Suspicious chest pain in the outpatient setting,
our clinic used to do two 911 calls per day because
we were identified as a small hospital.
We’re a pretty big facility,
so patients would come in with
acute chest pain on a regular basis.
So, I got very used to doing this routine,
calling 911 – activating 911 system first,
then giving the patient a baby aspirin,
initiating oxygen via facemask
and then initiating an IV placement
just in case the patient did worse.
But the vast majority of those patients who are transferred
actually ended up not having
acute ischemic events.
That’s the good news.
There's a few different modalities for patients with
more stable disease when you don't have to call 911
for assessing their risk for cardiovascular disease.
So, the classic is a treadmill test,
but there's also stress nuclear imaging
and stress echocardiogram available.
And we’ll talk about all of these modalities,
starting with the treadmill test.
Now, for that classic patient,
maybe like the gentleman in our case,
54 years old with cardiovascular risk factors
and symptoms very typical of angina,
he has a high pre-test probability for
having cardiovascular disease,
and, therefore, this test,
the treadmill stress test,
is really best for him.
Also, he is 54 and he can probably exercise
because you're going to want to be able to walk up a couple –
have the exercise capacity to at least
walk up a couple of flights of stairs
and/or jog briskly
at least for a few minutes
in order to complete the treadmill protocol.
The nice thing about treadmill testing,
it's fairly cheap and it also gives you
information on exercise capacity.
Some people really can't do it,
and so maybe it's not that they're having angina,
it’s just that they’re really debilitated
in terms of their ability to exercise,
and so that would be a very different remedy.
You’re going to start recommending them to get an exercise
program as opposed to being seen by a cardiologist
and possibly having a procedure on your heart.
However, the drawbacks of the stress treadmill,
it's clearly not as sensitive in diagnosing
cardiovascular disease among women
as well as patients with pretty common
changes on their electrocardiogram,
such as left ventricular hypertrophy,
such as left bundle branch block.
They shouldn't be referred, particularly
the patients with a bundle branch block
should not be referred to treadmill stress testing.
They need stress testing with cardiac imaging – period.
And so, let’s talk about those modalities.
You can see pictures there associated.
That's nuclear imaging on a stress test.
The nice thing about these modalities,
they are improved in terms of their sensitivity overall,
but particularly for women,
particularly for those patients with
changes on electrocardiogram.
Which to choose?
Nuclear study, echocardiogram.
They work – in terms of their ability to
discriminate cardiovascular disease,
they’re about the same,
so that's not a great reason to choose one or the other.
A lot of it comes down to local resources.
What do you have available?
What can be done most promptly for your patient?
You don't want to wait on these tests a long time.
The nice thing about the stress echocardiogram,
it can also tell you about valvular function.
It can estimate the patient's ejection fraction.
So, particularly, if there's a question of, well, heart failure could
play a role here and they also have a very slight murmur,
electrocardiogram would be what I would choose.
For very obese patients,
an echocardiogram uses ultrasound technology
and that can be limited if there's a lot of
chest wall thickness due to obesity.
Nuclear study would be a better
option for those patients.