Cardiac Stress Testing

Dr. Adil Hassan

Mentor: Dr. Hagiwara

Cardiac stress testing

Adil Hassan

  • Who needs stress testing?

  • 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)

  • Who should NOT be stressed?

  • Anyone that has unstable angina

  • Pre-stress considerations?

  • 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

  • What are the options?

  • Exercise stress test w/wo echo

  • Pharmacologic stress

  • Vasodilator vs inotrope/chronotrope

  • SPECT vs PET

  • Mechanism of action?

  • Vasodilators – adenosine, dipyridamole, and regadenoson

  • Relative perfusion defect from dilating normal coronary arteries compared to stenosed artery which can not dilate

  • Inotrope/chronotrope – Dobutamine

  • Primarily beta 1 and beta 2 agonist, increases HR and contractility

  • How to choose the best option?

  • If no contraindication to exercise stress test, start there

  • If you have a reason to not do exercise stress test and you must do pharm, choose a vasodilator over dobutamine whenever possible

  • When choosing your MPI (myocardial perfusion imaging), choose PET over SPECT if possible

  • Cannot use PET if BMI >40

  • Contraindications to all stress tests

  • Unstable angina

  • Acute MI (within 2 days)

  • Unstable angina

  • Arrhythmia with hemodynamic effect (hypotension)

  • Symptomatic sever valvular stenosis (aortic for example)

  • Decompensated HF

  • Endocarditis

  • Myocarditis, pericarditis

  • Acute aortic dissection

  • Acute PE or DVT

  • Contraindications to vasodilators

  • Active bronchospastic airway disease (agents can cause bronchospasm)

  • Significant hypotension

  • Sinus node dysfunction or high degree AV block without pacer

  • Caffeine should be stopped 12 hours prior to procedure

  • Contraindications to dobutamine

  • History of sustained or frequent ventricular arrhythmias or Afib with RVR

  • Recent MI (3 days)

  • Hemodynamically significant LV outflow obstruction (aortic stenosis or HOCM)

  • Aortic dissection

  • Moderate to severe hypertension (resting SBP >180)

  • Should hold beta blockers morning of Stress test

Previous Clinical Applications of Psychedelic Drugs 

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