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