Flashcards in General Cardiology Deck (74)
What are the absolute contraindications to EST?
AMI within 2 days
Ongoing Unstable Angina
Symptomatic Severe Valvular Stenosis
Decompensated Heart Failure
Aortic Dissection and Acute PE
What are the relative contraindications to EST?
Known left main stenosis
Moderate to severe AS with uncertain symptoms
Advanced or complete heart block
Recent Stroke or TIA
Hypertension uncontrolled >200
Uncorrected thyroid disease, anaemia or electrolyte disturbance
What are the limitations of EST?
1. Unable to exercise (severe lung disease, claudication, arthritis, deconditioning)
2. ECG changes at rest (not including RBBB or ST depression <1mm)
What is the use of the Modified Bruce Protocol?
Used in sedentary patients
What are the ECG features that make performing EST difficult?
Ventricular Paced Rhythm
St depression >1mm
Digoxin associated ST Changes
LV hypertrophy changes
Hypokalaemia associated ST changes
What are the absolute indications to stop an EST?
Drop in BP by 10 when accompanied by evidence of ischaemia
Moderate to severe angina
Signs of poor perfusion
ST elevation >1mm in leads w/o diagnostic q waves
Recovery protocol after EST if ischaemia is not found and if ischaemia is found?
Not Found - recovery in supine position with repeat ECG
Found - recovery in upright position to minimise risk of increasing ischaemia
What is the rate of life threatening complicaionts of EST?
1 in 10000
How does the type of ST depression influence interpretation of EST?
Horizontal or downsloping ST depression of >1mm is more specific for ischaemia than upsloping depression.
How would you interpret a patients' EST which shows ST depression confined to inferior leads?
Likely false positive.
How would you interpret a patients' EST which shows upsloping ST depression?
Likely not significant given prognosis is no different than those with normal exercise ECG
What is the sensitivity and specificity of >1mm of horizontal or downsloping ST segment depression on EST respectively?
60 and 90%
Does ST depression in the lateral leads on EST localise coronary artery lesions?
What is the sensitivity and specificity of aVR ST segment elevation on EST for coronary lesions respectively?
75 and 80 %
Exercise-induced ventricular ectopy is associated with what?
Exercise-induced ventricular arrhythmia and increased mortality risk
What is the specificity of anterior ST segment elevation on EST for a coronary lesion?
What is the specificity of inferior ST segment elevation on EST for a coronary lesion?
What is the significance of transient LBBB on EST?
Independent predictor of death and major cardiac events at four years
What is the significance of ST depression after EST during recovery?
Same interpretation as depression during exercise
What is the sensitivity and specificity of EST respectively?
68 and 77%
What is the sensitivity and specificity of Stress Echo respectively?
76 and 88%
What is the sensitivity and specificity of CTCA respectively?
90 and 65-90%
In which patient group does EST fit into best?
What is the preferred cardiac stress test in patients who cannot exercise to satisfactory workload?
Pharmacological stress testing with myocardial imaging
What is the preferred cardiac stress test in patients who can exercise and has LBBB or paced ECG?
Stress echocardiography or vasodilator stress radionuclide myocardial perfusion imaging
What is the preferred cardiac stress test in patients who can exercise and has abnormal baseline ECG?
Stress radionuclide myocardial perfusion imaging or stress echocardiography
What is the sensitivity and specificity of SPECT respectively?
88 and 77%
How do you define contrast induced AKI?
25% increase in creatinine after 48 hours
What are the interventions that can be used to reduce risk of contrast induced nephropathy?
1. Fluid hydration 12 hours
2. Sodium bicarbonate bolus 1 hr before
3. WH nephrotoxics
4. Statin therapy
5. Peri-procedural dialysis in CKD 4-5