Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise

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Chronic stable angina risk stratification cardiac stress imaging in patients who are unable to exercise On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.

Overview

One of the negative prognostic factor is the patients inability to perform exercise test. In patients who cannot exercise, depending on specific patient factors like heart rate, blood pressure, the presence or absence of bronchospasm, the presence of left bundle-branch block , and ventricular arrhythmias suitable type of pharmacologic stress test[1][2] is advised. Pharmacological agents such as dobutamine induces stress by increasing cardiac contractility and heart rate while vasodilators such as dipyridamole or adenosine increase the overall coronary blood flow and produce regional differences in perfusion.[3][4][5] The presence of a perfusion defect as observed with dipyridamole-thallium-201 is an independent prognostic factor.[6] Dobutamine induced ventricular wall motion abnormalities as seen on echocardiography is associated with myocardial viability and restenosis.[7][8]

ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Risk Stratification of Patients With Chronic Stable Angina Who Are Unable to Exercise (DO NOT EDIT)[9]

Class I
"1. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B)"
"2. Dipyridamole or adenosine myocardial perfusion imaging in patients with left bundle-branch block or electronically paced ventricular rhythm. (Level of Evidence: B)"
"3. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography to assess the functional significance of coronary lesions (if not already known) in planning PTCA. (Level of Evidence: B)"
Class IIb
"1. Dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)"
Class III
"1. Dipyridamole or adenosine myocardial perfusion imaging or dobutamine echocardiography in patients with severe comorbidity likely to limit life expectation or prevent revascularization. (Level of Evidence: C)"

References

  1. Verani MS (1993) Pharmacologic stress myocardial perfusion imaging. Curr Probl Cardiol 18 (8):481-525. PMID: 8222748
  2. Leppo JA (1996) Comparison of pharmacologic stress agents. J Nucl Cardiol 3 (6 Pt 2):S22-6. PMID: 8989683
  3. Beleslin BD, Ostojic M, Stepanovic J, Djordjevic-Dikic A, Stojkovic S, Nedeljkovic M et al. (1994) Stress echocardiography in the detection of myocardial ischemia. Head-to-head comparison of exercise, dobutamine, and dipyridamole tests. Circulation 90 (3):1168-76. PMID: 7916274
  4. Wagdy HM, Hodge D, Christian TF, Miller TD, Gibbons RJ (1998) Prognostic value of vasodilator myocardial perfusion imaging in patients with left bundle-branch block. Circulation 97 (16):1563-70. PMID: 9593561
  5. Nigam A, Humen DP (1998) Prognostic value of myocardial perfusion imaging with exercise and/or dipyridamole hyperemia in patients with preexisting left bundle branch block. J Nucl Med 39 (4):579-81. PMID: 9544659
  6. Gil VM, Almeida M, Ventosa A, Ferreira J, Aguiar C, Calqueiro J et al. (1998)Prognosis in patients with left bundle branch block and normal dipyridamole thallium-201 scintigraphy. J Nucl Cardiol 5 (4):414-7. PMID:9715986
  7. Shaw LJ, Eagle KA, Gersh BJ, Miller DD (1996) Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery. J Am Coll Cardiol 27 (4):787-98. PMID: 8613604
  8. Madu EC, Ahmar W, Arthur J, Fraker TD (1994) Clinical utility of digital dobutamine stress echocardiography in the noninvasive evaluation of coronary artery disease. Arch Intern Med 154 (10):1065-72. PMID: 8185419
  9. Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980

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