUTION
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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
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INDICATIONS TO STRESS
ECHOCARDIOGRAPHY
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Diagnosis of coronary artery disease
Risk-stratification of coronary artery disease
Risk-stratification in cardiac valve disease
Appraisal of myocardial viability
Patients unable to ambulate
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PREPARATION
• Avoid smoking
• Avoid food/beverages
• Take all medications unless
instructed otherwise
• Wear comfortable clothes and shoes
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KEY PHARMACOLOGICAL TESTS
Picano, Circ 1998
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DOBUTAMINE PROTOCOL
Sicari et al, Eur Heart J 2009
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DIPYRIDAMOLE PROTOCOL
Sicari et al, Eur Heart J 2009
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FURTHER APPLICATIONS
Sicari et al, Eur Heart J 2009
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LEARNING GOALS
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Scope of the problem
Stress ECG
Stress echocardiography
Reconciling the evidence
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PATIENTS APPROPRIATE FOR ROUTINE
ECG STRESS TEST WITHOUT IMAGING
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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
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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.
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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
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ABSOLUTE CONTRAINDICATIONS
TO DOBUTAMINE STRESS ECHO
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Suspected or known severe bronchospasm
2nd or 3rd degree AV block without pacemaker
Sick sinus syndrome without pacemaker
BP <90mmHg systolic
Xanthines taken in the last 12 hours, or dipyridamole use in
the last 24 hours
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FIRST THINGS FIRST: DIAGNOSTIC
PERFORMACE OF DIFFERENT TESTS
Grouping
Standard ET
 ET Scores
 Score Strategy
Thallium Scint
SPECT
Adenosine SPECT
Exercise ECHO
Dobutamine ECHO
Dobutamine Scint
Electron Beam
Tomography (EBCT)
# of
Total #
Studies Patients
147
24,047
24
11,788
2
>1000
59
6,038
16+14 5,272
10+4
2,137
58
5,000
5
<1000
20
1014
16
3,683
Sens Spec Predictive
Accuracy
68% 77%
73%
85%
85%
88%
89%
84%
88%
88%
60%
92%
85%
72%
80%
75%
84%
74%
70%
80%
88%
85%
80%
85%
80%
86%
81%
65%
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CHOOSING YOUR TEST
Heijenbrok-Kal et al, Am Heart J 2007
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CHOOSING YOUR TEST
Froelicher et al, Chest 1999
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CARDIAC STRESS IMAGING
Picano, Am J Med 2003
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ADVANTAGES OF STRESS ECHOCARDIOGRAPHY
COMPARED TO NUCLEAR STRESS TESTING
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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
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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 1st
line test, followed/substituted by imaging tests in all
the other cases
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Thank you for your attention
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