Chest pain other diagnostic studies: Difference between revisions

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{{Chest pain}}
{{Chest pain}}
{{CMG}}{{AE}}{{Aisha}}
{{CMG}}{{AE}} {{Sara.Zand}} {{Aisha}}
==Overview==
==Overview==
[[Invasive Coronary Angiography]] ([[ICA]])  is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]],  including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]]. [[ICA]] provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or [[surgical revascularization]]. ([[IFR]]  and  [[FFR]]) provide  [[physiologic]] characteristic of stenosis. [[Radiation]]  exposure to  the [[patient]]  during an  [[interventional  procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity. The spatial resolution of [[ICA]] is 0.3 mm; as such, it is impossible to visualize [[arterioles]] (diameter  of  0.1  mm)  that  regulate [[ myocardial  blood  flow]]. [[Coronary  vascular  functional]]  studies  can  be  performed  during  [[coronary  angiography]]. In  normal [[ coronary angiography]] there may be evident  abnormal  [[coronary  vascular  function]]. Assessment of [[coronary  microcirculation]] and  [[coronary vasomotion]] by [[coronary function testing]] are reasonable.
[[Invasive Coronary Angiography]] ([[ICA]])  is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]],  including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]]. [[ICA]] provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or [[surgical revascularization]]. ([[IFR]]  and  [[FFR]]) provide  [[physiologic]] characteristic of stenosis. [[Radiation]]  exposure to  the [[patient]]  during an  [[interventional  procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity. The spatial resolution of [[ICA]] is 0.3 mm, so, visualization of [[arterioles]] (diameter  of  0.1  mm)  that  regulate [[ myocardial  blood  flow]] is impossible. [[Coronary  vascular  functional]]  studies  can  be  performed  during  [[coronary  angiography]]. In  normal [[ coronary angiography]] there may be evident  abnormal  [[coronary  vascular  function]]. Assessment of [[coronary  microcirculation]] and  [[coronary vasomotion]] by [[coronary function testing]] are reasonable.


==Other Diagnostic Studies==
==Other Diagnostic Studies==
*[[Invasive Coronary Angiography]] ([[ICA]]) is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]],  including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]].  
* [[Invasive]] [[Coronary Angiography]] ([[ICA]]) is used to determine the presence and severity of a luminal obstruction of an [[epicardial coronary artery]],  including its [[location]], [[length]], and [[diameter]], as well as [[coronary blood flow]].  
*[[ICA]] provides the characterization of high-grade obstructive stenosis and the possibility for percutaneous or [[surgical revascularization]].
* [[ICA]] provides the characterization of high-grade obstructive stenosis and the possibility for percutaneous or [[surgical revascularization]].
* ([[IFR]]  and  [[FFR]]) provide  [[physiologic]] characteristic of stenosis.  
* ([[IFR]]  and  [[FFR]]) provide  [[physiologic]] characteristic of stenosis.  
*[[Radiation]]  exposure to  the [[patient]]  during an  [[interventional  procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity.
* [[Radiation]]  exposure to  the [[patient]]  during an  [[interventional  procedure]] varied 4 to 10 mSv and is dependent on [[procedural duration]] and complexity.
* The spatial resolution of [[ICA]] is 0.3 mm; as such, it is impossible  to visualize [[arterioles]] (diameter  of  0.1  mm)  that  regulate [[ myocardial  blood  flow]]. *[[Coronary  vascular  functional]]  studies  can  be  performed  during  [[coronary  angiography]].
* The spatial resolution of [[ICA]] is 0.3 mm; as such, it is impossible  to visualize [[arterioles]] (diameter  of  0.1  mm)  that  regulate [[ myocardial]] [[blood  flow]].
* [[Coronary  vascular  functional]]  studies  can  be  performed  during  [[coronary  angiography]].
* In  normal [[ coronary angiography]] there may be evidence of abnormal  [[coronary  vascular  function]].
* In  normal [[ coronary angiography]] there may be evidence of abnormal  [[coronary  vascular  function]].
* Assessment of [[coronary  microcirculation]] and  [[coronary vasomotion]] by [[coronary function testing]] are reasonable.
* Assessment of [[coronary  microcirculation]] and  [[coronary]] [[vasomotion]] by [[coronary]] [[function testing]] are reasonable.
 
 
 
 
==Contraindications of [[stress test]] for diagnosis of acute [[chest pain]]==
 
{| style="border: 2px solid #4479BA; align="left"
! style="width: 200px; background: #4479BA;" | {{fontcolor|#FFF| Exercise ECG}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Stress Nuclear}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Stress Echocardiography}}
! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|Stress CMR}}
! style="width: 400px; background: #4479BA;" | {{fontcolor|#FFF|Coronary CT Angiography}}
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Abnormal [[ST changes]] on resting [[ECG]], [[digoxin]], [[left bundle branch block]], [[Wolff-Parkinson-White]] pattern, [[ventricular paced rhythm]]  (unless test is performed to establish [[exercise capacity]] and not for diagnosis of [[ischemia]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* High-risk  [[unstable  angina]], complicated [[ACS]] or [[AMI]] (<2 d)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Limited [[acoustic]] windows (in [[COPD]] [[patients]])
*Inability to reach target [[heart rate]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Reduced [[GFR]] (<30 mL/min/1.73 m2)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Allergy]] to [[iodinated contrast]]
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
*Unable to achieve ≥5 [[METs]] or unsafe to [[exercise]]
*High-risk [[unstable angina]] or [[AMI]] (<2 days), ative [[ACS]], Uncontrolled [[ heart  failure]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* Contraindications  to  [[vasodilator]] administration
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Uncontrolled [[heart failure]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Contraindications to [[vasodilator]] administration
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | Inability to cooperate with [[scan acquisition]] and/or holding breath
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
*Significant [[cardiac]] [[arrhythmias]] ([[ VT]], [[complete atrioventricular block]]) or high risk for [[arrhythmias]] caused by [[QT prolongation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* Significant  [[arrhythmias]] ([[ VT]], second- or [[third-degree atrioventricular block]]) or [[sinus bradycardia]] <45 bpm
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
* High-risk  [[unstable  angina]], active [[ACS]] or [[AMI]] (<2 d)
*  Serious  [[ventricular arrhythmia]] or high risk for [[arrhythmias]] attributable to [[QT prolongation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Avoiding [[CMR]] in the presence of  implanted device due to  producing artifact limiting scan quality interpretatrion
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Clinical instability]] ([[acute respiratory distress]], severe [[hypotension]], unstable [[arrhythmia]])
|-
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
*Severe  symptomatic  [[aortic stenosis]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* Significant  [[hypotension]] ([[SBP]] <90 mm Hg)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*  [[Respiratory  failure]]
*Severe [[COPD]], acute [[pulmonary embolism]], severe [[pulmonary hypertension]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Significant  [[claustrophobia]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Renal]] impairment
|- 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
*  Severe  systemic  [[arterial hypertension]]≥200/110 mmHg
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
* Known  or  suspected [[ bronchoconstriction]] or [[ bronchospastic]] disease
* Severe  [[systemic  arterial hypertension]] (≥200/110 mm Hg)
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*  Contraindications  to  [[dobutamine]] (if [[pharmacologic stress test]] needed)
* [[Atrioventricular block]],  uncontrolled [[atrial fibrillation]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Caffeine]] use within past 12 hours
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Contraindication  to  [[beta blockade]] in the presence of an elevated [[heart rate]] and no alternative [[medications]] available for achieving target [[heart rate]]
|- 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
* Acute [[illness]] ( acute [[pulmonary embolism]], acute [[myocarditis]], acute [[pericarditis]], acute [[aortic dissection]]
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Recent use of [[dipyridamole]] or [[dipyridamole]] containing [[medications]]
* Use  of  [[methylxanthines ]] ( [[aminophylline]], [[caffeine]]) within 12 h
*  Known  [[hypersensitivity]] to [[adenosine]], [[regadenoson]]
 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
*Critical  [[aortic  stenosis]]
*Acute [[illness]] (acute [[pulmonary embolism]], acute [[myocarditis]], acute [[pericarditis]], acute [[aortic dissection]])
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Heart rate]] variability, [[arrhythmia]]
|-
|- 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
 
 
 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 
*[[Hemodynamically]]  significant [[LV outflow tract obstruction]]
* Contraindications of [[atropine]] use:
* [[Narrow-angle  glaucoma]]
* [[Myasthenia  gravis]]
* [[Obstructive  uropathy]]
* [[Obstructive]]  [[gastrointestinal]] disorders
* Severe [[systemic  arterial hypertension]] ≥200/110mmHg
 
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |
| style="padding: 0 5px; background: #F5F5F5; text-align: left;" |  Contraindication  to  [[nitroglycerin]] (if indicated)
|-
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 AHA/ACC/ASE Guideline<ref name="pmid34709879">{{cite journal |vauthors=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ |title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines |journal=Circulation |volume=144 |issue=22 |pages=e368–e454 |date=November 2021 |pmid=34709879 |doi=10.1161/CIR.0000000000001029 |url=}}</ref>
|-
|}


==References==
==References==

Latest revision as of 07:57, 24 December 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]

Overview

Invasive Coronary Angiography (ICA) is used to determine the presence and severity of a luminal obstruction of an epicardial coronary artery, including its location, length, and diameter, as well as coronary blood flow. ICA provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or surgical revascularization. (IFR and FFR) provide physiologic characteristic of stenosis. Radiation exposure to the patient during an interventional procedure varied 4 to 10 mSv and is dependent on procedural duration and complexity. The spatial resolution of ICA is 0.3 mm, so, visualization of arterioles (diameter of 0.1 mm) that regulate myocardial blood flow is impossible. Coronary vascular functional studies can be performed during coronary angiography. In normal coronary angiography there may be evident abnormal coronary vascular function. Assessment of coronary microcirculation and coronary vasomotion by coronary function testing are reasonable.

Other Diagnostic Studies



Contraindications of stress test for diagnosis of acute chest pain

Exercise ECG Stress Nuclear Stress Echocardiography Stress CMR Coronary CT Angiography
Reduced GFR (<30 mL/min/1.73 m2) Allergy to iodinated contrast
Uncontrolled heart failure Contraindications to vasodilator administration Inability to cooperate with scan acquisition and/or holding breath
Avoiding CMR in the presence of implanted device due to producing artifact limiting scan quality interpretatrion Clinical instability (acute respiratory distress, severe hypotension, unstable arrhythmia)
Significant claustrophobia Renal impairment
Caffeine use within past 12 hours Contraindication to beta blockade in the presence of an elevated heart rate and no alternative medications available for achieving target heart rate
Heart rate variability, arrhythmia


Contraindication to nitroglycerin (if indicated)
The above table adopted from 2021 AHA/ACC/ASE Guideline[1]

References

  1. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).