Ambulatory Report – Syncope, Stress, Cath OH MY!

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!)
    • Stressors
      • Treadmill or Bicycle
      • Pharmacologic = “Lexiscan” (which is Regadenoson) or Dobutamine
    •  Imaging
      • EKG
      • Echo
      • 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?

Evernote Link:


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