Cardiac Stress Testing

When to stress

use HEART score: IF meeting inclusion criteria,  predicts 6 week risk cardiac event

HIGH RISK(heart score 7-10, 50-65% risk cardiac event) - > call cards to consider going straight to cath

LOW RISK(heart score 0-3, ~1% risk cardiac event) - > consider discharge, consider outpatient stress

INTERMEDIATE(heart score 4-6, 12-16% risk cardiac event) - > admit for monitoring, consider stress

Stress Testing Options for ACS risk stratification

Types of stress: treadmill vs dobutamine vs Lexiscan(coronary vasodilator+nuclear perfusion CT)

Types of myocardial evaluation: EKG vs Echo vs nuclear perfusion CT

EKG vs Echo vs Nuclear

Consider EKG if:

• No prior history of CAD

• no EKG abnormalities

• use DUKE Treadmill score to grade results

Consider echo when Pre-test probability is low because potential for false negatives(missed ischemia):

• No prior history of CAD

• Atypical chest pain

• Low risk for CAD

Consider nuclear scan when Pre-test probability is high, more sensitive but more false positives:

• Prior history of CAD, CABG

• Pain highly suspicious for angina

• Intermediate to high risk for CAD

• Need done fast: Logistical regional pearl as of late 2018 - takes much longer to get stress echo

Treadmill vs dobutamine vs lexiscan?

Treadmill preferred when possible because gives you more information regarding the patient (EKG changes, exertional symptoms and functional class)

Dobutamine when cannot tolerate treadmill, but NOT w/ freq ventricular arrhytmias, afib RVR, left ventricular outflow obstruction, aortic dissection, SBP >180.  BONUS information similar to TTE. 

Lexiscan Nuclear should be ordered for patient with LBBB, Pacemaker that is actively paced a majority of the time and considered if patient has had a BB within 12 hours because a dobutamine or treadmill could be difficult and Lexiscan should be considered.

Lexiscan Nuclear should NOT be ordered for patients with severe COPD or reactive airway disease that are dependent on inhalers for daily use or have had caffeine within 24 hours.

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