Diagnostic tests for coronary artery diseases resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief:; Priyamvada Singh, M.D. [2]

Management

Exercise stress testing

Test	Indications	Advantages	Disadvantages
Exercise EKG	Initial test for suspected CAD	Information regarding functional capacity, and hemodynamic changes to exercise	Contraindicated with baseline EKG abnormalities i.e. LVH , LBBB, > 1mm ST depression, WPW, paced rhythm
Stress ECHO	a) With baseline EKG abnormality b) Information on an area of myocardium at risk is needed	a) Information regarding exercise data, wall motion abnormality, valvular defects, and pulmonary pressures b) portable, cheap, fast	Image quality, and interpretation difficult with baseline wall motion abnormality, decreased accuracy in single vessel disease, or delayed images
Nuclear SPECT perfusion	a) With baseline EKG abnormality b) Information on an area of myocardium at risk is needed	a) Technetium has superior images compared to thallium but has longer half life. For superior images technetium is used	Artifacts caused by diaphragm, or breast tissue Radiation exposure

Pharmacological stress testing

Test	Indications	Advantages	Disadvantages
Dobutamine echocardiography	a) Done in patients who can't exercise b) Information on an area of myocardium at risk is needed	Image qualities comparable to echocardiography	a) Hypertension b) Arrhythmia c) Beta blocker should be held prior to test
Dobutamine nuclear perfusion	a) Done in patients who can't exercise b) Information on an area of myocardium at risk is needed	a) Information regarding exercise data, wall motion abnormality, valvular defects, and pulmonary pressures b) portable, cheap, fast	a)Hypertension b) Arrhythmia c) Beta blocker should be held prior to test Radiation exposure
Vasodilator nuclear perfusion	a) Done in patients who can't exercise & have contraindications to dobutamine	a) Technetium has superior images compared to thallium but has longer half life. For superior images technetium is used	Artifacts caused by diaphragm, or breast tissue Radiation exposure

Management

Shown below is an algorithm summarizing the approach to [[disease name]].

Symptoms of Coronary artery disease

Pretest probability of CAD

Low

Intermediate

High

No other test required

EKG normal, patient can exercise

Start medical therapy for CAD

Exercise treadmill stress test

Failure to medical management, lifestyle compromising symptoms, progress to unstable angina