Thanks to James Anstey for presenting a great case of a 69 yo M from Ukiah h/o HTN, COPD, CKD, MI in 2010 p/w and episode of LH which evolved to syncope who got a cath and had Critical L Main dz (w/o > 50% stenosis in any of the other vessels) and got PCI to the vessel.
Stress Testing is a Popular Topic! Here are some previous posts with great pearls:
Stress Testing in a NUTSHELL (if you want more stuff, here’s my Evernote on Cardiac Stress Testing)
- There are STRESSORS and there are IMAGING Modalities – A “Stress Test” requires BOTH (you can mix & match like picking your cone type AND your ice cream flavor!)
- Treadmill or Bicycle
- Pharmacologic = “Lexiscan” (which is Regadenoson) or Dobutamine
- Nuclear Perfusion (within Nuclear you then have to choose between Tracers and the Imaging Modality)
- Tracers = Technetium (aka Myoview) and Rubidium
- Nuclear Imaging Options = SPECT and PET
- PET is more sensitive & specific and has lower radiation (but yes, it’s more $$$)
- The most common Stressor & Imaging combinations in the US are:
- Treadmill ECG
- Treadmill Echo
- Treadmill Nuclear MPI
- Supine Bike Echo
- Regadenoson Nuclear MPI
- Dobutamine Echo
Here are a couple two cents that I’ve gathered along the way about picking the right test: The Luke Zier Approach
- Step 1 = Is pt sxmatic
- do NOT stress if asxmatic
- Step 2 = Can pt exercise?
- If yes —> treadmill or bike (which can be assessed with ECG/echo/nuclear)
- If no —> chemical stress (most commonly assessed with echo/nuclear
- In terms of sensitivity:
- If want low-moderate —> ECG alone
- If want high-moderate —> Echo/Nuclear
- Step 3 = Does pt have normal ECG?
- LVH (hard to interpret the ST segment) OR known obstructive CAD w/ or w/o revise —> echo or nuclear imaging
- Resting LV WMA, paced rhythm or LBBB —> nuclear MPI should be performed over dobutamine echo
- Step 4 = Is pt high risk (should they go straight to cath?)
- Step 5 = Any contraindications?