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Cardiac Stress Testing in Contemporary Practice: Maximizing Value to Your Patient

Ritesh Dhar, MD, MS Intermountain Heart Institute Intermountain Medical Center, Murray, UT

Question

• 72 yo woman with palpitations. ECG shows AF, rate 95. No prior CV history. Going for total knee replacement next week.

• 1) Stress nuclear • 2) Dobutamine echo • 3) Echo • 4) ECG alone

Question

• 68 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged.

• 1) Repeat stress echo • 2) Stress nuclear • 3) Stress MRI • 4) Coronary CTA

An Imaging Epidemic?

Copyright ©2010 American College of Cardiology Foundation. Restrictions may apply.

Shaw, L. J. et al. J Am Coll Cardiol Img 2010;3:789-794

Medicare Fee-for-Service Spending for Imaging Services

Why? • Shift from in-patient to out-patient testing? • Medical cultural reasons? • Fear of litigation? (Out-pt, ER settings) • True increase in imaging services/options? • Technology-driven society? • Patient expectations? • Sicker patient population?

IMAGING UTILIZATION AND A NEED FOR GUIDANCE

• Unprecedented focus on assessment and improving quality

• Substantial regional variation • True nature of utilization unknown • Clinicians, patients, and payers seeking guidance

Hendel, ASNC 2015

Example

A = Appropriate M = May be appropriate R = Rarely appropriate

ACCF APPROPRIATENESS USE CRITERIA

• Literature-based (when available) approach to improve utilization of resource-intensive tests and procedures

• Serves as a method for focused reduction of procedures based on clinical value, not indiscriminant volume reduction

• Preserves patient/provider relationship

Hendel, ASNC 2015

SPECT Nuclear Study – ACCF/United Healthcare

• 2010 study with 6,000 patients

• 71% Appropriate • 15% May be appropriate • 14% Rarely appropriate

Hendel, 2010, JACC 55:156-62

Question

• Which of the following indications comprised the greatest number of inappropriately ordered tests?

1) Detection of CAD – Asymptomatic, low CHD risk 2) Preoperative assessment 3) Asymptomatic - < 2 years after PCI 4) Evaluation of chest pain – low CHD risk, interpretable ECG and able to exercise

Hendel, 2010, JACC 55: 156-62

Question

• Which of the following indications comprised the greatest number of inappropriately ordered tests?

1) Detection of CAD – Asymptomatic, low CHD risk 44% 2) Preoperative assessment 4% 3) Asymptomatic - < 2 years after PCI 24% 4) Evaluation of chest pain – low CHD risk, interpretable ECG and able to exercise 16%

Hendel, 2010, JACC 55: 156-62

Section 1

Question

• 35 yo man, DM1, asymptomatic, wants to “check his heart”

• 1) Echo • 2) Coronary Calcium score • 3) Stress nuclear • 4) Stress echo

Question

• 48 yo asymptomatic man with HL is worried about his heart. Younger brother had PCI last year, and remembers his father had CABG in his 60s.

• 1) ECG alone • 2) Exercise ECG • 3) Stress nuclear • 4) Coronary calcium score

Question

• 57 yo woman, asymptomatic, comes to you with “Heart Screening Score” of 955. You advise a statin, aspirin, and:

• 1) Echo • 2) Stress echo • 3) Coronary CTA • 4) Stress nuclear

Ex ECG RNI Echo

Asymptomatic patients

• Coronary calcium score ideal: • Men > 45 years, Women > 55 years • Intermediate-risk pts by Framingham • Low-risk with strong family history • Improved risk-stratification over Framingham

• Supercedes risk-stratification from lipids, etc

Question

• 48 yo man s/p PCI RCA 5 years ago, asymptomatic. ECG interpretable. Able to exercise. Select the best test.

• 1) Stress echo • 2) Exercise ECG • 3) Stress nuclear • 4) Coronary CTA • 5) No further testing

Question

• 64 yo woman with nonischemic cardiomyopathy. Insurance change, new patient. Feels well. Some edema managed with prn Lasix. Last echo 3 years ago, LVEF 45%.

• 1) Stress echo • 2) Echo • 3) No testing • 4) Stress nuclear

Section 2

Question

• 65 yo woman with HTN, HL and 3 months progressive SOB. Twisted her ankle last week.

• 1) Echo • 2) Dobutamine echo • 3) Pharmacologic nuclear stress • 4) Coronary CTA

Diamond-Forrester Classification of Pre-Test Probability

• Typical quality and duration • Provocation stress or exertion • Relieved with rest or NTG • Age • Gender

Imaging Should Alter Clinical Decision Making

• Pre-test probability scale

0% 100%

Test Threshold Treatment Threshold

Modified Pre-Test Probability Score

Morise. Am J Med. 1997; 102:350-56

Global CAD Risk

• Derived from well known Framingham studies • Used to predict 10 year risk in asymptomatic pts (ATP III) • Age • Gender • Total Cholesterol • HDL • Smoking status • Blood Pressure • Family history

Question

• 48 yo woman with HTN, HL, and strong family history with atypical chest pain. What is her pre-test probability for obstructive CAD?

• 1) Low • 2) Low-intermediate • 3) Intermediate • 4) High

Modified Pre-Test Probability Score

Morise. Am J Med. 1997; 102:350-56

Question

• Stress echo is discouraged in the evaluation of chest pain except in those with:

• 1) LBBB • 2) RBBB • 3) Prior MI • 4) Prior PCI • 5) Pacemaker • 6) Prior CABG

Question

• 48 yo man s/p PCI RCA 5 years ago with recurrent chest pain; less intense and different in character to prior angina. ECG interpretable. Able to exercise. Select the best test.

• 1) Stress echo • 2) Exercise ECG • 3) Stress nuclear • 4) Coronary CTA

Question

• 72 yo woman, new patient, has edema, SOB for 6 months, and states she had a heart attack 6 years ago.

• 1) Stress echo • 2) Stress nuclear • 3) Echo + Stress nuclear • 4) Stress echo + Stress nuclear

Question

• 68 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged.

• 1) Repeat stress echo • 2) Stress nuclear • 3) Stress MRI • 4) Coronary CTA

The Ischemic Cascade

Schinkel A et al. Eur Heart J 2003;24:789-800

The European Society of Cardiology

CARDIAC PET

Functional testing

• Ability of coronary artery (and collaterals) to provide blood supply to myocardium

• Measure perfusion and wall motion • Reflect both severity and consequences of obstructive

CAD

Anatomic/functional caveats

• Normal perfusion does not exclude atherosclerosis, but has outstanding prognosis

• Most plaques not hemodynamically significant • Neither strategies detect nonobstructive vulnerable

plaque that lead to MI

Cardiac PET

• Improved diagnostic accuracy, less artifacts • Fewer false positives • Much shorter – 30 minutes • Less radiation • Viability testing • Quantitative blood flow measurements • PET/CT: With calcium score

Cardiac PET

• Obese patients • Equivocal prior stress test • Negative prior stress test with recurrent symptoms • Procedural planning in those with CAD • Detect microvascular CAD • Disadvantage: only vasodilator, not exercise

Section 3

Question

• 68 yo woman with colon cancer pre-op evaluation for hemicolectomy. No CV symptoms. Cleans house and grocery shops fine, but no other exercise.

• 1) Echo • 2) ECG alone • 3) Stress echo • 4) Stress nuclear

Clinical Risk Factors for Pre-Operative Assessment

Question

• 55 yo otherwise healthy man with syncope.

• 1) ECG • 2) Echo • 3) Stress echo • 4) Stress nuclear

Question

• 72 yo woman with palpitations. ECG shows NSR with occasional PVCs. No prior CV history. Total knee replacement next week.

• 1) Stress nuclear • 2) Dobutamine echo • 3) No testing • 4) Echo

Question

• 72 yo woman with palpitations. ECG shows AF, rate 95. No prior CV history. Total knee replacement next week.

• 1) Stress nuclear • 2) Dobutamine echo • 3) Echo • 4) ECG alone

Question

• 58 yo woman with 1 month exertional intermittent chest pain. Stress echo last week normal. Symptoms unchanged.

• 1) Repeat stress echo • 2) Stress nuclear • 3) Stress MRI • 4) Coronary CTA

Cardiac CT Angiography

• Anatomic test with exceptional NPV • Outstanding in low-intermediate risk pts • Establishes anatomy, and diagnoses CAD: Aggressive risk

factor modification • With coronary calcium scoring, excellent risk stratification

and prognostic data • Use to confirm normal coronaries in those you believe do

not have CAD

Cardiac CT Angiography

Typical Radiation Doses • Stress Echo 0 mSv • CMR 0 mSv • CXR 0.05 mSv • SPECT (Tc-99m) 12-14 mSv • SPECT (Thallium) 20-26 mSv • Coronary CTA 4-8 mSv • Chest CTA (ro PE) 10-20 mSV • Abdomen/Pelvic CT 15-20 mSv • PET 4-8 mSv • Coronary Calcium Score 1-2 mSv • Cardiac Cath 4-10 mSv

TAKE-AWAY POINTS

Take-away points

• Tremendous monetary cost, radiation, and false-positive rate associated with cardiac imaging

• History taking and assessing pre-test probability, minimize false positives

• Understand the ischemic cascade. Stress echo for greater specificity (lower false positive), Nuclear perfusion for greater sensitivity

Take-away points

• Minimize Radiation Exposure: Echo < PET < CT <= SPECT

• Escalate testing. Avoid repeat stress testing of identical modality.

Refer for Cardiology evaluation Cardiac PET Cardiac CTA

Take-away points

• Follow-up testing is rarely appropriate in asymptomatic patients or those with stable symptoms

• Follow-up testing is rarely appropriate in asymptomatic patients after revascularization

• For preoperative assessments, those with > 4 METS do not require testing, regardless of type of surgery or risk profile.

• Rarely perform stress testing in asymptomatic patients

Thank You

• Ritesh Dhar, MD, MS • Intermountain Heart Institute • Cell: 801-783-6790 • Email: Ritesh.Dhar@imail.org