Chronic stable angina risk stratification cardiac stress imaging in patients who are able to exercise
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Associate Editor-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S.
Cardiac stress imaging consisting of echocardiography and myocardial perfusion scan, which are assessed both at rest and during stress, provide a useful way to stratify the risk of underlying coronary artery disease (CAD) and hence aid in the management of chronic stable angina. Cardiac stress imaging in a patient who is able to exercise is indicated in the presence of resting ECG abnormalities or in patients who are on digoxin. A normal post-stress thallium scan indicates a low probability of underlying CAD, however, a normal image in a patient with high-risk treadmill scores requires further evaluation.
- In patients with chronic stable angina, stress echocardiography is routinely used to stratify the risk of underlying coronary artery disease and as an alternative to stress thallium scan for detecting inducible myocardial ischemia.
- During stress, the extent and severity of abnormal contractile response is expressed as wall motion score index (WMSI).
|Contractile response||Peak WMSI||Cardiac event rate|
|Normal response||1.0||0.9% per year|
|Mild-to-moderate contractile dysfunction||1.1–1.7||3.1% per year|
|Severe contractile dysfunction||greater than 1.7||5.2% per year|
Myocardial Perfusion Imaging
- In patients with high pretest likelihood of coronary artery disease but without known CAD, myocardial perfusion scan or stress myocardial perfusion single-photon emission computed tomography (SPECT) yields incremental prognostic value and enhanced risk stratification.
- In patients with known CAD,a normal stress thallium test is associated with a annual mortality rate of 0.5% to 0.9%.
- A normal post-stress thallium scan indicates a low probability of underlying CAD. However, a normal scan in a patient with high-risk treadmill scores warrants further evaluation.
- Scintigraphic features suggestive of adverse cardiac events include:
- Cavity dilatation,
- Low ejection fraction,
- End-systolic and end-diastolic volumes,
- Post-stress myocardial stunning.
ACC / AHA Guidelines- Cardiac Stress Imaging for Risk Stratification of Patients With Chronic Stable Angina Who Are Able to Exercise (DO NOT EDIT)
|"1. Exercise myocardial perfusion imaging or exercise echocardiography to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block or an electronically paced ventricular rhythm and have either an abnormal rest ECG or are using digoxin. (Level of Evidence: B)"|
|"2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B)"|
|"3. Exercise myocardial perfusion imaging or exercise echocardiography to assess the functional significance of coronary lesions (if not already known) in planning PTCA. (Level of Evidence: B)"|
|"1. Exercise myocardial perfusion imaging in patients with left bundle-branch block. (Level of Evidence: C)"|
|"2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography in patients with severe comorbidity likely to limit life expectation or prevent revascularization. (Level of Evidence: C)"|
|"1. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)"|
|"2. Exercise, dipyridamole, adenosine myocardial perfusion imaging, or exercise or dobutamine echocardiography as the initial test in patients who have a normal rest ECG and are not taking digoxin. (Level of Evidence: B)"|
ESC Guidelines- Risk Stratification according to Exercise Stress ECG in patients Who Can Exercise (DO NOT EDIT)
|"1. All patients without significant resting ECG abnormalities undergoing initial evaluation. (Level of Evidence: B)"|
|"2. Patients with stable coronary artery disease after a significant change in symptom level. (Level of Evidence: C)"|
|"1. Patients post-revascularization with a significant deterioration in symptomatic status. (Level of Evidence: B)"|
ESC Guidelines- Risk Stratification according to Exercise Stress Imaging (Perfusion or Echocardiography) in patients Who Can Exercise (DO NOT EDIT)
|"1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST depression, paced rhythm, or Wolff Parkinson White syndrome which prevent accurate interpretation of ECG changes during stress. (Level of Evidence: C)
|"2. Patients with a non-conclusive exercise ECG, but intermediate or high probability of disease. (Level of Evidence: B)"|
|"1. In patients with a deterioration in symptoms post-revascularization. (Level of Evidence: B)"|
|"2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B)"|
- ↑ 1.0 1.1 Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA et al. (1998) Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 97 (6):535-43. PMID: 9494023
- ↑ Chaudhry FA (1996) The role of stress echocardiography versus stress perfusion: a view from the other side. J Nucl Cardiol 3 (6 Pt 2):S66-74. PMID: 8989689
- ↑ Yao SS, Qureshi E, Sherrid MV, Chaudhry FA (2003) Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease. J Am Coll Cardiol 42 (6):1084-90. PMID: 13678935
- ↑ Beller GA, Zaret BL (2000) Contributions of nuclear cardiology to diagnosis and prognosis of patients with coronary artery disease. Circulation 101 (12):1465-78. PMID: 10736294
- ↑ Hachamovitch R, Berman DS, Kiat H, Cohen I, Friedman JD, Shaw LJ (2002) Value of stress myocardial perfusion single photon emission computed tomography in patients with normal resting electrocardiograms: an evaluation of incremental prognostic value and cost-effectiveness. Circulation 105 (7):823-9. PMID: 11854122
- ↑ Hachamovitch R, Hayes SW, Friedman JD, Cohen I, Berman DS (2004) Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. J Am Coll Cardiol 43 (2):200-8. PMID: 14736438
- ↑ 7.0 7.1 Poornima IG, Miller TD, Christian TF, Hodge DO, Bailey KR, Gibbons RJ (2004) Utility of myocardial perfusion imaging in patients with low-risk treadmill scores. J Am Coll Cardiol 43 (2):194-9. PMID: 14736437
- ↑ Beller GA, Watson DD (2004) Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables. J Am Coll Cardiol 43 (2):209-12. PMID: 14736439
- ↑ Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48.  PMID: 10351980
- ↑ 10.0 10.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.