STRESS PROTOCOLS ADD.pptx imaging card iac

stress

1. STRESS ECHOCARDIOGRAPHY BY DR ANOSHA KAMAL CARDIOLOGY FELLOW-YEAR 1 Journal of the American Society of Echocardiography,JAN 2020 1

2. STRESS ECHOCARDIOGRAPHY SE is an effective method of detecting myocardial ischemia based on Stress indicated regional wall motion abnormality. B ased on principles outlined by the ischemic cascade . The goal is to determine whether ischemia is present or if there is baseline wall motion abnormalities then myocardium is viable or not. Journal of the American Society of Echocardiography,JAN 2020 2

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4. Indications of Stress echocardiography Journal of the American Society of Echocardiography,JAN 2020 4

5. Absolute contraindication Journal of the American Society of Echocardiography,JAN 2020 5

6. Relative contraindications Journal of the American Society of Echocardiography,JAN 2020 6

7. Absolute indications to terminate test Drop in systolic BP greater than 10mm from baseline despite increase in workload, if accompanied by other evidence of ischemia Limiting chest pain ( moderate to severe) Increase in CNS symptoms ( ataxia and near syncope) Signs of hypoperfusion ( Cyanosis and Pallor) Technical difficulties in monitoring Vitals and ECG Patients request Sustained Ventricular tachycardia ST elevation _>1mm in leads without Q waves ( other than V1/AVR) ST depression _> 3mm Journal of the American Society of Echocardiography,JAN 2020 7

8. Relative indication to terminate the test Drop in SBP > 10mm from baseline despite increase in workload but not accompanied by other evidence of ischemia STD > 2mm horizontal/down sloping or Marked axis deviation Multifocal non sustained VT /SVT or high degree AV block Fatigue /SOB/ leg cramps /wheezes/claudication SBP > 220 or DBP> 115 Journal of the American Society of Echocardiography,JAN 2020 8

9. Stress echocardiography It is very sensitive and specific test for diagnosis of underlying CAD SE is considered superior to ETT and comparable to myocardial perfusion scan Before performing stress Echocardiography , prior history of CAD and underlying valvular heart disease is necessary Rest Images taken before test and stress images after achieving desired heart rate ( Maximum heart rate is 85% ( 220- age) and atropine can be used if needed Journal of the American Society of Echocardiography,JAN 2020 9                                                     J ournal of Cardiovascular Development and Disease (JCDD) October 2022

10. Methodology Patients Preparation Equipment Performing the test Journal of the American Society of Echocardiography,JAN 2020 10

11. Patients preparation Written and informed Avoid heavy meals few hours before the test Anti-angina drugs as per indication Standard 12 lead ECG Connection Peripheral IV line Journal of the American Society of Echocardiography,JAN 2020 11

12. Equipment Echocardiographic machine with standard hemodynamic monitoring equipment is needed Resuscitation kit and defibrillator Treadmill machine Or bicycle machine Infusion pumps Software in echocardiographic machine to compare side by side rest vs stress images Journal of the American Society of Echocardiography,JAN 2020 12

13. STRESSORS Exercise Treadmill exercise Upright Bicycle protocol Supine bicycle protocols Pharmacological Dobutamine ( most widely used) Adenosine Dipyridamole Atrial pacing Journal of the American Society of Echocardiography,JAN 2020 13

14. Exercise protocols Journal of the American Society of Echocardiography,JAN 2020 14

15. Treadmill or exercise stress Echocardiography( ESE/TSE) Journal of the American Society of Echocardiography,JAN 2020 15

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19. BICYCLE ERGOMETRY Protocol- A typical symptom-limited supine bicycle protocol starts at a workload of 25 watts and increases by 25 watt increments every 3 minutes until an endpoint. Journal of the American Society of Echocardiography,JAN 2020 19

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21. Upright bicycle ergometer Journal of the American Society of Echocardiography,JAN 2020 21

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23. Pharmacological stressors Dobutamine ( most widely used) Adenosine Dipyridamole Journal of the American Society of Echocardiography,JAN 2020 23

24. Dobutamine stress echocardiography ( DSE) MOA: potent synthetic catecholamine which has both strong positive inotropic and chronotropic effects. At lower doses increases myocardial contractility and cardiac output and heart rate at higher doses Journal of the American Society of Echocardiography,JAN 2020 24

25. Dobutamine is administered via infusion pump with incremental doses every 3 minutes starting from 5 ug /kg/min then 10,15,20,30 and 40 until 85% heart rate ( age related ) is achieved ( atropine / moderate exercise can be used) Journal of the American Society of Echocardiography,JAN 2020 25

26. The plasma half-life of dobutamine is 2 minutes with the onset of action within 1 to 2 minutes; however, up to 10 minutes may be required to obtain the peak effect Antidote is inj: Esmolol 0.5 to 2mg/kg body weight over 1 mint Inj: metoprolol 2.5 to 5mg IV Journal of the American Society of Echocardiography,JAN 2020 26

27. The role of stress echo in detecting myocardial viability involves the demonstration of myocardial reserve Myocardial thickening is impaired when 20% or more wall is affected Therefore viability testing inform about the advantage of revasc. Dobutamine infusion protocol started from 2.5ug /kg/min with staged increase in dose 5,10, 20 Journal of the American Society of Echocardiography,JAN 2020 27

28. Pacing stress echocardiography Patient with PPM during dobutamine stress echo may require device reprogramming in order to attain maximum heart rate The usual dobutamine increase 5, 10 and 20 if ventricular pacing at the end of 20ug/kg/min then dobutamine increased and PPM rate increased to 70% for 3 mints then 85% for 3 minutes then stress images are taken and now cool down period begin dobutamine stopped and PPM rate decreased to 70% then to the usual rate Journal of the American Society of Echocardiography,JAN 2020 28

29. Dipyridamole stress Echocardiography Alternative to dobutamine Coronary vasodilator Contraindications are 2 nd /3 rd degree heart block, severe bronchospasm, unstable CVD and hypotension Two protocols - 1 . dipyridamole 0.56mg/kg over 4 mints then no dose for 4 minutes then 0.28mg /kg over 2 mints and then atropine 0.25mg every mint up to 1mg if needed 2 . 0.84mg/kg over 6 minutes with no atropine Aminophylline is an antidote Journal of the American Society of Echocardiography,JAN 2020 29

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35. Interpretation Journal of the American Society of Echocardiography,JAN 2020 35

36. Example No of normal segments : 16 No of akinetic segments on peak stress : 4 Calculate WMSI WMS1: 4*3 + 12/16 WMSI: 24/16= 1.5 ( Intermediate risk study) Journal of the American Society of Echocardiography,JAN 2020 36

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38. The common potential targets for Doppler examination following stress testing include 38

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49. THANK YOU Journal of the American Society of Echocardiography,JAN 2020 49