Lựa chọn nghiệm pháp gắng sức nào cho bệnh nhân bloc nhánh trái hoặc bệnh nhân được tạo nhịp tim

For prognosis: Vasodilator rMPI also provides important prognostic information in patients with CHD, which is incremental to clinical assessment Exercise and pharmacologic stress radionu

Lựa chọn nghiệm pháp gắng sức nào cho bệnh nhân bloc nhánh trái hoặc

bệnh nhân được tạo nhịp tim?

Selection of stress test for patients with

paced ventricular rhythm or left bundle branch block

TS NGUYỄN THỊ THU HOÀI VIỆN TIM MẠCH QUỐC GIA VIỆT NAM

Hội nghị Nhịp học Toàn quốc - Hà nội - 11/2016

Vietnam National Rhythm Conference

Indications for Stress Testing

• AHA/ACC endorse many indications for

stress testing

• 11 Class I indications

• 8 Class IIa indications

• 14 Class IIb indications

Gibbons et al Circulation 2002;106:1883

Categories of Patients

• Symptomatic patients without known CAD

• Patients with known CAD ± symptoms

• Patients with recent myocardial infarction

Categories of Patients

• Asymptomatic patients

– Type 2 diabetes

– Multiple risk factors

– Starting exercise program

Able to exercise?

Choice of Stress Testing Modality in Different Clinical Settings

Localize ischemia or assess viability?

Able to exercise?

Yes

No Marked baseline

ECG abnormalities, digitalis,

previous revascularization?

Standard Stress ECG

Pharmacologic imaging study

Exercise imaging study

Information from Stress Test

• Diagnostic testing

– Establish presence of coronary artery disease – ST segment changes (ischemia)

• Prognostic testing

– Estimate long-term survival

– Estimate short-term or long-term risk of CV event

• FAC or peak VO2

• Duke Treadmill Score

• Heart rate responses

Stress testing in LBBB

Stress testing in LBBB

ACC/AHA 2002 guidelines on exercise testing:

There is NO level of ST segment depression that confers diagnostic significance during exercise ECG testing in patients with LBBB

Exercise and pharmacologic stress radionuclide

myocardial perfusion imaging (rMPI)

False possitive rate in LBBB: 10-20%

Downloaded From: http://content.onlinejacc.org/ on 11/25/2016

Downloaded From: http://content.onlinejacc.org/ on 11/25/2016

Periyanan Vaduganathan, JACC 1996

TK đầu tâm trương, đây là giai đoạn bắt xạ tưới máu

Downloaded From: http://content.onlinejacc.org/ on 11/25/2016

O’Keefe JACC 1993

For prognosis: Vasodilator rMPI also provides

important prognostic information in patients with

CHD, which is incremental to clinical assessment

Exercise and pharmacologic stress radionuclide

myocardial perfusion imaging (rMPI)

Mairsse 1995, Marwick 2013, Haft 2015

Dobutamine stress echocardiography vs

dobutamine rMPI in LBBB

Dobutamine stress echo had a better accuracy and specificity than dobutamine rMPI because of false positive septal and anteroseptal perfusion defects associated with LBBB with rMPI

Mairsse 1995, Marwick 2013, Haft 2015

Dobutamine stress echocardiography vs

dobutamine rMPI in LBBB

Dobutamine stress echo had a better accuracy and specificity than dobutamine rMPI because of false positive septal and anteroseptal perfusion defects associated with LBBB with rMPI

Mairsse 1995, Marwick 2013, Haft 2015

Usefulness and limitations of dobutamine-atropine stress echo for the diagnosis of CAD in patients with

LBBB - a multicenter study

Usefulness and limitations of dobutamine-atropine stress echo for the diagnosis of CAD in patients with

LBBB - a multicenter study

The potential diagnostic value of DSE:

 Stress-induced new or worsening wall motion

abnormalities had a sensitivity of 68% and a specificity of 91%

 However, sensitivity for the anterior circulation was lower

(44%) in patients with abnormal septal thickening at rest

Geleijnse, Eur Heart J 2000

Usefulness and limitations of dobutamine-atropine stress echo for the diagnosis of CAD in patients with

LBBB - a multicenter study

 Echocardiography provide pertinent information on the

distribution and extent of CAD, chamber size, global and regional function, and valvular function

 Image interpretation can be more difficult when resting

regional wall motion abnormalities exist, and interobserver variability remains a limitation

 Image quality can be reduced in certain patients because of

body habitus or pulmonary disease

Thomas Allison, Mayo Clinic

Accuracy of dobutamine–atropine stress

echocardiography for the detection of

coronary artery disease in the anterior and

posterior circulation

Accuracy of dobutamine–atropine stress echocardiography for the detection of coronary artery disease in the anterior circulation in patients with normal and abnormal rest septal thickening

For prognosis:

- 387 patients who underwent either dobutamine or

dipyridamole stress echo

- Follow-up 29 months: patients with evidence of ischemia

on stress echo had significant reductions in 5 year survival (77% vs 92%) and 5 year survival free of a MI (60% vs 87%)

- Pharmacologic stress echo significantly improved risk stratification in those without previous MI, but not in those with prior MI

Cortigiani, Am J Med 2001

Exercise echocardiography in LBBB

Siêu âm gắng sức bằng xe đạp lực kế Siêu âm gắng sức bằng thảm chạy

Exercise-induced wall motion abnormalities had an overall sensitivity of 76% and a specificity of 83% The sensitivity was 100% for LAD but only 46% and 40% percent for LCx and RCA

Heller, 2011

Mordi 2014: 82 patients with LBBB, suspected CAD Dobutamine stress CMR (DSCMR) had higher specificity (87.5% vs 72.9%), negative predictive value

(80.8% vs 67.3%), accuracy (80.4% vs 72.0%) than DSE

Dobutamine stress CMR vs Echocardiography in patients with LBBB

Mordi I, JACC 2014

Paced Ventricular Rhythm

 A paced right ventricular rhythm produces

LBBB on the ECG

 Like LBBB, a paced ventricular rhythm

produces false positive defects on exercise rMPI

if pacing continues during exercise

Paced Ventricular Rhythm

 The effect of pacing on septal radionuclide uptake: thallium

rMPI and regional myocardial blood flow measurements

were obtained during RV pacing and during RA pacing

 Thallium uptake and blood flow were homogeneous

throughout the LV during RA pacing

 Septal abnormalities during RV pacing, as septal thallium

uptake was reduced by 31% with a comparable reduction in blood flow

Hirzel HO, Am J Cardiol 1984

Paced Ventricular Rhythm

Hirzel HO, Am J Cardiol 1984

 Inferoposterior, inferior, and apical walls are the

most common sites of false positive perfusion defects with right ventricular pacing in contrast to the septum in patients with LBBB

 Impaired microvascular flow may contribute to

these defects

Paced Ventricular Rhythm

JACC, 1997

 The LV seems to be activated much more rapidly,

while QRS duration and electromechanical delay are much longer with RV pacing

 The extent of incoordinate wall motion may be

much greater with LBBB

Paced Ventricular Rhythm

Diagnosis: As with LBBB, adenosine or dipyridamole rMPI is recommended by the ACC/AHA guidelines for the diagnosis of suspected CAD in patients with a paced ventricular rhythm

Paced Ventricular Rhythm

Specificity was much higher with dobutamine echocardiography (92% vs 31%), which also had a sensitivity of 88%

Dobutamine stress echocardiography vs exercise rMPI in patients with paced

rhythm

Ciaroni S, Echocardiography 2000

RECOMMENDATIONS

The 2007 ACC/AHA guidelines:

Evaluation by either vasodilator rMPI or dobutamine

LBBB, noting that the diagnostic accuracy of exercise imaging (rMPI or echocardiography) is inferior (due to low specificity) in this population based upon studies

RECOMMENDATIONS

Exercise imaging (rMPI or echocardiography) or dobutamine rMPI or the combination of exercise and dipyridamol stress is not recommended in patients with LBBB

RECOMMENDATIONS

The 2003 ACC/AHA/American Society of Nuclear Cardiology Task Force on cardiac radionuclide imaging also concluded that vasodilator rMPI is preferred over exercise rMPI in patients with LBBB

RECOMMENDATIONS

The 2002 ACC/AHA chronic angina guidelines recommend use of vasodilator rMPI in patients with a ventricular paced rhythm; this recommendation was not changed by the 2007 update

SUMMARY

 Vasodilator rMPI and dobutamine stress

echocardiography are more specific than exercise rMPI and exercise echocardiography for the diagnosis of coronary artery disease in patients with LBBB

 2007 ACC/AHA guidelines recommended the use

of vasodilator rMPI or dobutamine stress echocardiography for the diagnosis of coronary artery disease in this patient population

SUMMARY

In patients with a ventricular paced rhythm:

 ACC/AHA recommended: stress echocardiography may

be more specific, vasodilator rMPI may be indicated in this patient population as well

 For those patients with LBBB or ventricular paced

rhythm in whom exercise is possible and important, exercise rMPI may be performed Further testing is not necessary if no perfusion abnormalities are identified

THANK YOU VERY MUCH!