Clinical Evaluation of CAD.pptVIP

Clinical Evaluation of CADDiagnostic Testingfor Ischaemia Joel Niznick MD FRCPC Chest Pain Evaluation Approach to diagnosis of CAD Classification of chest pain Pre-test likelihood CAD Algorithm for chest pain evaluation in women Indications for stress testing High risk indicators-stress testing Indications for myocardial perfusion imaging (MPI) High risk indicators-MPI Coronary Distribution-Polar Map Comparing Perfusion Agents Sensitivity and specificity of cardiac testing Approach to diagnosis CAD -1- Confirm or deny presence of CAD with TMT High false positive rate in pre-menopausal females (up to 50%) or low pre-test likelihood CAD Exclude false positives with perfusion imaging Assess extent of CAD with perfusion imaging Approach to diagnosis CAD -2- Assess prognosis combining extent of CAD with severity of LV dysfunction:echo/MUGA Cardiac Cath:adverse prognostic indicators; refractory symptoms;3VCAD/2VCAD(prox.LAD) plus LV dysfunction (echo or MUGA),AP post MI Classification of Chest Pain Typical angina Steady retrosternal component Provoked by exertion or stress Relieved by rest or NTG Atypical angina 2 of 3 criteria Non-anginal chest pain 1 of 3 criteria Prevalence of CAD (%) in Symptomatic Patients According to Age and Sex Indications for Stress Testing Objective confirmation of ischaemia Assessing extent of ischaemia Documenting exercise capacity Functional assessment of known CAD Determining risk and prognosis Determining need for angiography High risk cut points Assessing response to treatment Contraindications for stress testing Acute myocardial infarction (within two days) Unstable angina pectoris Uncontrolled arrhythmias causing symptoms of hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Active endocarditis or acute myocarditis or pericarditis Acute aortic dissection Acute pulmonary or systemic embolism Acute noncardiac disorders that may affect exercise performance or may be aggrava