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HumayunIftikhar

TESTIN

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Objectives

• Review diferent stress and imagingmodalities.

• Understand the mechanisms odetection o ischemia with diferenttypes o stress/imaging.

• How to choose between diferenttypes o tests or your patient.

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 Types

 –  Treadmill !ercise

 – "icycle

• Upright# supine# semi$recumbent

 – %harmacological stress

• &obutamine

• 'denosine

• Ragadenoson

• presantine

 – %acing

Next, hoo!e the ty"e ofimaging#

• chocardiogram

• (uclear imaging –  Thallium

 – )estamibi

 –  Technetium

• )%*T

• %T

• *+R

$ir!t hoo!e the ty"e of!tre!!#

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*ontraindications

• ,ithin - days o acute +.

• Unstable angina

• )evere symptomatic ')

• Uncontrolled arrhythmias

• &H

• 'cute %

• 'cute endocarditis• 'cute aortic dissection

• nability to get consent

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 Treadmill 01

• *ornerstone or diagnosing ischemic heart diseaseor decades.

• "ruce protocol most commonly used.

• ndpoints2

 – &own$sloping )T depressions o 345mm at pea6 e!ercise.

 – )T segment elevation in a non$7 wave lead during or atere!ercise.

 – *hest pain

•

8imitations2 resting 01 abnormalities# digitalis use#ade7uate ischemic therapy that reduces wor6load#sensitivity/speci9city :5/;;< at best# lower inwomen.

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)tress chocardiogram

• valuation o cardiac unction at rest#with pharamacologic or dynamice!ercise# evaluation o *H&.

• 8ocali=e the culprit coronary artery#based on the location o the wallmotion abnormality.

• valuation o valvular lesion severity.

• valuation o pulmonaryhypertension.

• valuation o diastolic unction with

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maging

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ndpoints

• (ew wall motion abnormality

• ,orsening o e!isting wall motionabnormality

• Hypotension

• *hest pain

•

8> dilatation and drop in 8>• 'rrhythmias

• syncope

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&obutamine

• notropic agent.

• %redominant ?$5 agonist – Responsible or

inotropic/chron@tropic efect.

•

'lso A$5 and ?$- – Responsible or vasodilatory

efect.

• (et efect is increased *O.

• Onset o action B -minutes.

•

Hal lie B - minutes.• !creted via the

hepatobiliary system and6idney.

• Use in patients who areunable to perorm anye!ercise.

• ndications2

 – *'& – 'ortic )tenosis

 – +yocardia >iability

• )ide efects2 arrhythmias#hypotension# headache#

palpitations# urinaryurgency.

• 'tropine Use.

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*ontraindications

• )ustained ventricular arrhythmias.

• Recent myocardial inarction Cwithin one tothree daysD or unstable angina

Ccontraindicated or all stress modalitiesD.• Hemodynamically signi9cant let ventricular

outEow tract obstruction.

• 'ortic dissection.

• +oderate to severe systemic hypertensionCresting systolic blood pressure 35F@ to -@@mmHgD.

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+yocardia >iability and 8ow low ')

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>asodilators

'denosine

• 'ntiarrythmicagent.

• '5 receptoragonist.

• )mooth muscle cell

rela!ation# causingvasodilatory efect.

• >ery short hal lie.

Ragadenoson/le!iscan

• '-' receptoragnonist.

• 8onger hal lie.

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%resantine/&ipyradimole

• nhibits phosphodiesterase.

• ncrease in c'+% and c1+%

•

nhibits reupta6e o adenosine intoplatelets# R"*s and endothelial cells.

• *hronic use in low dose useul in%>&.

• High dose# given within a short time#produce more vasodilatory efect.

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*oronary steal phenomenon

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*ontraindications

• "ronchospastic airway disease

• )igni9cant baseline hypotension

•

))) and high degree '>"• Unstable coronary artery disease

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(uclear maging

 Thallium

• %roduced rom re9ning ometals.

• +any diferent isotops.

•

 Thallium$-@5 used ornuclear imaging.

• Hal lie B;Ghours.

• "inds to 0 ions.

• 'mount o thallium

correlates to amount oblood supply to the tissue.

•  To!ic in high doses.

• mages usually grainy.

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 Technitium/sestamibi

• 'lso 6nown as cardiolite.

• Radioactive tracer produced romdecay o molybdenum.

•  Tm$II isotope has a hal lie o :$;hrs.

• )estamibi is a stabili=er ligand.

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Ris6 )trati9cation

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,hich test is betterJ

• %hysiologic dynamic e!ercise isalways better to assess or *H& onany stress test.

• the patient is able to wal6 K$Lbloc6s and able to climb 5$- Eights ostairs w/o any symptoms# always

choose treadmill as an e!ercisemodality.

• maging2 cho

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 ThatMs tN