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