dr r.v.s.n. sarma., m.d., m.sc., consultant physician and chest specialist
DESCRIPTION
Cardiac Stress Testing. Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist. Visit us at: www.drsarma.in. Dedication of this CME. To my beloved mother. The Spectrum of CAD. The important distinction. Slowly progressive CAD CSA to USA to NSTEMI to STEMI and CVM - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/1.jpg)
Dr R.V.S.N. Sarma., M.D., M.Sc.,
Consultant Physician andChest Specialist
![Page 2: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/2.jpg)
To my beloved mother
![Page 3: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/3.jpg)
![Page 4: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/4.jpg)
• Slowly progressive CAD• CSA to USA to NSTEMI to STEMI
and CVM• Warning ++ long duration• Collateral CBF good• ECG / TMT evidence +• CAG will confirm CAD• Prognosis is good; Older• Non vulnerable plaques• Flow limiting narrowing• Form only 30 % of MI cases
• Group with sudden MACE• Give no time to act• SCD or Massive MI• No previous CSA or USA• No warning; Short duration• No time for collateral CBF• TMT/ CAG -ve before MACE• Prognosis is poor; Younger• Vulnerable ruptured plaques• Focus on factors causing rupture• Contribute to 70% of MI cases
![Page 5: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/5.jpg)
![Page 6: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/6.jpg)
1. Routine Treadmill (ECG only) – ETT or TMT
2. Stress Echocardiography Dobutamine Echocardiography (CSE) Exercise Stress Echocardiography (ESE)
3. Nuclear Imaging – Chemical Stress - MPI Dobutamine Nuclear Stress Adenosine Nuclear Stress Persantine Nuclear Stress
![Page 7: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/7.jpg)
• Exercise testing is a well-established procedure • It is in widespread clinical use for many decades • The “how-to” is beyond the scope of this talk• Although ETT is generally a safe procedure, both MI and death have been reported • Occur at a rate of up to 1 per 2500 tests (0.04%)• It is essential to screen and choose the pt for
ETT
![Page 8: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/8.jpg)
![Page 9: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/9.jpg)
Perfect Lead contact – shaving the chest area in men Should be supervised by a well trained physician, who should be available immediately for
emergencies Careful monitoring & recording in each stage of
exercise The electrocardiogram (ECG) Heart rate Blood pressure And during ST-segment abnormalities and chest pain.
The patient should be monitored continuously For transient rhythm disturbances, ST-segment changes
and ECG manifestations of myocardial ischemia.
![Page 10: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/10.jpg)
Bicycle Ergo meter Treadmill Test
![Page 11: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/11.jpg)
![Page 12: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/12.jpg)
• Cycle Ergo meters are generally – Less expensive and smaller– Less noisy than treadmills – ECG disturbances are minimum– But, produce less motion of the upper part of
body– The fatigue of the quadriceps muscles is a
major limitation
• Treadmills are much more commonly used• Supine stress testing is not routinely used
![Page 13: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/13.jpg)
• Age• Gender• Angina• H/o previous
MI• Q waves in ECG• Resting ST-T
changes• Diabetes• Dyslipidemia• Smoking
• Diagnostic Test utility• Most in
intermediate probability
• Least in high or low probability
• Typical Angina• Sub-sternal
location• Provoked by
exertion or emotion
• Relieved by rest/GTN
![Page 14: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/14.jpg)
Age
Gender
Typical/Definite Angina Pectoris
Atypical/Probable Angina Pectoris
Non-Anginal Chest Pain
Asymptomatic
30-39
Males
Intermediate
Intermediate
low (<10%)
Very low (<5%)
30-39
Females
Intermediate
Very Low (<5%)
Very low
Very low
40-49
Males
High (>90%)
Intermediate
Intermediate
low
40-49
Females
Intermediate
Low
Very low
Very low
50-59
Males
High (>90%)
Intermediate
Intermediate
Low
50-59
Females
Intermediate
Intermediate
Low
Very low
60-69
Males
High
Intermediate
Intermediate
Low
60-69
Females
High
Intermediate
Intermediate
Low
High = >75% Intermediate = 15-75% Low = <15% Very Low = < 5%
![Page 15: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/15.jpg)
Use a computer model or
Use the probability table
![Page 16: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/16.jpg)
![Page 17: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/17.jpg)
Absolute• Acute myocardial infarction (within 2 days)• High-risk unstable angina• Uncontrolled cardiac arrhythmias • Symptomatic severe aortic stenosis• Uncontrolled symptomatic heart failure• Acute pulmonary embolus or pulmonary
infarction• Acute myocarditis or pericarditis• Acute aortic dissection
![Page 18: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/18.jpg)
Relative Left main coronary stenosis Moderate stenotic valvular heart
disease Electrolyte abnormalities Severe arterial hypertension Tachy or Brady arrhythmias HOCM and other outflow obstructions Mental or physical impairment High-degree atrio-ventricular block
![Page 19: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/19.jpg)
Absolute indications• Drop in SBP of >10 mm Hg from baseline BP with
accompanying evidence of ischemia • Moderate to severe angina• Increasing nervous system symptoms ataxia,
dizziness• Signs of poor perfusion (cyanosis or pallor)• Technical difficulties in monitoring ECG or SBP• Subject’s desire to stop; Sustained ventricular
tachycardia• ST elevation (≥1.0 mm) in leads without diagnostic Q
![Page 20: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/20.jpg)
Relative indications• Drop in SBP of ≥10 mm Hg BP without ischemia• ST or QRS changes - ST depression (>2 mm of
horizontal or down sloping ST-segment ↓) or axis shift
• Arrhythmias VT, multifocal PVCs, triplets of PVCs, SVT,• Heart block or brady arrhythmias, BBB or IVCD • Fatigue, shortness of breath, wheezing, leg cramps, IC• Increasing chest pain; Hypertensive response >
250/115
![Page 21: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/21.jpg)
• Only Manual SBP measurement for safety
• Adjust to clinical history (couch potatoes)
• Age predicted Heart Rate Targets ? ?
• The BORG Scale of Perceived Exertion
• METs - not ‘Minutes’ have to be used
• Use standard ECG analysis + 3 minute recovery
• Use scores, ST/HR Index, Heart rate recovery
• ST segment changes alone will not suffice
![Page 22: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/22.jpg)
![Page 23: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/23.jpg)
![Page 24: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/24.jpg)
o Metabolic Equivalent Term o 1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2 /Kg/min -70 kg, 40 yr mano Actually differs with thyroid status, post exercise,
obesity, disease stateso By convention just divide ml O2/Kg/min by 3.5
METs = Speed x [0.1 + (Grade x 1.8)] + 3.5 3.5
Calculated automatically by Device!
![Page 25: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/25.jpg)
• Total of 1+6 (Seven 3 minute stages) – (3+18 min)
• Each minute exercise is approximately 1 MET
• Pretest plain walking + 6 Stages of graded exercise
• In each stage there is increase in speed and gradient• Initial 1.7 mph with 10% gradient (upward inclination)
• Maximum 5.5 mph with 20% gradient
• Modified Bruce – 2 warm up stages (1.7 mph 0%, 5%)• For elderly and patients with reduced exercise capacity
![Page 26: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/26.jpg)
![Page 27: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/27.jpg)
o 1 MET = "Basal" = 3.5 ml O2 /Kg/min
o 2 METs = 2 mph on level
o 4 METs = 4 mph on level
o < 5METs = Poor prognosis if < 65 years
o10 METs = Medical Rx as good as CABG
o 13 METs = Excellent prognosis
o 16 METs = Aerobic master athlete
o 20 METs = Super athlete
![Page 28: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/28.jpg)
![Page 29: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/29.jpg)
• Lead V5 alone consistently outperforms other leads
• False + ves are high with the inferior leads
• Without prior MI and with normal resting ECGs, the precordial leads alone are a reliable marker for CAD.
• Exercise-induced ST-segment only in inferior leads is not significant for CAD.
• Down sloping or horizontal ST-segment is a stronger predictor of CAD but not up sloping ST
![Page 30: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/30.jpg)
J point depression of 2 to 3 mm in leads V4 to V6 with rapid up sloping ST segments depressed approximately 1 mm 80 m sec after the J point. This response should not be considered abnormal.
![Page 31: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/31.jpg)
In lead V4 , the exercise ECG result is abnormal early in the test, reaching 0.3 mV (3 mm) of horizontal ST segment depression at the end of exercise. Consistent with a severe ischemic response.
![Page 32: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/32.jpg)
This “slow up sloping” ST segment at peak exercise indicates an ischemic pattern with a high coronary disease prevalence pretest. A typical ischemic pattern is seen at 3 minutes of the recovery phase when the ST segment is horizontal and 5 minutes after exertion when the ST segment is down sloping.This is typical ischemic response
![Page 33: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/33.jpg)
• Early repolarization is a common resting pattern of ST in normal persons.
• Exercise-induced ST-segment is always considered from the baseline ST level.
• ST is seen after a Q-wave infarction, but ST in leads without Q waves occurs in only 1 of 1000 (0.1%) patients of ETT.
• ST is very arrhythmogenic and localizes the IHD
![Page 34: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/34.jpg)
• MACE : Sudden Cardiac Death (SCD), AMI and USA• Ruptures of high-risk or vulnerable plaques• Inner plaque material is exposed to blood and initiates
formation of a platelet-fibrin thrombus on the rupture.• The rupture may seal without detectable sequelae or• The patient may experience ACS or SCD. • Majority of the vulnerable plaques appear insignificant
on the CAG ,before rupture (less than 75% stenosis)• Majority of the stenosis > 75% have no vulnerable
plaques
![Page 35: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/35.jpg)
LV Functional Damage Severity of CAD Modifiable factors
H/o Prior MI, ECG Path Qs Anatomic - SVD, DVD, TVD DM, HT, Dyslipidemia
CHF, Cardiomegaly in CXR Degree of stenosis and extent Excess weight, Smoking
EF (<40%) and ESV Transient IHD on Holter Other co-morbidities
LV -RWMA on Echocardio ETT induced ST deviations Other Metabolic factors
Conduction disturbances Progressive symptoms of IHD Ventricular arrhythmias
MR, Exercise tolerance Increasing age
![Page 36: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/36.jpg)
Systolic Blood Pressure x HR = Double Product
Example: SBP 170 x HR 160 = 27, 200Double product must be at least: 20, 000
SBP should rise > 40 mmHgDiastolic BP may decline by 10 mm Drop of > 10 mm in SBP is
ominous (Exertional Hypotension)
![Page 37: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/37.jpg)
• Age Predicted Maximum HR (PrMHR) = (220 – Age in years)
• Example: For a 55 years pt Pr MHR = (220-55) = 165
• THR = 90% of Pr MHR of 165 = 148• Chronotropic Incompetence = < 85% of Pr
MHR• In this case 85% of 165 (Pr MHR) = < 140 BPM• Chronotropic Index (CI)= of less than 0.8 is
very significant• (HRpeak – HR rest)÷ (PrMHR –HRrest) • If this pt achieved HRpeak of 130 from HRrest
of 90• CI = (130 – 90) ÷ (165 – 90) = 40 ÷ 75 = 0.53
is very low
![Page 38: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/38.jpg)
Abnormal • If the HR is not reduced by at
least 22 BPMfrom peak exercise heart rate to heart ratemeasured after 2 minutes.
• It is strongly predictive of all-cause mortality.
![Page 39: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/39.jpg)
![Page 40: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/40.jpg)
• Duke score = Exercise time – 5 × (ST-segment deviation in mm) – 4 × Exercise Angina Index (EAI)
• Exercise time is based on a standard Bruce protocol
• ST deviation is < 1 mm, is taken as 0.• ST deviation = Max exercise ST – Base line ST• E A I value: 0 if no exercise angina 1 if exercise angina occurred 2 if angina severe enough to stop
ETTInterpretation contd…
![Page 41: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/41.jpg)
• High-risk group: The Duke score of –11 13% of patients fall in this group.
Average annual CV mortality 5%.• Intermediate risk : The Duke score of + 4 to – 10
53% of all patients fall in this group Annual CV mortality 0.5% to 4%
• Low-risk group: The Duke score of + 5 34% of patients fall in this group.
Average annual CV mortality < 0.5% • For Duke treadmill score Nomogram. See next slide
…
![Page 42: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/42.jpg)
This nomogram applies to patients with known or suspected coronary artery disease, without prior revascularization or recent myocardial infarction, who undergo exercise testing before coronary angiography.
![Page 43: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/43.jpg)
![Page 44: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/44.jpg)
Variable Circle response Points
Maximal Heart Rate
Less than 100 bpm = 30
100 to 129 bpm = 24
130 to 159 bpm =18
160 to 189 bpm =12
190 to 220 bpm =06
Exercise ST Depression
1-2mm =15
> 2mm =25
Age >55 yrs =20
40 to 55 yrs = 12
Angina History Definite/Typical = 5
Probable/atypical =3
Non-cardiac pain =1
Hypercholesterolemia?
Yes=5
Diabetes? Yes=5
Exercise test Occurred =3
induced Angina Reason for stopping =5
Total Score
Choose only one per group
<40: Low probability
40-60: Intermediate probability>60: High probability
![Page 45: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/45.jpg)
Variable Circle response Points
Maximal Heart Rate
Less than 100 bpm = 20
100 to 129 bpm = 16
130 to 159 bpm =12
160 to 189 bpm =08
190 to 220 bpm =04
Exercise ST Depression
1-2mm =06
> 2mm =10
Age >65 yrs =25
50 to 65 yrs = 15
Angina History Definite/Typical = 10
Probable/atypical =6
Non-cardiac pain =2
Estrogen status Positive = -5; Negative = +5
Diabetes? Yes =10
Smoking? Yes =10
Exercise Induced Angina
Occurred =9
Reason for stopping =15
Total Score
Choose only one per group<37: Low probability
37-57: Intermediate probability>57: High probability
![Page 46: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/46.jpg)
954 patients - clinical/TMT reports
Sent to 44 expert cardiologists,
40 cardiologists and 30 MD physicians
Scores did always better than all three
The experts were the nearest to scores
![Page 47: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/47.jpg)
SCORE = (1=yes, 0=no)
METs<5 + Age>65 + History of CHF + History of MI or Q wave
a=0, b=1, c=2, d=more than 2
![Page 48: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/48.jpg)
![Page 49: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/49.jpg)
ETT Result CAD Prob Average Mortality Recommend
Low risk 40% 1% per year Medical Rx.
Intermediate 40 to 60% 2 – 3 % per year Imaging/CAG
High risk 60% 4% per year CAG soon
Co morbidity + Any prob. Any level risk Medical Rx.
![Page 50: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/50.jpg)
Sensitivity is
True positives
a
Total CAD
a + c
CAD by CAG
No CADby CAG
TMT + VETrue Positives
aFalse Positives
b
TMT – VEFalse Negative
cTrue Negatives
d
Total CADa + c
Total No CADb + d
TE
ST
GOLD STANDARD
Specificity is
True Negatives
d
Total No CAD
b + d
SnNOUT (Minimum FN)
SpPIN (Minimum FP)
![Page 51: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/51.jpg)
Sensitivity is
True positives
60
Total CAD
100
CAD by CAG
No CADby CAG
TMT + VETrue Positives
60False Positives
60
TMT – VEFalse Negative
40True Negatives
240
Total CAD100
Total No CAD300
TE
ST
GOLD STANDARD
Specificity is
True Negatives
240
Total No CAD
300
SnNOUT (Rules out 60%)
SpPIN (Confirms 80%)
![Page 52: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/52.jpg)
• Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. Circulation 1989; 80:87-98.
• Meta-analysis of 147 consecutive studies involving 24,074 patients
62
64
66
68
70
72
74
76
78
SENSITIVITY SPECIFICITY
SnNout SpPin
![Page 53: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/53.jpg)
0
10
20
30
40
50
60
70
80
90
100
1 vessel 2 vessel 3 vessel All CAD
Stress ECG
Stress ECHO
Nuclear
![Page 54: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/54.jpg)
• Sensitivity of ETT is as low as 30 % v/s 62% in men
• Stress imaging is not the first alternative in women
• Just as in men Exercise ECG testing is the first test
• Multiple CV risk factors, Severe long standing DM, PVD, CKD are indications for ETT
• Routinely in asymptomatic men/women without any CV Risk factors – ETT is not indicated
• The false positive ETT results - unwanted tests and treatments preclude the use of ETT as a routine test.
![Page 55: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/55.jpg)
• Risk stratification and assessment of prognosis
• Functional capacity for activity level after discharge
• Assessment of adequacy of medical therapy
• To decide on diagnostic or treatment options.
• ETT after MI is safe but after 2 to 3 weeks
• Fatal Re MI and cardiac rupture – 0.03%• Non fatal Re MI with recovery – 0.09%• Complex arrhythmias, including VT, is –
1.4%
![Page 56: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/56.jpg)
• The two types of patients – Implications for testing
• Sensitivity (SnNout) : 62%; Specificity (SpPin) : 78%
• Pretest probability : If intermediate ETT is very useful
• METs < 5; 5-10; >10, > 13 ; Bruce protocol - minutes
• Max SBP at least 40 mm more; THR – 90% of MHR
• Drop in SBP ominous, Chronotropic Incompetence
• Double product : Max SBP x Max attained HR
• ST segment depression > 1 mm V1 – V6• Exercise induced angina – 0, 1 and 2• Duke score, Nomogram, VA score :
Prediction of CAD
![Page 57: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/57.jpg)
www.cardiology.org for all the calculators
http://www.emedicine.com/med/topic2961.htm
http://www.aafp.org/afp/990115ap/401.html
http://www.acc.org/clinical/guidelines/exercise
http://www.annals.org/cgi/content/full/118/2/81
http://www.webmd.com/heart-disease/exercise-
electrocardiogram
http://circ.ahajournals.org/cgi/content/full/
96/1/345#T1
http://www.mssm.edu/medicine/general-medicine/
ebm/CPR/CAD.html
![Page 58: Dr R.V.S.N. Sarma., M.D., M.Sc., Consultant Physician and Chest Specialist](https://reader035.vdocuments.mx/reader035/viewer/2022062308/56812b33550346895d8f4120/html5/thumbnails/58.jpg)