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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Absolute Contraindications to EST
• Acute MI (within 2 days)
• Ongoing unstable angina
• Uncontrolled hemodynamically-significant
arrhythmia
• Active endocarditis
• Symptomatic severe AS
• Decompensated heart failure
• Acute PE, pulmonary infarction, DVT
• Acute myocarditis, pericarditis
• Acute aortic dissection
• Physical limitations
Mnemonic:
I – Inflammation
D – Dissection
O – Ongoing angina
N – No consent
O – Ongoing MI
T – Thrombosis
S – Severe AS
T – Technical issues
R – Rhythm
E – Endocarditis
S – Systolic dysfunction
S – Slow
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EST Results
• Positive
• Negative
• Equivocal
• Uninterpretable
• Maximal vs. submaximal test
– Patient should reach 85% of age predicted maximum heart rate
– (Max HR = 220 – age)
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EST Results
Positive test
– ≥ 1mm STE
– ≥ 1 mm STD (horizontal or
downsloping)
High risk features*
– Duke Treadmill Score -11 or less
– <5 METs achieved
– Low threshold angina / ischemia
– STE
– Severe STD ≥ 2mm
– Ischemia on ≥ 5 leads
– Ischemia ≥ 3 mins into recovery
– Abnormal BP response [failure to
achieve SBP>120, drop in BP >10,
drop below baseline]
– Ventricular arrhythmia
2014 CCS – Stable Ischemic Heart Disease
2013 AHA – Exercise standards for testing and training
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Myocardial Perfusion Imaging
• Radioactive tracer (e.g. 99mTc) is used that distributes into myocardium proportionally
with blood flow
• SPECT imaging detects decay of tracer
• Stress = exercise vs. pharmacologic (e.g. dipyridamole)
– Pharmacologic stress based on coronary perfusion mismatch after vasodilation
• dipyridamole (aka persantine) most commonly used for nuclear stress, less commonly adenosine
• Dobutamine used commonly for stress echocardiography
– Diseased coronary vessels are already maximally dilated and develop perfusion mismatch
– False negatives can be seen:
• Drug interactions with dipyridamole (caffeine, theophylline – hold before test!)
• Severe flow limiting triple vessel or left main disease (“balanced” ischemia so no perfusion mismatch
detected)
• Consider as a potential first-line test if patient cannot complete ECG stress test
• Contraindications: active or severe asthma/COPD, as dipyridamole can cause
bronchospasm
– Reversal agent for dipyridamole is aminophylline
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Coronary CT Angiography (CCTA)
NB. CCTA is not the same as a Coronary Artery
Calcium (CAC) Score from CT.
- CAC scoring is recommended for further risk
stratification of intermediate risk (FRS 10-19%)
asymptomatic patients aged > 40 who are not
candidates for statin based on other risk
factors
- Can consider CAC scoring for low risk patients
with family hx premature CV Dz and genetic
dyslipidemia
- CAC score > 100 is basically a statin indicated
condition; start therapy regardless of FRS
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Coronary CT Angiography (CCTA)
• Procedure specifics:
– Low dose CT with beta blockade +/- IV nitro given (HR target <60), breath hold
– 2-4mSv (~background annual radiation dose)
• Indications:
– Diagnosis of CAD for low to intermediate pre-test prob patients
– Risk stratification in patients with stable CAD
• Contraindications:
– ACS
– Severe structural heart disease (AS or HCM)
– Usual CT precautions: Contrast Allergy, Renal Failure, Pregnancy
SCOT-HEART N Engl J Med. 2018 Sep 6;379(10):924-933.
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Risk Stratify and Follow patients
• None of the noninvasive cardiac tests
are perfect
– Do not memorize table!
• Clinical history, pretest probability
(based upon gender, age etc) vitally
important in interpreting stress results
• All patients with stable CAD should
have resting LVEF imaging (eg TTE) –
CCS 2014
15
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Treatment of Chronic Stable CAD
General Principles
• Educate on symptom management, lifestyle changes, medication adherence, target
#SDOH risk factors, multidisciplinary team based care [ACC/AHA 2023]
• Treat symptoms with medical therapy first
• Consider revascularization if refractory symptoms, high risk structural disease (e.g. LM
disease), LV dysfunction, severe MR
Optimal Medical Therapy (OMT) is non-inferior to revascularization (PCI/CABG) for
patients with Stable CAD
• COURAGE 2007, ORBITA 2017, ISCHEMIA 2019
• ISCHEMIA: Median 3.2 years follow-up; no difference in primary outcome (MACE)
invasive strategy vs. conservative strategy
– Extended 7-year follow-up data showed no difference in all-cause mortality was no different
with invasive strategy. However, CV death was lower (offset by non-CV death for reasons that
are unclear). Bottom line is all-cause was not reduced by an invasive strategy.
#SDOH = social determinants of health. Features in a major cardiology guideline for the first time in 2023!
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Treatment of Chronic Stable CAD
• ALL patients with CAD:
– Commence medical treatment for CAD
– Aspirin + statin for evidence of coronary atheroscerosis regardless of the
modality of diagnosis
– Clopidogrel can be used as SAPT if ASA intolerant
• CAPRIE trial 1996 showed reduced MACE with clopidogrel over ASA in
patients with CAD/stroke/PAD
• HOST-EXAM study (Circulation, 2023) showed lower rates of cardiovascular
death, MI, stroke and bleeding with long term clopidogrel compared to ASA
after 1 year of DAPT post PCI (12.8% vs 16.9%)
• For now ASA monotherapy is the long term antiplatelet of choice for chronic
stable CAD though this may change in the next few years
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• Adjunctive therapies:
– Smoking cessation (
see RESP lecture
)
• Counselling + smoking cessation meds (buproprion,
varenicline, NRT) more effective than either alone
– Cardiac rehabilitation
• After recent MI/PCI/CABG – I-A
• Stable CAD or post heart transplant - I-B
• Recommended to reduce risk of CV complications with
sexual activity (4 METs) (AHA/ACC 2023)
– Weight management counselling
– Physical activity (150 minutes/wk aerobic, 2 days/wk
weight training if no contraindications)
– Alcohol – reduce ≤1/d women, ≤ 2/d men
– Vaccines – annual flu (I-C), COVID + boosters (I-C),
pneumococcal (II-a)
• Antianginal (symptomatic benefit):
– Beta blockers: reduce HR/contractility, indicated
for most patients*
– CCBs: reduce HR/contractility (non-
dihydropyridine, beware if LVEF<40%), reduce
preload (dihydropyridine)
– Nitrates: venodilate, reduce LVEDP
– Others: ranolazine (calcium modulator that
reduces angina, just so you’re aware of but use in
Canada is rare)
• Disease modifying therapies:
– ACE inhibitors: HTN, T2DM, LVEF <40%, CKD, can
be considered for all for vascular protection
– Beta blockers: LVEF<40%
• *If no previous MI and LVEF >50 = use of BB therapy
does not ↓ MACE, in absence of other indication for
BB (eg for control of HTN or rapid afib) – ACC/AHA
2023
– CAD + DM: SGLT2i or GLP1RA
– Hypertension, dyslipidemia, diabetes management
18
Treatment of Chronic Stable CAD
AHA/ACC Chronic Stable CAD 2023
Stable CAD “Don’t”:
• Non-prescription dietary supplements NOT
recommended! NO in ↓ MACE/Death
(Omega 3 Fatty acids, Vit C, D, E, Ca, beta-carotene)
• Do not recommend alcohol for purpose of CV protection.
• Do not use chronic NSAID = harm (CV/bleeding)
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