Dr. Adil Hassan
Mentor: Dr. Hagiwara
Cardiac stress testing
Adil Hassan
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Who needs stress testing?
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Anyone presenting with new complaint of angina or recurrent complaint of angina (regardless of medical history) with NO evidence of active ischemia (EKG changes, elevated troponin)
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Who should NOT be stressed?
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Anyone that has unstable angina
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Pre-stress considerations?
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What is the patients pretest probability of having a positive stress test? If you think this is real angina or that the stress test will be equivocal or worse, better to just proceed to angiography
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What are the options?
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Exercise stress test w/wo echo
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Pharmacologic stress
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Vasodilator vs inotrope/chronotrope
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SPECT vs PET
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Mechanism of action?
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Vasodilators – adenosine, dipyridamole, and regadenoson
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Relative perfusion defect from dilating normal coronary arteries compared to stenosed artery which can not dilate
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Inotrope/chronotrope – Dobutamine
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Primarily beta 1 and beta 2 agonist, increases HR and contractility
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How to choose the best option?
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If no contraindication to exercise stress test, start there
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If you have a reason to not do exercise stress test and you must do pharm, choose a vasodilator over dobutamine whenever possible
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When choosing your MPI (myocardial perfusion imaging), choose PET over SPECT if possible
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Cannot use PET if BMI >40
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Contraindications to all stress tests
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Unstable angina
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Acute MI (within 2 days)
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Unstable angina
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Arrhythmia with hemodynamic effect (hypotension)
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Symptomatic sever valvular stenosis (aortic for example)
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Decompensated HF
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Endocarditis
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Myocarditis, pericarditis
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Acute aortic dissection
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Acute PE or DVT
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Contraindications to vasodilators
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Active bronchospastic airway disease (agents can cause bronchospasm)
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Significant hypotension
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Sinus node dysfunction or high degree AV block without pacer
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Caffeine should be stopped 12 hours prior to procedure
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Contraindications to dobutamine
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History of sustained or frequent ventricular arrhythmias or Afib with RVR
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Recent MI (3 days)
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Hemodynamically significant LV outflow obstruction (aortic stenosis or HOCM)
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Aortic dissection
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Moderate to severe hypertension (resting SBP >180)
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Should hold beta blockers morning of Stress test
