Cat using gxt to screen for cad moore 10 30-13 (final)
1. Case
• 63yo M /c PMH of HLD/HTN, s/p TBI &
subsequent temporal lobectomy for persistent
seizures
• Presents with severe 9/10 back pain starting
24 hours ago, evaluated in ED
– CTPA/cTnT x1 negative, required IV opioids for
pain control in ED
– Further Hx: CP 1-2/10 associated with
dyspnea/cough while walking on treadmill at
home for 20-30 minutes
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
2. Case
• Additional PMHx/PSHx: LBP/HNP L4-5 with
broad bulge & mild NF impingement on MRI
2012
• FSHx: Occasional Etoh; 10 PY smoking hx, quit
10 years ago; Mother SCD/ACS 42 years of age
(heavy smoker)
• Meds: ASA, ACEI, B-blocker, Vytorin;
Topamax/Clonazepam for seizures.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
3. Case
• PE:
–
–
–
–
VSS, AOx3, NAD
HS RRR /s M, Lungs CTAB
Left Chest Wall TTP, L-Spine paraspinal TTP
No edema, or focal neuro findings
• Labs/Imaging:
– CMP/CBC WNL, cTnT negative, Last Lipids Jul 13
LDL 57, HDL/TG WNL
– CT Head NAIP, CTPA NEOD, pCXR NACPD
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
4. Case
• Cardiac Diagnostics:
– EKG no acute changes compared to previous
studies
– GXT 2007 Full Bruce Protocol /s evidence of
ischemia, low risk study. Baseline chest wall pain
2/10 before and after study.
• Seen in ED, or ED follow up: What Now?
– 63 yo M with back & atypical CP, also with
multiple cardiac RF (age, lipids, smoking, FH)
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
5. Treadmill Test: You’re doing it wrong
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6. Case
• GXT Performed:
– Modified Bruce 13:30, 9.2 METS, max effort
– RHR 55 achieved MHR 148 (94% predicted)
– No BP drop, ST depression 1mm at peak & all 5
minutes of recovery
• LHC /c CA: 70-80% obstruction midLAD, subsequent PTCA /c stenting of same
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
7. Exercise Stress Testing for CAD
• Graded Exercise Stress Test
– Simple/Cheap/Effective (if used properly)
– Evaluates Exercise Tolerance & ECG Changes
related to CAD
– Highly dependent on determination of pretest
probability of CAD
• Pretest Probability
– Age/Gender/Pain Character (DFM)
– DM/Smoking/HLD/Q-waves (Duke)
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
8. Exercise Stress Testing for CAD
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9. DFM Compared To DCS
Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
10. How do we prevent a GXT “Fail”?
Madigan Army Medical Center IM Oral Exam Workgroup
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13. Clinical Question
• Population
– Primary Care population at risk of CAD
• Intervention
– Improve diagnostic efficiency for CAD
• Comparison
– Evaluate DF vs. DCS estimation of rick of CAD
• Outcome
– Reduce unnecessary testing
“What is the best way to determine the pretest
probability of CAD”
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
16. In case you still can’t find Ovid…
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17. COMBINED PREDICTIVE MODELS
BMJ 2012;344:e3485 doi: 10.1136/bmj.e3485 (Published 12 June 2012)
Madigan Army Medical Center IM Oral Exam Workgroup
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18. Major Studies
• Prediction model to estimate presence of
coronary artery disease: retrospective pooled
analysis of existing cohorts
– BMJ 2012;344:e3485 doi: 10.1136/bmj.e3485
(Published 12 June 2012)
• Comparison of the Diamond-Forrester method
and Duke Clinical Score to predict obstructive
coronary artery disease by computed
tomographic angiography
– Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi:
10.1016/j.amjcard.2011.11.028. Epub 2012 Jan 9.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
19. Clinical Question - Background
• Determination of the Pretest Probability of
CAD
– Diamond and Forrester method (DFM)
• Age, Gender, Character of Pain
– Duke Clinical Score (DCS)
• DFM + Smoking, DM, HLD, Q-waves on EKG
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
20. Which Method is Best?
• DFM:
– 18% low, 65% intermediate, 17% high risk
• DCS: 53% of patients had a reclassification of
their risk (most changed from intermediate to
low or high risk)
– 50% low, 19% intermediate, 35% high risk
• Net reclassification improvement for the
prediction of obstructive CAD was 51%
Am J Cardiol. 2012 Apr 1;109(7):998-1004. doi: 10.1016/j.amjcard.2011.11.028.
Epub 2012 Jan 9.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
21. Outline for Conducting Pooled Analyses
• Search strategy
• Study inclusion criteria
• Obtain primary data
• Prepare data for pooled analysis
• Estimate study-specific effects
• Examine whether results are heterogeneous
• Estimate pooled result
• Conduct sensitivity analyses
Friedenreich CM, Methods for pooled analyses of epidemiologic studies. Epidemiology; 1993; 4:295-302.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
24. Summary of Evidence
• Use the DCS:
Duke Chest Pain - CAD Risk Calculator
• Consider use of
COURAGE
calculator (patients
with known CAD for
clinical guidance)
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
25. Bottom Line
• Routinely use a Combined Prediction Model
(DCS or CAD Consortium) for Predicting the
Pretest Probability of CAD
– Rational to use FH, Smoking, HLD, HTN for
adjustment of pretest probability
– Timing of pain is important
• Reassess Risk of CAD (Frequency?)
– Every 2-3 years is rational
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
26. Current Research
• Ongoing Research
– Evaluate new modalities of CV Non-Invasive
Diagnostics
– Health System Utilization
• Future Directions
– Reassessment of risk/disease
– Evaluation after medical treatment
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
27. Effect on Patient Case
• In this case:
– The patient was reassessed
– GXT was performed
– Critical LAD lesion identified and stented
• Outcome was excellent
• Key Point: Use of the “Cardiac 4”
– ASA, ACEI, BB, Statin
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
28. References
(in addition to those already cited)
• Up To Date:
– “Exercise ECG testing to determine prognosis of
coronary heart disease“
– “Stress testing for the diagnosis of coronary heart
disease“
• Diamond GA, Forester JS. Analysis of probability
as an aid in the clinical diagnosis of coronaryartery disease. NEJM 1979;300:1350-8
• Pryor DB et al (from Duke University) Estimating
the likelihood of significant coronary artery
disease Am J Med 1983;75:771-80.
Madigan Army Medical Center IM Oral Exam Workgroup
5 APR 2013
Notas del editor
AHLTA Bx showed multiple presentations to PCM for L arm, chest wall, and back pain. Indeed working dx for this admission was costrochondritis.
Change slide titleClearly, in retrospect, the patient probably did not have recurrent arm, chest wall, or back pain, he probably had atypical angina over the past 2-3 years. How do we make that decision to call pain “nonanginal.”