1 Evaluation of Chest pain in the Office and Cardiac Stress Testing Chad Link, DO FACC Sparrow Hospital Thoracic and Cardiovascular Institute Chairman- TCI Cardiology Section Disclosures Speakers Bureau – Actelion Pharmaceuticals, Pfizer and BMS Clinical Research Support – Sanofi Aventis Case Question • Cc: Chest pain • HPI: This is a 30 year old male who presents to your office with complaints of substernal chest pain that has been going on for the past 5 days. He describes the pain as a “sharp pain” that is constant for most of the day. It doesn’t change with position and can occur both at rest or with exertion. He does not experience the pain at night and has no trouble sleeping. He denies any other associated symptoms with the pain. He is otherwise healthy and has no previous medical conditions. He is taking no medications.
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Evaluation of Chest pain in the Office and Cardiac Stress Testing
Chad Link, DO FACC
Sparrow Hospital
Thoracic and Cardiovascular Institute
Chairman- TCI Cardiology Section
Disclosures
Speakers Bureau – Actelion Pharmaceuticals, Pfizer and BMS
Clinical Research Support– Sanofi Aventis
Case Question
• Cc: Chest pain
• HPI: This is a 30 year old male who presents to your office with
complaints of substernal chest pain that has been going on for the
past 5 days. He describes the pain as a “sharp pain” that is constant
for most of the day. It doesn’t change with position and can occur
both at rest or with exertion. He does not experience the pain at night
and has no trouble sleeping. He denies any other associated
symptoms with the pain. He is otherwise healthy and has no previous
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
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Imaging Agents
Stressor Pro Con
EKG Simple, less
expensive
Less information. May not be
able to localize the lesion. Can
not use if there are baseline
EKG abnormalities i.e. LBBB
with ST changes
Echocardiogram Good if patient has
pre-existing EKG
abnormalities. More
info than EKG.
Less expensive
than nuclear.
Operator dependent to some
extent. May have poor
windows due to body habitus.
Pre-existing wall motion
abnormalities may make
interpretation more
challenging.
Cardiolite/Technetium Localizes ischemia
and infarcted
tissue.
Expensive
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Sensitivity and Specificity
Sensitivity Specificity
Exercise EKG 68% 77%
Stress Echo 76% 88%
Nuclear Imaging
79-92% 73-88%
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Last but not least… cost
TEST COST - done
Hospital
COST - done
Office
ETT $ 637 $ 239
STRESS ECHO
$ 1600 $657
NUCLEAR
SCAN
$ 3000-$4400
$937
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
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STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Case Question
A 60yo man is evaluated for chest pain of 4 months’ duration. He describes the pain as sharp, located in the left chest, with no radiation or associated symptoms, that occurred with walking one to two blocks and resolves with rest. Occasionally, the pain improves with continued walking or occurs during the evening hours. He has hypertension. Family history does not include cardiovascular disease in any first-degree relatives. His only medication is amlodipine.
On physical examination, he is afebrile, blood pressure is 130/80mHg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No carotid bruits are present, and a normal S1 and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are normal. EKG showed normal sinus rhythm.
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
Case Question
• Which of the following is the most
appropriate diagnostic test to perform next?
a. Adenosine nuclear perfusion stress test.
b. Coronary angiography
c. Echocardiography
d. Exercise treadmill
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
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Case Question
First, are the symptoms suspicious for unstable
angina?
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Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD?
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Pre-Test Probability
Age Nonanginal pain Atypical angina Typical angina
Men Women Men Women Men Women
30-39 4% 2% 34% 12% 76% 26%
40-49 13% 3% 51% 22% 87% 55%
50-59 20% 7% 65% 31% 93% 73%
60-69 27% 14% 72% 51% 94% 86%
ACC/AHA 2012 Guidelines
Low probability - <10% - no further testing, except for prognostic information.
Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise
ECG as first modality).
High probability - >90% - non invasive testing for prognosis/management prior to
cardiac cath.
Modalities of Cardiac Stress Test Tiffany T. Nguyen MD April 2014
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Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise?
ww.uptodate.cwom
Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise? Yes
So, now are choices are Exercise EST, Exercise
Echocardiography and Exercise Cardiolite
(technetium). Which one should we perform on this
Intermediate Risk Patient?
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Case Question
Do they have the following:
WPW
Paced Rhythm
LBBB
Greater than 1 mm ST depression at rest
Digoxin use with ST changes
LVH with ST Changes
NO…..
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Case Question
First, are the symptoms suspicious for unstable
angina? No
Second, what are his risk Factors? Age and HTN
Third, what is he pre-test probability of CHD? 27%
or intermediate risk
Can he exercise? Yes
So, now are choices are Exercise EST, Exercise
Echocardiography and Exercise Cardiolite (over
utilized). Which one should we perform on this
Intermediate Risk Patient?
ww.uptodate.cwom
Sensitivity and Specificity
Sensitivity Specificity
Exercise EKG 68% 77%
Stress Echo 76% 88%
Nuclear Imaging
79-92% 73-88%
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram
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Take Home Points
• Stress testing is indicated for patients with intermediate
pre-test probability
• Each stress test has two components: an imaging
modality and stress modality
• When determining which stress test to order, keep in
mind their ability to exercise, whether any
contraindications are present, cost by LOCATION ,
body weight and specificity and sensitivity
STRESS TESTING Indications, modalities and patient selection Dr. Kalyana Sundaram