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C L I N M E D2 C A RD S 1 JENNIFER RAYBUR N, M.D. IES ASSISTANT STUD MTSU PHYSICIAN  Employ a comprehensive Employ approach to the cardiac patient OBJECT...

C L I N M E D2 C A RD S 1 JENNIFER RAYBUR N, M.D. IES ASSISTANT STUD MTSU PHYSICIAN  Employ a comprehensive Employ approach to the cardiac patient OBJECT Inventory the common Invent symptoms of cardiovascular disease and relate them to ory IVES the development of a differential diagnosis Distinguish various Distin cardiovascular tests and procedures and relate their guish role in evaluation and treatment of disease  HEART ANATOM Y REFRES H  CARDIAC PHYSICAL EXAMINATION SURFACE TOPOGRAPHY OF THE HEART AUSCULTATORY SITES ARTERIAL SUPPLY TO HEART CORONARY ARTERIAL SUPPLY TO THE HEART Artery/Branch Origin Course Distribution Anastomoses Circumflex and Right Right aortic Follows coronary (AV) sulcus Right atrium, SA and AV nodes, and posterior coronary (RCA) part of IVS anterior IV sinus between atria and ventricle branches of LCA SA nodal RCA near its Pulmonary trunk and SA node Ascends to SA node origin (in 60%) Right marginal Passes toward inferior margin of Right ventricle and apex of heart RCA IV branches heart and apex Posterior Runs in posterior IV groove to apex Right and left ventricles and posterior third of Anterior IV branch interventricular RCA (in 67%) of heart IVS of LCA (at apex) RCA near origin of AV nodal posterior IV Passes to AV node AV node artery Runs in coronary sulcus and gives Left Most of left atrium and ventricle, IVS, and AV coronary (LCA) Left aortic sinus off anterior IV and circumflex bundles; may supply AV node RCA branches SA nodal Circumflex branch Ascends on posterior surface of Left atrium and SA node of LCA (in 40%) left atrium to SA node Posterior IV Anterior Passes along anterior IV groove Right and left ventricles and anterior two interventricular LCA to apex of heart thirds of IVS branch of RCA (at apex) Passes to left in coronary sulcus Circumflex LCA and runs to posterior surface of Left atrium and left ventricle RCA heart Left marginal Circumflex branch Left ventricle Follows left border of heart IV branches of LCA Posterior Runs in posterior IV groove to apex Right and left ventricles and posterior third of Anterior IV branch LCA (in 33%)  HEART SOUNDS HTTPS://WWW.YOUTUBE.COM/WATCH?V=ZNHI-L_C-LS (HEART SOUNDS) NORMALLY ONLY THE CLOSURE OF THE VALVES CAN BE HEARD S1 (FIRST HEART SOUND/LUB) IS CLOSURE OF THE TRICUSPID AND MITRAL VALVES (AV VALVES) S2 (SECOND HEART SOUND/DUB) IS CLOSURE OF THE AORTIC AND PULMONIC VALVES (SEMILUNAR VALVES) S3 (THIRD HEART SOUND) MAY BE HEARD AFTER S2. IT IS NORMAL IN CHILDREN AND YOUNG ADULTS. AFTER AGE 30, IT SIGNIFIES VOLUME OVERLOAD TO THE VENTRICLE (ENLARGED VENTRICULAR CHAMBER) S4 (FOURTH HEART SOUND) MAY BE HEARD BEFORE S1. IT MAY INDICATE A NONCOMPLIANT OR STIFF VENTRICLE S2 CAN BE SPLIT INTO A2 AND P2 (AORTIC AND PULMONIC COMPONENTS OF S2). AORTIC VALVE CLOSES BEFORE THE PULMONIC VALVE (CALLED PHYSIOLOGIC SPLITTING OF S2)  PULSES AND BLOOD PRESSURE ARTERIAL PULSE IS PRODUCED BY THE HTTPS://WWW.YOUTUBE.COM/WATC EJECTION OF BLOOD INTO THE AORTA H?V=BAXNXWIWDK8 ARTERIAL BLOOD PRESSURE IS THE LATERAL (HOW TO MEASURE JUGULAR VENOUS PRESSURE EXERTED BY A COLUMN OF BLOOD PRESSURE) AGAINST THE ARTERIAL WALL (HYDROSTATIC PRESSURE). RESULT OF CARDIAC OUTPUT, BLOOD VOLUME, AND PERIPHERAL VASCULAR HTTPS://YOUTU.BE/AWXBAG0E3E4 RESISTANCE (HOW TO MEASURE JVP) JUGULAR VENOUS PULSE PROVIDES DIRECT INFORMATION ABOUT THE PRESSURES IN THE RIGHT SIDE OF THE HEART (CENTRAL VENOUS PRESSURES), BECAUSE THE JUGULAR SYSTEM IS IN DIRECT CONTINUITY WITH THE RIGHT ATRIUM  CARDIAC PHYSICAL EXAMINATION HTTPS://WWW.YOUTUBE.COM/WATCH?V=XU_XEUMJ3ZC (CARDIAC EXAM VIDEO) SEE ALSO BATE’S VIDEO NOTE GENERAL APPEARANCE AND MEASURE BLOOD PALPATE FOR A SYSTOLIC IMPULSE OF THE RIGHT PRESSURE AND HEART RATE. VENTRICLE, PULMONARY ARTERY, AND AORTIC OUTFLOW ESTIMATE THE LEVEL OF JUGULAR VENOUS PRESSURE. TRACT AREAS ON THE CHEST WALL. AUSCULTATE THE CAROTIDS (BRUIT) ONE AT A TIME. AUSCULTATE S1 AND S2 IN SIX POSITIONS FROM THE BASE TO THE APEX. PALPATE THE CAROTID PULSE INCLUDING CAROTID IDENTIFY PHYSIOLOGIC AND PARADOXICAL SPLITTING OF S 2. UPSTROKE (AMPLITUDE, CONTOUR, TIMING) AND PRESENCE OF A THRILL. AUSCULTATE AND RECOGNIZE ABNORMAL SOUNDS IN INSPECT THE ANTERIOR CHEST WALL (APICAL IMPULSE, EARLY DIASTOLE, INCLUDING AN S3 AND OF MITRAL PRECORDIAL MOVEMENTS). STENOSIS AND AN S4 LATER IN DIASTOLE. PALPATE THE PRECORDIUM FOR ANY HEAVES, THRILLS, OR DISTINGUISH SYSTOLIC AND DIASTOLIC MURMURS, USING PALPABLE HEART SOUNDS. MANEUVERS WHEN NEEDED. IF PRESENT, IDENTIFY THEIR TIMING, SHAPE, GRADE, LOCATION, RADIATION, PITCH, AND PALPATE AND LOCATE THE PMI OR APICAL IMPULSE. QUALITY  COMMON SYMPTOMS OF CARDIOVASCULAR DISEASE TABLE 45-1 IN GOLDMAN TEXTBOOK: CARDINAL SYMPTOMS OF CARDIOVASCULAR DISEASE: CHEST PAIN OR DISCOMFORT DYSPNEA, ORTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNEA, WHEEZING PALPITATIONS, DIZZINESS, SYNCOPE COUGH, HEMOPTYSIS FATIGUE, WEAKNESS PAIN IN EXTREMITIES WITH EXERTION (CLAUDICATION) COMMON SYMPTOMS OF CV DISEASE CHEST PAIN THE MOST IMPORTANT SYMPTOM QUESTIONS TO ASK: WHERE IS THE PAIN? OF CARDIAC DISEASE (BUT NOT HOW LONG HAVE YOU HAD THE PAIN? PATHOGNOMONIC) DO YOU HAVE RECURRENT EPISODES OF PAIN? WHAT IS THE DURATION OF THE PAIN? MANY CAUSES OF CHEST PAIN HOW OFTEN DO YOU GET THE PAIN? WHAT DO YOU DO TO MAKE THE PAIN BETTER? THAT ARE NON-CARDIAC WHAT MAKES THE PAIN WORSE? BREATHING? LYING FLAT? MOVING YOUR LEVINE’S SIGN: ARMS OR NECK? PATIENT MAY HOW WOULD YOU DESCRIBE THE PAIN? BURNING? PRESSING? CRUSHING? DULL? ACHING? THROBBING? KNIFE-LIKE? SHARP? CONSTRICTING? DESCRIBE ANGINA BY STICKING? CLENCHING THEIR FIST AND DOES THE PAIN OCCUR AT REST? WITH EXERTION? AFTER EATING? WHEN MOVING YOUR ARMS? WITH EMOTIONAL STRAIN? WHILE SLEEPING? DURING SEXUAL INTERCOURSE? PLACING IT OVER THEIR IS THE PAIN ASSOCIATED WITH SHORTNESS OF BREATH? PALPITATIONS? NAUSEA OR VOMITING? COUGHING? FEVER? COUGHING UP BLOOD? LEG STERNUM PAIN? COMMON SYMPTOMS OF CV DISEASE CHEST PAIN ANGINA CHARACTERISTICS: RETROSTERNAL, DIFFUSE RADIATES TO L ARM, JAW, BACK, NECK ACHING, DULL, PRESSING, SQUEEZING, VISE-LIKE MILD TO SEVERE LASTS MINUTES (5-10 MIN) PRECIPITATED BY EFFORT, EMOTION, EATING, COLD RELIEVED BY REST, NITROGLYCERIN COMMON SYMPTOMS OF CV DISEASE PALPITATIONS QUESTIONS TO ASK: HOW LONG HAVE YOU HAD PALPITATIONS? DO YOU HAVE RECURRENT ATTACKS? IF SO, HOW FREQUENTLY DO THEY OCCUR? WHEN DID THE CURRENT ATTACK BEGIN? HOW LONG DID IT LAST? WHAT DID IT FEEL LIKE? DID ANY MANEUVERS STOP IT? DID IT STOP ABRUPTLY? CAN YOU TAP OUT ON THE TABLE WHAT THE RHYTHM WAS LIKE? HAVE YOU EVER FAINTED WITH THE PALPITATIONS? WHAT BRINGS THEM ON? EXERCISE? LYING ON YOUR SIDE? EATING? WHEN TIRED? ANY ASSOCIATED SYMPTOMS? ANY INTOLERANCE TO HEAT? COLD? WHAT MEDS ARE YOU ON?  COMMON SYMPTOMS OF CV DISEASE DYSPNEA PAROXYSMAL NOCTURNAL DYSPNEA (PND): OCCURS AT NIGHT OR WHEN PATIENT IS SUPINE PND RESULTS FROM GRADUAL REABSORPTION INTO THE CIRCULATION OF LOWER EXTREMITY INTERSTITIAL EDEMA AFTER LYING DOWN WITH SUBSEQUENT EXPANSION OF INTRAVASCULAR VOLUME AND INCREASED VENOUS RETURN TO THE HEART ORTHOPNEA: HOW MANY PILLOWS DO YOU NEED TO PROP UP ON WHEN SLEEPING? LABORED BREATHING WHEN LYING FLAT DUE TO REDISTRIBUTION OF INTRAVASCULAR BLOOD FROM THE GRAVITY DEPENDENT PORTIONS OF THE BODY. DYSPNEA ON EXERTION (DOE)  COMMON SYMPTOMS OF CV DISEASE SYNCOPE TRANSIENT LOSS OF CONSCIOUSNESS THAT IS DUE TO INADEQUATE CEREBRAL PERFUSION CAN BE RELATED TO CARDIAC AND NONCARDIAC CAUSES WHAT WERE YOU DOING JUST BEFORE YOU FAINTED? HAVE YOU HAD RECURRENT FAINTING SPELLS? IF SO, HOW OFTEN DO YOU HAVE THESE ATTACKS? WAS THERE AN ABRUPT ONSET TO THE FAINTING? DID YOU LOSE CONSCIOUSNESS? IN WHAT POSITION WERE YOU WHEN YOU FAINTED? WAS THE FAINTING PROCEEDED BY ANY OTHER SYMPTOMS? NAUSEA? CHEST PAIN? PALPITATIONS? CONFUSION? NUMBNESS? HUNGER? DID YOU HAVE ANY WARING THAT YOU WERE GOING TO FAINT? DID YOU HAVE ANY BLACK, TARRY BOWEL MOVEMENTS AFTER THE FAINT?  COMMON SYMPTOMS OF CV DISEASE OTHER FATIGUE IS A COMMON SYMPTOM OF DECREASED CARDIAC OUTPUT DEPENDENT EDEMA HEMOPTYSIS (MITRAL STENOSIS) CYANOSIS  CARDIAC TESTING MODALITIES RADIOGRAPHY (CXR) CARDIAC RADIOGRAPHY: USEFUL TO EVALUATE THE SIZE OF THE HEART CHAMBERS AND THE PULMONARY CONSEQUENCES OF CARDIAC DISEASE RADIOGRAPHY CANNOT DELINEATE MYOCARDIUM, VALVES, AND INTRACARDIAC STRUCTURES UNLESS THEY ARE CALCIFIED HEART BORDERS CAN BE SEEN ON RADIOGRAPHY FRONTAL (PA VIEW) RADIOGRAPH OF THE CHEST IS USEFUL FOR ASSESSING THE SIZE OF THE L VENTRICLE, LA APPENDAGE, PULMONARY ARTERY, AORTA AND SUPERIOR VENA CAVA LATERAL RADIOGRAPH EVALUATES THE RV SIZE, POSTERIOR BORDERS OF THE L ATRIUM AND VENTRICLE, AND THE ANTEROPOSTERIOR DIAMETER OF THE THORAX Posteroanterior A&B; Lateral C&D CARDIAC TESTING MODALITIES: ECHOCARDIOGRAPHY NON-INVASIVE ULTRASOUND PROCEDURE USED TO EVALUATE THE STRUCTURE AND FUNCTION OF THE HEART EVALUATES AND ASSESSES FOR: THE SIZE AND SHAPE OF HEART, AND THE SIZE, THICKNESS AND MOVEMENT OF HEART’ S WALLS (CARDIOMYOPATHY) THE HEART’S PUMPING STRENGTH (EJECTION FRACTION) EJECTION FRACTION - THE AMOUNT OF BLOOD PUMPED OUT OF THE HEART DURING EACH HEARTBEAT (CONTRACTION) USUALLY EXPRESSED AS A PERCENTAGE – NORMAL IS LVEF > 55- 75% FOR EXAMPLE, AN EJECTION FRACTION OF 60 PERCENT MEANS THAT 60 PERCENT OF THE TOTAL AMOUNT OF BLOOD IN THE LEFT VENTRICLE, WHEN IT IS FULL, IS PUMPED OUT WITH EACH HEARTBEAT. ECHOCARDIOGRAPH Y CONT ’ D EVALUATES AND ASSESSES FOR (CONT): IF THE HEART VALVES ARE WORKING CORRECTLY (REGURGITATION, STENOSIS) IF THERE IS A TUMOR OR INFECTIOUS GROWTH AROUND HEART VALVES (ATRIAL MYXOMA) PROBLEMS WITH THE PERICARDIUM (PERICARDIAL EFFUSION) PROBLEMS WITH THE AORTIC ARCH (AORTIC ANEURYSM) BLOOD CLOTS IN THE CHAMBERS OF THE HEART. ATRIAL AND VENTRICULAR SEPTAL DEFECTS ALSO USED IN CARDIAC STRESS TESTING (DOBUTAMINE STRESS ECHO)  ECHOCARDIOGRAPHY TYPES OF ECHOCARDIOGRAPHY TRANSTHORACIC ECHOCARDIOGRAM(TTE) TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE) STRESS ECHOCARDIOGRAPHY INTRACARDIAC ECHOCARDIOGRAPHY 3-DIMENSIONAL ECHOCARDIOGRAPHY CONTRAST ECHOCARDIOGRAPHY CARDIAC TESTING MODALITIES TYPES OF DOPP ECHOCARDIOGRAPHY 2-D LER ECHOCARDIOGRAPHY/ IMAGI TTE NG Transesoph ageal ECHO TEE  TRANSTHORACIC ECHOCARDIOGRAPHY (TTE) Major Indications Advantages Limitations Heart Failure Accurate diagnosis of Operator dependent structural heart disease data acquisition & severity Cardiomyopathy Quantitation of LV size Interpretation requires and function expertise Valvular Disease Quantitation of Image quality limits pulmonary pressures, diagnosis in some valve function and patients (COPD, large intracardiac shunts body habitus) Congenital Heart Disease Widely available May require microbubble contrast agents Pulmonary Hypertension Portable Aortic Disease Fast Pericardial Disease  CARDIAC STRESS TESTING DIAGNOSTIC TESTING FOR CORONARY ARTERY DISEASE CAN BE CATEGORIZED AS PROVIDING FUNCTIONAL AND/OR ANATOMIC EVIDENCE OF ATHEROSCLEROTIC BURDEN. FUNCTIONAL STUDIES: REVEAL THE PRESENCE OF ISCHEMIA (EXERCISE ECG, SINGLE-PHOTON EMISSION CT (SPECT, PET), THE EXTENT OR SEVERITY OF ISCHEMIA (SPECT, PET), INFORMATION ON CORONARY BLOOD FLOW (PET, CT), AND DEVELOPMENT OF WALL MOTION ABNORMALITIES (ECHO, CARDIAC MR). ANATOMIC INFORMATION IS OBTAINED FROM INVASIVE ANGIOGRAPHY, CORONARY CT ANGIOGRAPHY (CTA), AND CORONARY ARTERY CALCIUM SCORING (CAC) APPROPRIATE, COST-EFFECTIVE STRESS TESTING IS BASED ON HISTORY, EXAMINATION FINDINGS, AND PRETEST PROBABILITY OF CAD (TAKES INTO ACCOUNT AGE, SEX, & SYMPTOMS) STRESS TESTING IS MOST EFFECTIVELY USED IN PATIENTS WITH AN INTERMEDIATE PRETEST PROBABILITY OF CAD (10% TO 90%), IN WHOM A POSITIVE TEST RESULT SIGNIFICANTLY INCREASES DISEASE LIKELIHOOD, AND A NEGATIVE TEST RESULT SIGNIFICANTLY DECREASES LIKELIHOOD STRESS TESTING IN PERSONS WITH A LOW LIKELIHOOD OF DISEASE, SUCH AS YOUNG PATIENTS WITH ATYPICAL SYMPTOMS, OFTEN YIELDS FALSE POSITIVE RESULTS, POTENTIALLY RESULTING IN UNNECESSARY TESTING, DIAGNOSES, AND HARM. IN PATIENTS WITH A HIGH PRETEST PROBABILITY, INVASIVE ANGIOGRAPHY RATHER THAN STRESS TESTING IS APPROPRIATE.  CARDIAC TESTING MODALITIES STRESS TESTING SYMPTOMATIC NO CURRENT CHEST PATIENTS PAIN IF HEMODYNAMICALLY UNSTABLE WITH NONINVASIVE CARDIAC STRESS SYMPTOMS: GO STRAIGHT TO DIAGNOSTIC TESTING (PROVOCATIVE) WITH OR CORONARY ANGIOGRAPHY WITHOUT IMAGING TO INCLUDE IF HEMODYNAMICALLY STABLE WITH EXERCISE TREADMILL WITHOUT ONGOING CHEST PAIN, NON-ISCHEMIC IMAGING, EXERCISE TREADMILL WITH ECG, AND NEGATIVE TROPONIN VALUES (UNSTABLE ANGINA): CAN DO CORONARY IMAGING, STRESS RADIONUCLIDE ANGIOGRAPHY IF LIKELIHOOD OF ACS IS MYOCARDIAL PERFUSION IMAGING, HIGH OR REST CARDIAC IMAGING STRESS ECHO, STRESS CARDIAC MRI; (RADIONUCLIDE MYOCARDIAL PERFUSION CORONARY CTA IMAGING); 2D ECHO; CARDIAC CTA  PATIENTS WITH CHEST PAIN SUGGESTIVE OF ANGINA PATIENTS WITH ACUTE CHEST PAIN PATIENTS WITH A RECENT ACS PATIENTS WITH KNOWN CAD AND NEW OR WORSENING SYMPTOMS INDICATIO PATIENTS WITH PRIOR CORONARY NS FOR REVASCULARIZATION PATIENTS WITH VALVULAR HEART DISEASE CARDIAC PATIENTS WITH NEWLY DIAGNOSED HEART FAILURE STRESS OR CARDIOMYOPATHY TESTING PATIENTS WITH SELECT ARRHYTHMIAS PATIENTS UNDERGOING NON-CARDIAC SURGERY NOT INDICATED AS A SCREENING TEST FOR CAD IN ASYMPTOMATIC PATIENTS!! CARDIAC TESTING MODALITIES STRESS TESTING  CARDIAC IMAGING MODALITIES INDICATIONS FOR STRESS TESTING INDICATIONS FOR CHOICE OF STRESS TESTING DEPENDS ON STRESS TESTING PATIENTS WITH SYMPTOMS SUGGESTIVE OF ANGINA MANY FACTORS PATIENTS WITH ACUTE CHEST PAIN ABILITY TO PERFORM ADEQUATE PATIENTS WITH RECENT ACS EXERCISE PATIENTS WITH KNOWN CAD & NEW OR WORSENING SYMPTOMS RESTING ECG FINDINGS PATIENTS WITH PRIOR CORONARY RE-VASCULARIZATION CLINICAL INDICATION FOR PATIENTS WITH VALVULAR HEART DISEASE PERFORMING THE TEST PATIENTS WITH NEWLY DIAGNOSED HEART FAILURE OR CARDIOMYOPATHY PATIENT’S BODY HABITUS PATIENTS WITH CHRONIC LEFT VENTRICULAR DYSFUNCTION AND CHD HISTORY OF PRIOR CORONARY PATIENTS WITH SELECT ARRHYTHMIAS REVASCULARIZATION PATIENTS UNDERGOING NON-CARDIAC SURGERY  CARDIAC IMAGING MODALITIES CONTRAINDICATIONS TO EXERCISE ECG STRESS TESTING NEED TO KNOW THE REASONS NOT TO PERFORM AN EXERCISE ECG TEST !!!: LEFT BUNDLE BRANCH BLOCK VENTRICULAR PACING VENTRICULAR PRE-EXCITATION SYNDROMES (WOLF-PARKINSON-WHITE) >1MM RESTING ST DEPRESSION (ABNORMALITIES) LVH (LEFT VENTRICULAR HYPERTROPHY) ON DIGOXIN PRIOR HISTORY OF RE-VASCULARIZATION ISCHEMIA LOCALIZATION IS NEEDED ASSESSMENT OF MYOCARDIAL VIABILITY IS NEEDED CARDIAC IMAGING MODALITIES EXERCISE STRESS TESTING STRESS TESTING TO EVALUATE FOR CAD SHOULD ALWAYS BE PERFORMED WITH EXERCISE UNLESS EXERCISE IS CONTRAINDICATED, OR THE PATIENT IS UNABLE EXERCISE STRESS TESTING PROTOCOLS USE TREADMILL OR BICYCLE ERGOMETRY TO INCREASE WORKLOAD IN A STEPWISE MANNER, WHICH ALLOWS ADEQUATE TIME FOR DEVELOPMENT OF MAXIMAL METABOLIC DEMAND A STANDARD BRUCE PROTOCOL INCREASES SPEED AND GRADE OF THE TREADMILL EVERY THREE MINUTES. ACHIEVING 85% OF THE AGE-PREDICTED MAXIMAL HEART RATE IS ADEQUATE FOR IDENTIFYING OBSTRUCTIVE CAD; HOWEVER, PATIENTS SHOULD EXERCISE UNTIL LIMITED BY SYMPTOMS STRESS TESTING SHOULD BE TERMINATED WHEN: THE PATIENT HAS EXERTED MAXIMAL EFFORT, REQUESTS TO STOP, OR EXPERIENCES SIGNIFICANT SYMPTOMS SUCH AS ANGINA OR LIGHTHEADEDNESS THE TEST SHOULD ALSO BE STOPPED FOR: EXERTIONAL HYPOTENSION, SIGNIFICANT HYPERTENSION (>200/110 MMHG), ST –SEGMENT ELEVATION OR DEPRESSION, OR SIGNIFICANT ARRHYTHMIAS  EXERCISE STRESS TEST (TREADMILL) POSITIVE IF THERE IS MORE THAN 1MM ST SEGMENT DEPRESSION SEEN IN ANATOMICALLY CONTIGUOUS LEADS OR IF HYPOTENSION DEVELOPS (DROP OF MORE THAN 10MMHG SYSTOLIC) OR DEVELOPMENT OF S3, S4, OR CARDIAC MURMUR OR SYMPTOMS CONTRAINDICATED IN CARDIAC INSTABILITY, SIGNIFICANT AORTIC STENOSIS, HYPERTROPHIC CARDIOMYOPATHY, SEVERE AND UNCONTROLLED HYPERTENSION HARD TO INTERPRET IN PATIENTS WITH BASELINE EKG ABNORMALITIES SUCH AS LBBB, LVH, OR WHO HAVE A PACEMAKER SHOULD NOT BE PERFORMED IN LOW-RISK PATIENTS BEST CANDIDATES ARE INTERMEDIATE RISK PATIENTS OTHER EXERCISE STRESS TESTS STRESS ECHOCARDIOGRAPHY RECOMMENDED WHEN BASELINE ECG FINDINGS ARE ABNORMAL OR WHEN INFORMATION ON A PARTICULAR AREA OF MYOCARDIUM IS AT RISK IS NEEDED PROVIDES INFORMATION ON ISCHEMIA, HEMODYNAMIC SIGNIFICANCE OF VALVULAR ABNORMALITIES, AND PULMONARY PRESSURES DURING EXERCISE PERFORMED WITH SUPINE OR UPRIGHT BICYCLE ERGOMETRY OR WITH A TREADMILL PROTOCOL AND REQUIRES POST STRESS IMAGES WITHIN 90 SECONDS DEVELOPMENT OF NEW WALL MOTION ABNORMALITIES INDICATES ISCHEMIA IN THE VISUALIZED TERRITORY RESTING WALL MOTION ABNORMALITIES THAT DO NOT IMPROVE AT PEAK EXERCISE MAY INDICATE INFARCTED OR HIBERNATING MYOCARDIUM OTHER MYOCARDIAL PERFUSION IMAGING (MPI) ALSO KNOWN AS NUCLEAR STRESS EXERCISE TESTING USES DIFFERENCES IN MYOCARDIAL BLOOD FLOW TO DETECT ISCHEMIA STRESS IN SPECT MPI, A RADIOTRACER IS INJECTED AT REST AND AT PEAK EXERCISE/VASODILATION, AND THE RADIOTRACER IS TAKEN UP BY THE TESTS MYOCARDIUM RELATIVE TO BLOOD FLOW. REST IMAGES ARE COMPARED WITH IMAGES OBTAINED AFTER STRESS SPECT PERFUSION DEFECTS OBSERVED AFTER STRESS INDICATE FLOW-LIMITING CAD MYOCARDI REGIONS WITH FIXED DEFECTS CAN INDICATE INFARCTED OR HIBERNATING MYOCARDIUM AND VIABILITY ASSESSMENT CAN HELP DISTINGUISH BETWEEN THE TWO AL GATED IMAGES CAN PROVIDE AN ASSESSMENT OF LEFT VENTRICULAR PERFUSIO SYSTOLIC FUNCTION SPECT IMAGING CAN ALSO QUANTIFY THE EXTENT AND SEVERITY OF DISEASE N MAGING VASODILATORS: * preferred stress agent for radionuclide myocardial perfusion imaging (SPECT) DOBUTAMINE: synthetic catecholamine that stimulates beta1 –adrenergic receptors thus increasing heart rate (chronotropic effect) and myocardial contractility (inotropic) * preferred agent for stress echo  CONTRAINDICATIONS TO VASODILATOR STRESS AGENTS (ADENOSINE, DIPYRIDAMOLE, A2A AGONISTS) INCLUDE: PRONOUNCED ACTIVE BRONCHOSPASTIC AIRWAY DISEASE SIGNIFICANT HYPOTENSION PHARMACO SICK SINUS SYNDROME UNSTABLE ACUTE CORONARY SYNDROME LOGIC CONTRAINDICATIONS TO DOBUTAMINE STRESSOR INCLUDE: CERTAIN TYPES OF ARRHYTHMIAS S RECENT MI AORTIC DISSECTION RESTING SYSTOLIC BP > 180 MMHG  CARDIAC IMAGING MODALITIES NUCLEAR/PHARMACOLOGIC IMAGING ASSESSES HEART FUNCTION USING INJECTED, RADIOACTIVELY LABELED TRACERS AND GAMMA CAMERA DETECTORS HAVE GREATER SENSITIVITY AND SPECIFICITY THAN STANDARD EXERCISE ELECTROCARDIOGRAPHY FOR THE DETECTION OF ISCHEMIA DETECT, QUANTIFY, AND LOCALIZE MYOCARDIAL ISCHEMIA; PERFORM STRESS TESTING IN PATIENTS WITH BASELINE ECG ABNORMALITIES; DISTINGUISH VIABLE MYOCARDIUM FROM SCAR TISSUE APPROPRIATE FOR PATIENTS WITH BASELINE ABNORMALITIES OF THE ST SEGMENT APPROPRIATE FOR PATIENTS WITH ORTHOPEDIC OR NEUROLOGIC CONDITIONS THAT PRECLUDE EXERCISE  CARDIAC IMAGING MODALITIES PHARMACOLOGIC STRESS TESTING REMEMBER EXERCISE IS PREFERRED OVER PHARMACOLOGIC STRESSORS IF POSSIBLE DOBUTAMINE: INCREASES MYOCARDIAL OXYGEN DEMAND AND ELICITS ISCHEMIA BECAUSE OF INSUFFICIENT PERFUSION TO THE AFFECTED MYOCARDIUM. AGENT OF CHOICE IN PATIENTS WITH BRONCHOSPASTIC LUNG DISEASE VASODILATORS (DIPYRIDAMOLE, REGADENOSON, AND ADENOSINE): PRODUCE HYPEREMIA AND A FLOW DISPARITY BETWEEN MYOCARDIUM SUPPLIED BY UNOBSTRUCTED VESSELS AND MYOCARDIUM SUPPLIED BY STENOTIC VESSELS BECAUSE OF THE INABILITY OF THE DISTAL VASCULATURE TO DILATE FURTHER. IN PATIENTS WITH A LBBB UNDERGOING MYOCARDIAL IMAGING, VASODILATOR INDUCED STRESS IS PREFERRED TO EXERCISE OR DOBUTAMINE BECAUSE OF POTENTIAL FOR FALSE- POSITIVE SEPTAL PERFUSION ABNORMALITIES  CARDIAC IMAGING MODALITIES PHARMACOLOGIC STRESS TESTING Imaging Modality Utility Advantages Disadvantages Dobutamine Echocardiography Patients who cannot exercise OR Images are acquired continuously CI: Severe baseline area of myocardium at risk is Test can be stopped as soon as hypertension, unstable angina, needed ischemia is evident severe tachyarrhythmias, HCM, Stepwise increases in severe AS & large aortic dobutamine dose allow staged aneurysm assessment of wall motion abnormalities Vasodilator myocardial perfusion Cannot exercise May minimize effect of B- CI: active bronchospastic imaging Minimizes septal abnormalities in blockade on perfusion defect size disease, theophylline use, SSS, patients with LBBB Can be performed sooner after hypotension, & high degree AV acute MI block Radiation exposure Adenosine & dipyridamole may cause chest pain, dyspnea, or flushing Dobutamine myocardial perfusion Cannot exercise Has sensitivity and specificity CI: Severe baseline hypotension, imaging Contraindications to vasodilator similar to those of exercise and unstable angina, severe stress vasodilator perfusion imaging in tachyarrhythmias, HCM, severe When an area of at -risk the diagnosis of myocardial AS, & large aortic aneurysm myocardium is needed ischemia Radiation exposure  VITY AND SPECIF ICITY OF STRESS TESTS  CARDIAC IMAGING MODALITIES CT VS. MR CARDIAC CT (CTA) CARDIAC MR (MRI) DIAGNOSE ABNORMALITIES ASSESS MYOCARDIAL STRUCTURE AND FUNCTION (VENTRICULAR MASS & OF THE GREAT VESSELS VOLUME); NEOPLASTIC DISEASE, INTRACARDIAC THROMBUS, (AORTIC DISSECTION, PE, CARDIOMYOPATHIES ANEURYSM) DIAGNOSE AORTIC AND PERICARDIAL ASSESS PERICARDIAL DISEASE DETECT AREAS OF ISCHEMIA VS. DISEASE AND MYOCARDIAL INFARCTED MYOCARDIUM ABNORMALITIES DETECT CORONARY ARTERY CALCIFICATION AND STENOSES  CARDIAC IMAGING MODALITIES DIAGNOSTIC TESTS Imaging Modality Utility Advantages Limitations PET/CT Provides best perfusion images Shorter study duration & less Not widely available in patients with increased BMI radiation exposure than More expensive Provides data on myocardial myocardial perfusion imaging Used with pharmacologic perfusion, function, and Absolute myocardial blood flow stress agents only (no exercise viability can be measured option) Can be combined with CAC Radiation exposure scoring Dobutamine or adenosine Excellent spatial resolution for Accurate test for myocardial Claustrophobia cardiac MR imaging visualization of wall motion ischemia or viability CI in patients with older abnormalities during pacemakers, ICD, or other dobutamine infusion implanted device Identifies perfusion Certain gadolinium contrast abnormalities during adenosine agents are CI in CKD patients infusion with gadolinium as a Sinus rhythm and slower heart contrast agent rate are needed for improved Provides data on infarction and image quality viability Limited availability and Identifies anomalous coronary expertise artery origin  CARDIAC IMAGING MODALITIES CORONARY ARTERY CALCIUM SCORE (CAC) TYPE OF ELECTRON BEAM CT THAT IS USED TO DETECT CORONARY CALCIUM BUILD UP IN THE CORONARY ARTERIES CORONARY PLAQUE HAS SIMILAR RADIODENSITY TO THAT OF BONE AND APPEARS WHITE ON CT THE CORONARY ARTERY CALCIUM SCORE (AGATSON SCORE) IS A MEASURE OF TOTAL CORONARY CALCIUM THAT CORRELATES WITH ATHEROSCLEROTIC PLAQUE BURDEN AND PREDICTS THE RISK OF CORONARY EVENTS INDEPENDENTLY OF OTHER RISK FACTORS. GET A SCORE BETWEEN ZERO AND UPWARDS, WHICH IS AN INDEPENDENT MARKER OF RISK FOR CARDIAC EVENTS, CARDIAC MORTALITY, AND ALL-CAUSE MORTALITY  AGATSTON SCORE IS A SEMI-AUTOMATED TOOL TO CALCULATE A SCORE BASED ON THE EXTENT OF CORONARY ARTERY CALCIFICATION DETECTED BY AN UNENHANCED LOW-DOSE CT SCAN IT ALLOWS FOR AN EARLY RISK STRATIFICATION AS PATIENTS WITH A HIGH AGATSTON SCORE (>160) HAVE AN INCREASED RISK FOR A MAJOR ADVERSE CARDIAC EVENT (MACE) AGATST ALTHOUGH IT DOES NOT ALLOW FOR THE ASSESSMENT OF SOFT NON-CALCIFIED PLAQUES, IT HAS SHOWN A GOOD CORRELATION WITH CONTRAST-ENHANCED CT ON CORONARY ANGIOGRAPHY GRADING OF CORONARY ARTERY DISEASE (BASED ON SCORE TOTAL CALCIUM SCORE) NO EVIDENCE OF CAD: 0 CALCIUM SCORE MINIMAL: 1-10 MILD: 11-100 MODERATE: 101-400 SEVERE: >400  1. SCREEN FOR CAC IN SELECTED ASYMPTOMATIC ADULTS ≥ 40 YEARS OF AGE AT INTERMEDIATE TO HIGH RISK (7.5 TO