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CHEST PAIN Evaluation and Diagnostic Testing

CHEST PAIN Evaluation and Diagnostic Testing. Jerome Yatskowitz, MD Assistant Professor, Division of Cardiology University of New Mexico Health Sciences Center. OUTPATIENT PRESENTATION CHEST PAIN.

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CHEST PAIN Evaluation and Diagnostic Testing

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  1. CHEST PAINEvaluation and Diagnostic Testing Jerome Yatskowitz, MD Assistant Professor, Division of Cardiology University of New Mexico Health Sciences Center

  2. OUTPATIENT PRESENTATION CHEST PAIN • 52 YEAR OLD FEMALE SHARP, RIGHT SIDED CHEST PAIN, REST/NOT EXERTIONAL LASTING 1 TO 2 MINUTES COMES AND GOES • NO H/O CAD • HTN, Mother MI age 52 • PHYSICAL EXAM NORMAL WITH CHEST PAIN REPRODUCED BY PALPATION • ECG NORMAL

  3. WHAT WOULD YOU RECOMMEND FOR YOUR PATIENT? • EXERCISE ECG TREADMILL STUDY • EXERCISE STRESS ECHO • RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST • CT CORONARY ANGIOGRAM • REASSURANCE WITH NO FURTHER TESTING

  4. OBJECTIVES • EVALUATE THE CHARACTERISTICS OF AGE, GENDER, CHEST PAIN QUALITY AND RISK FACTORS IN THE ASSESSMENT OF PATIENT PRESENTING WITH CHEST DISCOMFORT • IDENTIFY LOW, INTERMEDIATE, AND HIGH RISK PATIENTS WITH CHEST PAIN • APPLY THESE PRINCIPLES FOR OPTIMAL EVALUATION AND TESTING • DIFFERENTIATE AMONGST THE MULTIPLE STRESS TESTING AND DIAGNOSTIC MODALITIES

  5. CHEST PAIN IN THE OUTPATIENT SETTING • HISTORY, PHYSICAL EXAM, AND AVAILABLE TESTS • BENIGN TO LIFE THREATENING • MOST COMMON ARE GI 20% AND MUSCULOSKLELETAL 50% • CARDIAC • STABLE 10%.  OUTPATIENT • ACUTE 2-4%  ED

  6. LIFE THREATENING CONDITIONS ACUTE CORONARY SYNDROME ACUTE AORTIC DISSECTION PULMONARY EMBOLISM TENSION PNEUMOTHORAX PERICARDIAL TAMPONADE ESOPHAGEAL RUPTURE

  7. HISTORY • AGE • SEX • CHEST PAIN QUALITIES • CARDIAC RISK SCORES

  8. DIAGNOSTIC STRESS TESTING PRETEST PROBABILITY OF DISEASE ESTIMATE OF THE LIKELIHOOD OF CAD BASED ON AGE, GENDER, SYMPTOMS (CHEST PAIN CHARACTERISTICS), AND CLINICAL HISTORY (HTN, DM, LIPIDS) PRE TEST PROBABILITY  POST TEST LIKELIHOOD OF DISEASE PRE TEST PROBABILITY DETERMINES THE NEED AND OPTIMAL TEST LOW PRE TEST PROBABILITY (POSITIVE TEST LIKELY TO BY FALSELY POSTIVE) PRE TEST PROBABILITY STRESS TESTING MOST USEFUL IN PATIENTS WITH INTERMEDIATE PRESTEST PROBABILITY STRESS TESTING LESS USEFUL IN PATIENTS WITH HIGH PRE TEST PROBABILITY (NEGATIVE TEST LIKELY TO BE FALSELY NEGATIVE)  CONSIDER FOR RISK STRATIFICATION AND/OR INVASIVE TESTING

  9. CLINICAL SCENARIO • 59 YEAR OLD FEMALE SUBSTERNAL CHEST PRESSURE RADIATING TO LEFT ARM LASTING UP TO 15 MINUTES OCCURING AT REST WITH RELIEF WITH HUSBAND’S NTG. • NO CARDIAC HISTORY • H/O HTN, DM, TOBACCO • PHYSICAL EXAM NORMAL • ECG LVH WITH REPOLARIZATION ABNORMALITY

  10. WHAT WOULD YOU RECOMMEND FOR YOUR PATIENT? • EXERCISE ECG TREADMILL STUDY • EXERCISE STRESS ECHO • RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST • CT CORONARY ANGIOGRAM • REASSURANCE WITH NO FURTHER TESTING

  11. STRESS TESTING • IMPORTANT DIAGNOSTIC AND PROGNOSTIC TOOL IN EVALUATION AND MANAGEMENT OF KNOWN OR SUSPECTED CAD • MOST COMMON STRESS MODALITIES • EXERCISE ECG – NONIMAGING • STRESS IMAGING WITH RADIONUCLIDE MPI OR ECHO • DIAGNOSIS OF CAD AND RISK STRATIFICATION • SYMPTOM LIMITED EXERCISE PREFERRED • ADDITIONAL INFO SYMPTOMS, EXERCISE CAPACITY, HEMODYNAMIC RESPONSE • PHARMACOLOGIC STRESS UNABLE TO EXERCISE

  12. CHOOSING THE APPROPRIATE STRESS TEST • ABILITY TO PERFORM ADEQUATE EXERCISE • RESTING ECG • CLINICAL INDICATION FOR PERFORMING THE TEST • BODY HABITUS/LUNG DISEASE/BREAST IMPLANTS • HISTORY OF PRIOR CAD/REVASCULARIZATION CLINICAL DATA • SIDE EFFECTS OF EACH TEST (MPI VASODILATORS VS. DOBUTAMINE) • COSTS • TEST AVAILABILITY & EXPERTISE • RADIATION EXPOSURE • ADDITIONAL DESIRED CLINICAL INFORMATION (ECHO)

  13. INDICATIONS FOR STRESS TESTING • SYMPTOMS SUGGESTIVE OF ANGINA & INTERMEDIATE TO HIGH RISK PRE TEST LIKELIHOOD OF CAD • KNOWN CAD WITH NEW OR WORSENING SYMPTOMS (CLINICAL CHANGE) • PRIOR CABG > 5 YEARS AND > 2 YEARS PCI • VALVULAR HEART DISEASE SEVERITY • ASSESSMENT OF NEWLY DIAGNOSED HEART FAILURE/CARDIOMYOPATHY • ARRHTHYMIAS (CHRONOTROPIC INCOMPETENCE; EXERCISE INDUCED ARRHYTHMIAS • NON CARDIAC SURGERY

  14. STRESS TESTING NOT INDICATED • SCREENING OF ASYMPTOMATIC LOW RISK PATIENTS (RARE EXCEPTIONS PATIENTS WITH MULTIPLE RISK FACTORS/HIGH RISK OCCUPATIONS) • LOW RISK PATIENTS WITH ATYPICAL OR NONCARDIAC (NONANGINAL) CP • UNSTABLE CAD/ACS • NON CARDIAC SURGERY

  15. MODATLITIES TO FOR STRESS TESTING/ASSESSMENT FOR CAD • EXERCISE VS. PHARMACOLOGIC • EXERCISE ELECTROCARDIOGRAPHIC TREADMILL • ECHO • NUCLEAR/MYOCARDIAL PERFUSION IMAGING • CT CORONARY ANGIOGRAM (CTCA) • CARDIAC MRI

  16. CLINICAL SCENARIO • 65 YEAR OLD MALE WITH BURNING CHEST DISCOMFORT AWAKES FROM SLEEP WITH DIAPHORESIS • DOES ACTIVITIES OF DAILY LIVING BUT NEEDS TO USE STORE MOTORIZED SCOOTER WHEN SHOPS AT WALMART • HTN, TOBACCO, DYSLIPIDEMIA, FATHER CABG AGE 68 • LOSARTAN, METOPROLOL, SIMVASTATIN • ECG NORMAL

  17. WHAT WOULD YOU RECOMMEND • EXERCISE ECG TREADMILL STUDY • EXERCISE STRESS ECHO • RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST • CT CORONARY ANGIOGRAM • REASSURANCE WITH NO FURTHER TESTING

  18. CHOOSING A STRESS TEST • EXERCISE VERSUS PHARMACOLOGIC • ALL PATIENTS WHO CAN EXERCISE SHOULD • UNABLE TO EXERCISE TO ADEQUATE WORKLOAD  PHARMACOLOGIC STRESS • ELECTROCARDIOGRAM (ECG)NORMAL OR ABNORMAL (ECG VS. IMAGING) • VENTRICULAR PREEXCITATION (WPW) • VENTRICULAR PACED RHYTHM • LBBB • ST DEPRESSION • DIGOXIN • LVH WITH REPOLARIZATION ABNORMALITIES

  19. WHICH STRESS TEST? • FOR PATIENTS WHO CAN EXERCISE  EXERCISE TESTING • WALK > 5 MINUTES ON FLAT SURFACE • CLIMB 1 OR MORE FLIGHT OF STAIRS WITHOUT STOPPING • VALUABLE INFORMATION BEYOND ECG/IMAGING • EXERCISE DURATION, HR RECOVERY, BLOOD PRESSURE • INABILITY TO PERFORM EXERCISE IS A MARKER OF INCREASED RISK • FOR PATIENTS UNABLE TO EXERCISE.  PHARMACOLOGICAL STRESS TEST • TYPICALLY PERFORMED IN PATIENTS UNABLE TO EXERCISE • LBBB • VENTRICULAR PACED RHYTHM

  20. STRESS TESTING SELECTION • PRE TEST LIKELIHOOD OF DISEASE • EXERCISE  YES OR NO • ECG  NORMAL OR ABNORMAL • ACCURACY OF SPECIFIC STRESS TEST • EXPERTISE OF YOUR PERFORMING INSTITUTION • H/O KNOWN CAD, KNOWN PREVIOUS INFARCT  MPI • LUNG DISEASE  ECHO • BREAST IMPLANTS/OBESITY  MPI • COSTS • RADIATION • ADVANTAGE OF ADDITIONAL INFORMATION  ECHO

  21. EXERCISE ECG TESTING • EFFECTIVELY RISK STRATIFY PATIENTS • PHYSIOLOGIC, REPLICATES SYMPTOMS • EXERCISE CAPACITY & HEMODYNAMIC RESPONSE PREDICTORS OF PROGNOSIS • INABILITY TO EXERCISE ASSOCIATED WITH INCREASED CV RISK • NORMAL RESTING ECG • REASONABLE FOR WOMEN • ANNUAL CARDIAC EVENT RATES IN PATIENT WITH NEGATIVE TEST/LOW RISK SCORE IS <1% • SIMPLE, WIDELY AVAILABLE, LOW COST

  22. EXERCISE OR PHARMACOLOGICAL STRESS IMAGING • RADIONUCLIDE STRESS MYOCARDIAL PERFUSION IMAGING (MPI) • STRESS ECHOCARDIOGRAPHY • SIMILAR OVERALL DIAGNOSTIC ACCURACY • BOTH BETTER PERFORMANCE THAN EXERCISE ECG • PHARMACOLOGIC MPI PREFERRED IN LBBB/VENTRICULAR PACING EVEN IF PATIENT CAN EXERCISE

  23. RADIONUCLIDE MYOCARDIAL PERFUSION IMAGING • INFORMATION ON EXTENT, SEVERITY, & LOCATION OF ISCHEMIC TERRITORY • INFORMATION ON LV FUNCTION • INCREASED SENSITIVITY/SPECIFICITY OVER EXERCISE ECG TREADMILL • VASODILATOR (PHARMACOLOGIC) TESTING WHEN UNABLE TO EXERCISE • MORE COSTLY • EXPOSURE TO RADIATION • ARTIFACT ISSUES

  24. STRESS ECHOCARDIOGRAPHY • NO RADIATION • MORE SENSITIVE AND SPECIFIC THAN EXERCISE ECG TREADMILL • INFORMATION ON LV FUNCTION, ISCHEMIC TERRITORY, EXTENT OF ISCHEMIA • DOBUTAMINE (PHARMACOLOGIC) IN THOSE UNABLE TO EXERCISE • SHORTER TEST THAN RADIONUCLIDE MPI • ADDITIONAL INFORMATION READILY AVAILABLE • VALVULAR DISEASE, PROXIMAL AORTA DISEASE, PERICARDIAL, PULMONARY HTN • LIMITATIONS OF SUBOPTIMAL IMAGING • LUNG DISEASE, BREAST IMPLANTS, LARGE BODY HABITUS

  25. CLINICAL DECISION SCENARIO • 62 YEAR OLD FEMALE WITH KNOWN CAD, USA WITH PCI TO RCA 2015, NO MI PRESENTING WITH EXERTIONAL SOB ON WALKING UP HILLS ONLY RELIEVED BY REST FOR PAST 3 MONTHS. • HTN, DYSLIPIDEMIA, TYPE 2 DM • METOPROLOL, LISINOPRIL, ASA, ATORVASTATIN, NTG PRN • PE. 2/6 SYSTOLIC MURMUR UPPER RSB • ECG. NSR WITH NONSPECIFIC ST & T WAVE ABNORMALITIES

  26. YOUR RECOMMENDATIONS • EXERCISE ECG TREADMILL STUDY • EXERCISE STRESS ECHO • RADIONUCLIDE PHARMACOLOGIC VASODILATOR STRESS TEST • CT CORONARY ANGIOGRAM • REASSURANCE WITH NO FURTHER TESTING

  27. DECISIONS TO DIAGNOSTIC STRESS TESTING • SOUND CLINICAL JUDGEMENT • BENEFITS AND HARMS OF TESTING • MEDICAL COMMUNITY CONTINUES TO TEST TOO MANY LOW RISK PATIENTS • “NO TEST” IS A CARDIAC TEST • THE QUESTION IS NOT WHICH TEST TO ORDER, BUT IS ANY TEST NEEDED • REMEMBER BEYOND THE CHEST PAIN EVALUATION, PRIMARY PREVENTIVE MEDICAL THERAPY AND LIFESTYLE MODIFICATIONS

  28. CONCLUSION • AGE, GENDER, CHEST DISCOMFORT CHARACTERISTICS, RISK FACTORS • PRE TEST PROBABILITY OF CAD.  POST TEST PROBABILITY OF DISEASE • LOW, INTERMEDIATE, HIGH RISK OF CORONARY ARTERY DISEASE • IS TESTING NEEDED • OPTIMAL STRESS TEST • EXERCISE, ECG, PHARMACOLOGIC SIDE EFFECTS, RADIATION, H/O CAD, OTHER CLINICAL INFORMATION (ECHO) • EVALUATE PATIENT FOR MEDICAL/LIFESTYLE THERAPIES FOR PREVENTION OF CORONARY ARTERY DISEASE

  29. CHOOSING A STRESS TEST:CLINICAL FACTORS • CLINICAL DATA • SIDE EFFECTS • COSTS • TEST AVAILABILITY & EXPERTISE • BODY HABITUS • RADIATION EXPOSURE • ADDITIONAL DESIRED CLINICAL INFORMATION (ECHO)

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