Chapters Transcript Video Choosing the Right Stress Testing Back to Symposium Right. All right, guys, uh, thank you for those who stayed back to the end. I promise I'll be within the next 15 minutes and we're going to talk about risk stratification for stress testing, right? And when you think about it, it's like, uh, Goldilocks and the Three Bears. You know, every stress test doesn't fit every patient, but there is a stress test that will almost always fit every patient. Right. So, my disclosures, the first slide was made using AI. My second disclosure is, I have no financial conflicts. My 3rd disclosure is that I used AI to make the disclosure about using AI. All right. OK. So, um, you know, when we think about patients, and these are patients that all of us are seeing, right? Uh, they have, you know, symptoms that are very classically cardiac, and there are symptoms that are very classically unlikely to be cardiac. So, uh, you know, 24 year old at a college athlete who's having pain in her chest after lifting. Waits for 2 hours, which is reproducible, it's probably not cardiac, and these are patients that you don't really have to do any form of testing, right? Uh, but on the other hand, someone who's 65 with type 2 diabetes, kidney disease, hypertension, who's having chest pain after exertion, which is new over the past few weeks, that gets better with rest, probably is cardiac, right? And that's all what the 2021 chest pain guidelines spoke about. And at the end of the day, it's all about risk. You can kind of put these patients into different buckets. There's either low risk or no risk, and then you have high risk on the other spectrum. And you know, when you look at, when you think about it, most of it is a bell curve, right, depending on your clinic, and most of these patients fall into this intermediate risk category. Um, and really at the end of the day clinical judgment is key because you can have all the guideline documents you have, but at the end of the history and physical exam is really key, and, um, and the and why this is, and I promise this is the only graph that I have on here is because the way how tests are made, um, and this goes to Bayes' theorem is that the pre-test probability of a test influences their post-test probability, right? And what does that mean? So what that means is that if you look. At this graph from uh Long who kind of did this for nuclear stress testing. When you look at the purple curve, that is your neg that is the negative predictive value. So if your, if your nuclear stress tests were to be negative, and then on the uh on the, on, you know, on the, on the top is the uh the red curve, which is a positive test and look at these pretest likelihood in the x axis for, so if you have a patient whose pre-test probability is 5%, that college athlete, if you were to nuclear stress. Test them, uh, even if that nuclear stress test were to be positive, it's only increasing your test to around 20%, right? But if that test were to be negative, it goes from 0 to 0%. So that test really doesn't change your clinical judgment at the end of the day. On the other hand, think about the diabetic hypertensive CKD patient who probably has a pre-test likelihood of upwards of 90%. A negative test is only going to drop them down to about 60 or 70%. You still won't believe it, but on the other hand, a positive test test is going to take your 90 to 95%. So they're gonna come to the table of truth to me or Brian, right? The cat lab. Uh, but really, when you look at the bang for your buck, it is going to be in your intermediate risk. So someone who has about that 50% where you're going to do a. Coin flip on do they have something going on with their heart that's causing their symptoms, that is where a positive stress test really gives you, uh, you know, a push towards doing something more, and a negative test probably tells them, hey, you don't need anything, um, and you can probably just do lifestyle measures and a baby aspirin. Right? So, uh, again, this is, uh, from the chest pain guidelines. A good rule of thumb is low pretest probability, no testing, ideally, class one. Uh, if patients really push you, you can do a coronary artery calcium score and an exercise EKG because exercise, uh, the, the amount a patient can exercise has always been a strong prognostic measure across the board for any risk, uh, you know, level patient. Intermediate to high pretest, if they're young, you don't think they have a lot of calcium score, and you really, again, are not believing that these patients have physiological. clinically significant coronary artery disease, a test that looks at anatomy such as coronary CTA is favored because these are patients who might have maybe 20-30% plaque, and you can use that information to show them those pictures and be like, hey, you need to be on a statin, or, hey, you need to exercise more, eat less red meat, don't eat what Dennis is eating. It's all a lot of, uh, you know, salt in it. He's probably going to be one of us who gets heart failure. Um, or you can have like intermediate high pretest problem, right? So those are patients who you want to do a nuclear stress test because they're, I know they're gonna have plaque in their heart. All I care about is, is that plaque causing their chest pain or is it heartburn from their gastroparesis and diabetes, right? And, uh, this is just kind of. You know, there was this big loggerheads between cardiologists when these guidelines came out. The people who read the nuclear stress testing were sad that they kind of pushed up the CCTAs, but at the end of the day, you know, they're they're, they're complementary. They're not, you know, one or the other. You just have to pick it for the right test. Um, and the reason why the guidelines were changed when you kind of look back at the data is we used to overestimate how frequent coronary artery disease was. That was the Diamond Forrester classification from, you know, the 1980s and 1990s, but once all of us new cardiologists came, we figured out that they were wrong and actually your. Overestimating risk in a lot of patients, right? So the, the, anything in the orange is the higher risk, so above, like, you know, 50%, and anything in the light green is really low risk, less than 20%, right? So that is why we have these guidelines to tell us that, uh, coronary artery disease is prevalent, but at the same time, not everyone needs testing. And then when you have these tests and, you know, we, whenever we did a stress test, we're talking about low, medium, and high risk. And when you guys get those results, the question is, what are those things that you need to look for in each of these tests? And I think this is a good slide. What is high risk? High risk is more than 3% risk of uh death, MI, stroke, all the bad things, right? So each of these stress tests have something that makes them high risk. So these are patients that, you know. Always feel free to pick up the pick up the phone and call the cardiologist and let them, hey, this is a patient at a higher stress test. Do you want to see them in the clinic and can you expedite their testing? You know, CTAs have, you know, if they have multi-vessel disease or a left main of more than 50% or a very high calcium score, high risk. Ischemia on nuclear stress testing of more than 10% myocardium or two coronary artery territories, high risk again, an ejection fraction of less than 35% high. Risk exercise EKG with a really poor exercise capacity or a Duke treadmill score that's really, really negative in the, you know, -10 or more again it kind of tells us that they didn't exercise as much and they had a lot of ST changes, high risk, and a stress echo again if they have LV dilatation, drop in their LVEF, multiple coronary arteries, it's the same theme over and over again, high risk. That's when you call the cardiologist. I'm going to use the next 5 minutes to go through two tests, uh, 2 cases. where two of your colleagues did a fantastic job, and I'm going to show that one of these cases was from 2 days ago. So it's a 59-year-old male has all the risk factors under the sun, but he is very, very functional. He complained of progressive chest discomfort and heaviness and associated fatigue for 3 to 4 months. He has noticed a decrease in their functional status in addition to this vague chest pain that he was having, uh, especially when he was hiking, and he was hiking in Utah. Um, his, he had a coronary CTA back in 2022 when he was 54 years. So remember, he's below that 65 year age mark, and he did have moderate disease in his LAD with some concern about vulnerable plaques. So he had soft plaque, the kind of plaque that can rupture and cause a big heart attack, and non-obstructive CAD in the RCA in the right coronary artery and the circumflex territories, and his coronary artery calcium score wasn't terrible. Uh, so his card, you know, his, so this is where we did sequential testing to kind of make sure that, hey, he has plaque. Is this functionally significant? And this is a great example as to how the next test, which was a stress echo, was picked. Kudos to whoever picked that because they did not radiate the patient the second time, because he already got some radiation for the coronary CTA and he was a thin guy. He had great echo pictures and windows, right? He was already on Coreg and amlodipine for hypertension. So show of hands, how many of y'all would do another coronary CTA on this patient? How many of you would do a nuclear stress test? And Hamia Yel would send him for a cardiac cath. All right, so I think again this is a case where either or, right? And this is what I'm gonna show you guys. He had another coronary CTA done and that was the right call because as you can see there and it'll play again, he did have high risk plaque of greater than 70% in his proximal LAD territory. So again, you know, he had probably a little bit of worsening from his previous and he had uh some plaque in his uh RCA as well, right? Um, so this was a patient who. His PCP very astutely had him see a cardiologist and given his symptoms we did a heart catheterization on him. Uh, that big vessel that's coming straight down from 12 o'clock to 6 o'clock is the LAD and as you can see the dye is where everything needs to be nice and black, and he has a spot there, you know, approximately a third down which has an 80% stenosis in his LAD. Uh, the, the panel on the right is his right coronary artery and the CTA was absolutely right over there as well because the mid. Portion over there in that coronary artery at around 9 o'clock on that screen has uh about a 50 to 60% stenosis. We at Centera have been doing physiological assessment in the cath lab without using wires for approximately a year and a half now, and, uh, my thought was if it was just the LED, I was gonna fix it. Uh, it'll save him his chest being open, but it was two arteries, probably we should kind of talk to him on what he wants, uh, but he was not a diabetic, which kind of gives us a little bit more cue on fixing it, um, and. His RCA on the top panel there we were able to do this non-invasively in real time was non-significant. Anything above 0.8 is non-significant, but the LED, uh, I just wanted to check, uh, for my own kind of, uh, you know, if my eyes and the physiology met, and it was 0.75. So his symptoms are coming from his LED because now we have data that even though he has two blockages, the, the right coronary artery is not physiologically significant. The LED is, and we go ahead and we put a stent in the LED. If you, if you can click on that. Last video, the, the, it should play as well. Sorry, thank you. So we used I was guided PISA, essentially, we, uh, size the stent to the vessel like we size the shoe to the foot. It has been shown to reduce mace like, uh, Doctor Mitchell just spoke about in addition to medical therapy. This took us about 40 minutes to do and he went home the same day we went through the wrist. Last case, this is a 47-year-old male again, uh, has a bunch of risk factors, came in with symptoms of chest pain and exertional symptoms. He said that it got, it got to the point where he was walking. And half a block and and and it kind of had to stop him and he had to stop um at this point he had a stress test done again this was a case where you could go either way, right? But stress test again showed what we needed to see because he was in that intermediate range based on his symptoms and his risk factors. This was a stress test that I read. I called his PCP and even before I could tell him about the patient, he's like, I think I know who you're talking to me about, right? He was like, Is it this guy? I'm like, Yes. And I was like, would you like me to see him in my clinic or cath him? And he's like, uh, whatever you want. I saw him in my clinic the next Monday, uh, um, and, uh, you can see here on the stress test that his whole anterior wall, uh, all the way down from the mid LAD territory is out, and it's, it's, it's worse on stress images, which are the middle pictures. It needs to be nice and yellow. It looks like someone took a bite out of that, the apex there, and that means that portion of the heart is not getting enough blood flow. And, uh, it's, it's a little worse on rest, but, uh, it, it's still there. It's a lot worse. On the stress pictures, so this is his cath. He has a non-dominant uh RCA on the left two panels, but what's concerning is that on the middle panels, his whole, his whole LED is 100% occluded. He has a chronic total occlusion of the LED, and when you stay on the cath pictures for a little bit longer, the good news is he has actually collaterals, and the occlusion is so proximal that he has pretty good distal targets. So this is a patient who we spoke to our surgeon, and he's getting bypass surgery at, uh, in, in 2 weeks' time. Right? So, uh, and, and this is a great case again that shows us how you use stress testing to kind of figure out what the best test for the patient is. Either of these two patients could have undergone a nuclear stress test or a CTA respectively, and we would have kind of figured out what was going on with them because they were both intermediate risk candidates, right? So at the end of the day, it's not always black and white, it's shades of gray, but clinical judgment is key, um, and this is one of the flow. Charts, there's, I think 4 or 5 of them on the chest pain guidelines, but as you can see here, nothing is a class 3 recommendation. Nothing is something that you can never do. It's usually a green or a yellow, and the green, you know, again, at the end of the day, think about how you stratify your patients and then figure out what the best test for them. There's a lot of patients who don't need any testing, and there's a lot of patients who you're really concerned about. Just give one of us a call or an Epic chat, and we'll try to get them in sooner. Thank you for your, uh, time. Published Created by Related Presenters Anand Muthu Krishnan, MD Cardiology View full profile
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