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Jeffrey Kempf, MD Gabrielle LaCroix, RN, CCRN. Evaluating Cardiovascular Diseases with Cardiac SPECT and PET. Nuclear Cardiac Stress Testing. Stress Test Options. ETT (EST / Regular) Bruce protocol ETT with Myocardial Perfusion Imaging(TST) Pharmacological Stress Dipyridamole (Persantine )

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Jeffrey kempf md gabrielle lacroix rn ccrn l.jpg

Jeffrey Kempf, MD

Gabrielle LaCroix, RN, CCRN

Evaluating Cardiovascular Diseases with Cardiac SPECT and PET



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Stress Test Options

  • ETT (EST / Regular) Bruce protocol

  • ETT with Myocardial Perfusion Imaging(TST)

  • Pharmacological Stress

    • Dipyridamole (Persantine )

    • Adenosine

    • Dobutamine

      Stress ECHO: Exercise

      Dobutamine


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ACC/AHAExercise Guidelines

  • ACC/AHA statistics 1:2500 can experience MI or death.

  • Perform only with appropriate indications and considerations

  • Requires supervision by trained physician or individual who meets ACC/AHA competency guidelines


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Exercise Stress Test

  • Indications

    • Diagnose suspected CAD in patients with chest pain(atypical /typical) and normal EKG

    • Assess long term-risk in patients thought to be at intermediate /high risk for significant CAD

    • Evaluate suspected arrhythmias

    • Assess functional ability

    • Evaluate effectiveness of medical/surgical therapy


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Absolute Contraindications

  • Recent AMI (within 48 hrs)-RWJUH 4 days

  • Unstable Angina

  • Uncontrolled arrhythmias

  • Severe symptomatic aortic stenosis

  • Uncontrolled symptomatic CHF

  • Acute pulm embolus/pulm infarction

  • Acute aortic dissection/aneurysm

  • Uncontrolled HTN


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Relative Contraindications

  • Left main disease

  • Mod stenotic valve disease

  • Electrolyte abnormalities

  • Severe arterial HTN (sys BP>200mm Hg, dias >110mm Hg)

  • Tachy/Brady arrhythmias

  • HCM or LVOT obstruction

  • Acute DVT

  • CVA within 3 months

  • Inability to adequately exercise

  • Acute systemic illness (pneumonia, severe anemia, infections)


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EKG Exclusion Criteria

Resting EKG abnormalities which render interpretation inconclusive and nuclear stress would be indicated.

  • Baseline ST segment depressions > 1mm

  • Digoxin

  • WPW

  • Left Bundle Branch Block

  • PPM

  • EKG criteria for LVH


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Exercise Procedure(Bruce Protocol)

  • Goal 220-age= 100% MPHR, need 85% for diagnostic study.

  • Low-level or Modified Bruce: Goal 75% MPHR or symptom limited.

  • NPO for 3 hours

  • Must be able to walk treadmill

  • Notify if ICD present

  • No smoking ( no nicotine patches)

  • Hold beta blockers, nitrates (check with MD)

  • Comfortable clothing/shoes



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Indications for termination of test

Absolute

  • Drop in sys BP of >10mm Hg from pre-test standing BP despite increase in workload with ischemic evidence

  • Moderate to severe angina

  • Sustained VT

  • ST elevation > 1mm in leads without diagnostic Q waves

  • Subjects desire to stop

  • Dizziness, near syncope, ataxia

  • Technical difficulties with EKG/BP

  • Signs of poor perfusion (pallor, cyanosis)


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Relative

  • Drop systolic BP > 10mm Hg despite increase workload without evidence of ischemia

  • ST depression ≥ 2mm horizontal/downsloping

  • Arrhythmias: multifocal PVC’s, triplets, tachy/brady arrhythmias

  • Fatigue, leg cramps, SOB, wheezing

  • New BBB or IVCD

  • HTN: sys > 250mm Hg, dias >115mm Hg


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ST Depression -Represents subendocardial ischemia -Abnormal >1mm horizontal/downsloping at .08sec past “J” point.



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Myocardial Perfusion ImagingSPECT

  • Indications

    • Detects presence/location/extent of myocardial ischemia in patients with R/O ACS

    • Risk stratification after ACS

    • Identify fixed defects, evaluate EF and viability

    • CP with abnl EKG’s (LBBB, PPM, LVH, NSSTW changes)

    • Equivocal ETT

    • Inability to exercise (pharmacological stress)


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MPI Radiopharmaceuticals

  • Thallium 201

  • Technetium–99m

    • Sestamibi (Cardiolyte)

    • Tetrafosmin (Myoview)

  • Dual Isotope

    • Thallium injected for resting images

    • Tech -99m injected at peak stress

  • Resting Thallium -utilized to assess viability(no stress)


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ThalliumMPI Prep

MI ruled out by cardiac markers

NPO 6-12 hrs, NO CAFFEINE 24 hrs

Wgt. <350 lbs.

Consent

IV access (peripheral preferred)

No nuclear scans 24 hrs.(V/Q, bone)

Be able to lie flat with hands behind head for 15 mins. x 2

Must be able to walk treadmill

Notify if ICD present

Pregnancy test for premenopausal women


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PHARMACOLOGICAL MPI

  • Indications: inability to exercise, abnl EKG (LBBB, PPM/ICD), risk stratification

  • Dipyridamole(Persantine)-indirectly causes coronary dilatation by blocking adenosine receptor sites.

    • Infused over 4 min, isotope at 7-9 min or hemodynamic response

  • Adenosine- potent vasodilator

    • Infused over 4 min, isotope at 2 min

    • Low level exercise diminishes side effects


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CONTRAINDICATIONS

  • Asthma/Severe COPD (can induce bronchospasm)

  • Hypotension

  • Recent CVA (within 30 days)

  • NY HA Class IV CHF

    SIDE EFFECTS

  • Chest Pain

  • Headache

  • Flushing

  • Nausea

  • Transient asystole & heart block(Adenosine)


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Dipyridamole/Adenosine prep

  • NPO 12 hours (No Caffeine for 24 hrs)

  • No methylxanthines(bronchodilators)

  • Actual wgt. (drugs are wgt. based!)

  • Systolic BP>95mm Hg

  • No oral dipyridamole

  • Hold beta blockers

  • Use with caution: migraines


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DOBUTAMINE

  • + Inotropic effect, increases myocardial O2 demand

  • Prep: same as ETT (no beta blockers, ICD off, etc)

  • Infuse 5-40 mcg/kg/min over 15 min

  • Goal to achieve 85% MPHR (atropine given 35% time)

  • End points same as ETT( EKG changes, CP, HTN etc.)

    SIDE EFFECTS

    • HTN

    • Chest pain

    • Arrhythmias(PVC’s 15%, SVT/Atrial 8%, NSVT 4%)

    • Palpitations/Anxiety