Stress Testing for Chest Pain: goal is to convert

intermediate risk patients to high or low risk

I am having chest pain, ECG is

non-diagnostic: contrast?
Joseph L. Blackshear, MD
Mayo Clinic Florida

Exercise ECG is the standard

Imaging if baseline ECG changes present, or

patient cannot exercise, mitral valve prolapse,

digoxin, WPW
Treadmill or Bicycle
Goal HR is 85% of age predicted maximum
Other endpoints: BP fall > 20, VT, SVT, BP
> 220/110, intolerable symptoms, new RWMA

Duke Treadmill Score

Exercise time - (5 X ST deviation) - (4
X chest pain [1=nonlimiting,
2=limiting])
Moderate risk= -9 to 4
Low risk= 5 to 15
High risk= -10

Early Risk Stratification

Men or women with an intermediate
Duke treadmill score should, in general,
be referred for additional risk
stratification with a cardiac imaging study

Contrast as Standard of Care

Improved specificity of rest or exercise echo:
ie to see all segments
When precise EF is important: eg ICD
decision-making
Disorders of the cardiac apex: thrombus,
aneurysm, apical HCM
Problem solving 1001, ie RV not seen, is that
clear space a psuedoaneursym, etc

Contrast: Policies
Nurse to start IV
Nurse prepare and administer contrast
during study

Saline, Optison, Definity are options

Nurse and Cardiac Sonographer perform

the test
Cardiologist immediately available
Contrast used if two or more LV segments
not well seen or if non-contrast images
insufficient to answer clinical question

Immediate ECG
Biomarker measurement (Tn or CKMB)
If Tn/CKMB neg at 6 hr, repeat at 9 or 12 hr.
controversial: CKMB subforms, myoglobin,
CRP

Appropriate studies
assumes ECG not interpretable or patient
unable to exercise

Chest pain evaluation

New CHF or LV dysfunction
New atrial fibrillation and clinical risk factors
Non sustained ventricular tachycardia
Known disease, worsening symptoms
Viability in ischemic cardiomyopathy
Stress hemodynamics, AS, MS, pulmonary hypertension
Pre-op, intermed-high risk surgery with clinical risk
factors or poor exercise tolerance
Use of contrast if 2 or more contiguous segments are NOT
seen on non-contrast images

Contrast Procedures
Explain procedure to patient
Precautions/contraindications/allergies:
octaflouropropane (Definity)

IV access 18-22 ga, or saline flush to hospital

indwelling IV to confirm patency

Definity, Optison refrigerated.

Ensure contrast at room temp before

administering
Do not aspirate blood into syringe before injecting
Do not use if clear; should be turbid, milky

Definity Procedures
Agitate 45 sec in Vialmix agitator-mandatory
OK to use for 12 hr after activation
vent with spike or 16-20 gauge needle
bolus (weight chart) over 30-60 sec, ie begin with

0.2-0.3 ml followed by 2-5 ml saline flush

infusion: mix 1.3 ml with 50 ml saline @ 4-10
ml/min.
Diluted injection: 1 ml+9 ml saline, slow boluses
of 1-4 ml as needed for optimal EBD. Additional
0.5 ml + 4.5 ml saline as needed

Coronary Artery Territories

Short Axis
Mid

Apical
13
14

Basal
1

7
8

12

16
15

11
10

3
4

LAD

RCA

LCX

68 year old man

Hx MI with documented coronary

occlusion
Rest study to evaluate function

70 year old woman

History of MI
Occluded vessel stented
Pre-op screening for upcoming hip
surgery
Dobutamine echo

39 year old woman

Cresendo chest discomfort, possibly

relieved by acid suppression

Severly obese, diabetes for 8 yr
Hypertension
Exercise ECG negative for ischemia,
but developed angina on treadmill

Unable to exercise
Patients expected to perform < 5 METs
may be better evaluated with
pharmacological stress imaging

Dobutamine echo vs Nuclear

perfusion scanninig

Sensitivity 85%, Specificity 88% vs thallium,

sensitivity 85%, specificity 81%
Sensitivity for single vessel disease 58-61%,
two vessel disease 86%, and three vessel
disease 94 % for both techniques

Adenosine:

Dobutamine
Beta agonist
Alpha agonist above 5-10 mcg/kg/min
Side effects: nausea, vomiting, headache,

tremor, anxiety
MI rare, AF in perhaps 1-5%
Dobutamine 5-50 mcg/kg/min atropine, 0.25
mg incrementally up to 2 mg total, beginning
after D20, if HR not 70% of target

Meta-analysis of exercise
echo and SPECT perfusion
imaging, 1990-2005

Negative predictive value for MI and cardiac death:

SPECT: 98.8% (95% CI = 98.5-99.0%)
Ex Echo: 98.4% (95%CI =97.9-98.9%)
Annualized event rates 0.5% per year
Prognostic utility similar in men and women

avoid in asthma

Quinones M et al Circ 85:1026, 1992* pre-contrast

Metz LD et al JACC 2007;49:227

Dobutamine stress

70 year old woman with remote myocardial infarction

Possible apical HCM by TTE

74 year old with CHF, ICD

Sensitivity and Specificity of

Viability Testing
# patients

Sens(% ) Spec(% )

Sestam ibi

207

83

69

DSE

448

84

81

Tl Reinject

209

86

47

FDG PET

332

88

73

Tl-redist

145

90

54

MRI emerging as dominant test

58 year old man

Vague chest discomfort for 36 hr
Arrives at hospital with anterior Q waves,

positive enzymes
Cath: total LAD occlusion
Exercise thallium study two months later
shows no viability
Presents asking if he should be revascularized

Cardiac MR and Viability Assessment

Kaandorp: Heart, Volume 91(10).October 2005.1359

47 year old man, mass in femur

No symptoms
Smokes 1 PPD for 25 years
Diabetic 15 years, insulin requiring
ECG: poor R wave progression
Dobutamine: interscapular pain at
peak; ECG unchanged

Severe 3 vessel disease, sent for CABG

79 year old woman, pre chemo echo for esophageal cancer

Right coronary

Post chemo, dehydration, nausea, vomiting, tachycardia

ST elevation, sinus tachycardia, troponin peak 0.21

Left coronary

48 hr later

8 days later

Tako-tsubo

Synonyms

Apical ballooning syndrome

Takotsubo cardiomyopathy
Ampulla cardiomyopathy
Stress induced cardiomyopathy
Broken heart syndrome

Clinical Features
90% women about age 70
identifiable trigger unless anesthesia,

sedation, altered mental status, hypotension,

pulmonary edema, hypoxia/intubation etc
Chest pain 75%
ST elevation, but minor in > 50%, other ECG
abnormalities
Troponins usually positive, CK +/Increasingly recognized because of dramatic
echo findings which are usually transient

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Diagnostic Criteria
Tsuchihashi

Acute chest
symptoms
Characteristic apical
ballooning WMA
Deep T inversions on
ECG
Reversibility of
WMA
No obstructive CAD

Mayo

Transient akinesis or
dyskinesis > 1
coronary vascular
territory
Absence of CAD
New ST elevation or
T wave inversion
Absence of head
trauma, SAH, pheo,
myocarditis, HOCM

67 year old W developed chest pain while attending KY Derby

Cath showed normal coronaries. Initial echo from outside hospital

Triggers

Emotional upset, sudden pain,

physical stress, tachycardia from any

cause
Sudden hypotension in ICU patient
with sedation, intubation, anesthesia
etc

Follow up one week later

Wafarin therapy, INR 2.0-3.0 for one month

11

Variants of Apical Ballooning Syndrome

Mid

Classic

Ap Ballooning with damage (rare)

Classic

Base
Haghi D et al Int J Cardiol 2007; 120:205

Enzymes

Anterior MI

Myocarditis

Takotsubo vs AMI

CK total usually < 300

Troponin T skewed: about 50% of

values <1.0, 80%< 2.0, few outliers 230 ng/ml

Takotsubo
ST 7.93.4
CKMB 3423 IU
Wall score day 1: 13.8
Wall score day 3: 4.4
Perf score day 1: 11.4
Perf score day 3: 3.2

Acute MI
ST 7.33.7
CKMB 32698 IU
Wall score day 1: 13.9
Wall score day 3: 11.7
Perf score day 1: 15.8
Perf score day 3: 13.5

Ito K, Annals of Nuclear Med 2003;17:115

Apical ballooning: Tc sestamibi, rest and stress studies

Acute

MIBG cardiac scintigraphy assesses cardiac adrenergic function

Processed by NE uptake and storage mechanisms. Reduction indicates
denervation which improves by 3 months

Follow up
Alexanderson E, J Nuc Card 2007:14:129

Akashi Y, J Nuc Med 2004;45:1121

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Proposed mechanism
STRESS
After one month

After one month

After 3 months
With carvedilol

Sympathetic nervous system activation

? Endothelial or microvascular
toxicity

Myocardial NE release

Microvascular spasm
Transient myocardial ischemia

Calcium overload

Myocardial injury
Washout rate is an index of sympathetic activity in relation
to the ability to store NE. WR is increased acutely suggesting functional
denervation

Reversible LV dyfunction

Contraction band necrosis

reversible

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