Dr. Adil Hassan
Mentor: Dr. Hagiwara
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)
Anyone that has unstable angina
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
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
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
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
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
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