Cardiac Testing Pete Bell, MD in collaboration with Julia Smith, FLMI

1. Cardiac TestingPete Bell, MD in collaboration with Julia Smith, FLMI

2. Cardiac Testing

3. Heart Anatomy

4. Who needs cardiac testing? Clinically: New onset of chest pain, dyspnea Pre-operative evaluation Elderly Special occupation (pilot, police officer, bus driver) In presence of known risk factors for heart disease Known heart disease.

5. Who needs cardiac testing? Underwriting--Applicants • Age and amount (ECG/ Treadmill for older ages/ higher face amounts) • Abnormal resting ECG • History of heart disease

6. Cardiac Testing: pros and cons

7. Cardiac Testing: pros and cons

8. Does chest pain mean heart disease? Common causes of chest pain: • Angina due to coronary artery disease, spasm, syndrome X • Heart Attack • Mitral Valve Prolapse • Pericarditis • Recent chest trauma • Peptic Ulcer • Aortic dissection • Atypical chest wall pain • Anxiety or panic disorder • Asthma, bronchitis, pneumonia, pleuritis • Gastrointestinal If chest pain is new onset, worsening, accompanied with chest tightness, dyspnea or risk factors associated with heart disease, then getting an ECG is the first step to evaluate. If chest pain is chronic or recurrent, angina due to coronary artery disease is a possibility and treadmill testing is the first step

9. Chest Pain in Males In men: Men delay evaluation and treatment. Musculoskeletal, respiratory, GI CAD symptoms classic: Exertional chest pressure Dyspnea, nausea and vomiting CAD risk factors remain very powerful prognosticators:

10. Chest Pain in Females In women: • Coronary artery disease onset is typically ten years later than men • Chest pain often due to other causes • Mitral Valve Prolapse • Musculoskeletal, respiratory, gastro-intestinal • Symptoms of coronary artery disease may not be classic: • Mid back pain • Nausea and vomiting • Risk factors for coronary artery disease remain very powerful prognosticators:

11. Risk Factors for Coronary Artery Disease • Tobacco exposure-includes cigarette/cigar smoking/chewing tobacco/secondhand cigarette smoke • Dyslipidemia • Hypertension • Diabetes • Obesity • Physical inactivity and low fitness • Family history of cardiovascular disease in 1-st degree relative • < 55 years old in men • < 65 years old in women

12. Medical Case #1 55 year old female, applying for 2.5 million of life insurance Exam :BP 135/85, 5.5/145, no pertinent physical findings, family history negative for CAD Labs: total cholesterol 217, HDL = 58, Ratio = 4.2 glucose 109, HOS WNL Minor ST-T changes on ECG Present History: • Sharp, fleeting (less than a minute) chest pain, onset 2 months ago • No shortness of breath, no palpitations. • Non-positional, stops spontaneously Past Medical History: • Mild osteoarthritis • Hypertension, treated x five years • Meds: Dyazide, Lisinopril and Aspirin as needed • Non-smoker

13. Probability of Disease

14. Medical case #1 Offer, postpone for additional testing?

15. ECG abnormalities Major ST-T changes may give the appearance of ischemia even if NO real ischemia is present. Juvenile T Waves can be a normal variant-mostly seen in young healthy females, persistently negative T wave leads V1-V3, usually not deeply inverted. Major T wave inversions – ischemia or LVH Minor T wave changes potential causes: CAD * Obesity * Electrolyte Imbalance-Hypokalemia * Hyperventilation * Hypothyroid * Medication Non specific ST changes are not diagnostic

16. Probability of Disease 1 in 10 chance of coronary heart disease

17. Risk Assessment Low risk for CAD

18. Medical case #2 Same applicant, 55 year old female, applying for 2.5 million of life insurance Same Minor T changes on insurance resting ECG. Producer is concerned.

19. Medical Case #2 How to improve the offer? • Stress test?

20. Bruce Protocol

21. METS and activity level 2-3 Walking at a slow pace ,Playing musical instrument, Dancing (slow), Golf using power cart, Bowling, Fishing 4-5 Walking at a very brisk pace , Climbing stairs, Dancing (moderately fast), Bicycling <10 mph, leisurely, Slow swimming, Golf, carrying clubs 6 Slow jogging (one mi/ 13 to 14 min) , Ice or roller skating, Doubles tennis (if you run a lot) 6-8 Rowing, canoeing, kayaking vigorously, Dancing (vigorous), Some exercise apparatuses 7-12 Singles tennis, squash, racquetball 8 Jogging (1 mile every 12 min), Skiing downhill or cross country 10 Running 6 mph (10-minute mile) 13.5 Running 8 mph (7.5-minute mile) 16 Running 10 mph (6-minute mile)

22. Poor prognostic findings on Stress Test • Low workload • Mets <6.5 • Time: < 5-6 minutes on Bruce protocol • Low peak Heart Rate • Pulse < 120 without Beta-Blocker therapy • Systolic Blood Pressure decreased or flat response • Remains under 130 mmHg • ST segment depression >2mm • ST segment depression in multiple leads • Prolonged ST depression after Exercise (>6 min) • ST Elevation without abnormal Q wave • Increase in complex ventricular ectopy • Exercise induced typical Angina • Frequent ventricular ectopy

23. Medical case #2 Same applicant, 65 year old female, applying for 2.5 million of life insurance • Same Minor T changes on insurance resting ECG. • How to reconsider the offer? Minor ST changes on ECG=> Negative stress ECG Producer no longer concerned

24. Medical case #3 Same applicant, 55 year old female, applying for 2.5 million of life insurance • Sharp, fleeting (less than a minute) chest pain, onset 2 months ago • no dyspnea or palpitations • ECG with minor ST-T changes • Standard treadmill test performed to consider for improved offer, but it comes back with 1- 2 mm ST depression at 7 METS exercise.

25. Stress Test Tracing

26. Medical case #3 Minor ST changes on ECG=> Positive stress ECG Now what?

27. Probability of Disease

28. Post-Test Probability Post Test probability of disease is now 47%

29. Post-Test Decision • Flip a coin

30. Medical Case #2 Oh boy, what now? • Stress Echo? • Perfusion Stress Test?

31. Stress test, Stress Echo, Nuclear stress If the treadmill is equivocal or positive -- a stress perfusion treadmill or stress echocardiogram can be performed to investigate further. If the workload on the follow up stress perfusion/echo is equal to or higher than that achieved on the original treadmill, then follow up stress perfusion/ echo results are considered valid.

32. Stress Echo The echocardiogram is a cardiac ultrasound performed at rest and after exercise. It shows the structure of the heart • valves • chambers size and wall motion function • wall thickness • wall motion during exercise - abnormal may be indicative of ischemia.

33. Stress Echo

34. Nuclear stress AKA - Perfusion study, Cardiolite study, Nuclear Test, Thallium Study, Myocardial Perfusion Imaging (MPI), Stress SPECT. • involves injecting a radioactive tracer into the bloodstream • obtains images of the heart using a gamma camera. • pictures are taken shortly after exercise and then after resting for 2/3 hours If the perfusion is normal during rest, but diminished following exercise, the results are consistent with a obstruction in one or more coronary arteries. If the test shows reduced perfusion during both rest and exercise, then the blood flow is limited at all times and is consistent with a prior myocardial infarction

35. Stress Echo • 6.0 minutes – stage II of Bruce protocol • BP 173/98 Max HR = 159 • 7 METS • Stopped because target heart rate achieved • No chest pain or palpitations • Echo showed no wall motion abnormalities, normal wall thickness, chamber size and valves

36. Post-Test Probability • Post Test probability of disease is 10%

37. Risk Assessment Low risk for CAD Happy Producer

38. Medical case - #4 70 year old male, non smoker applying for $500,000, Term • 5.6, 180 lbs • 130/86, 140/80, 130/70 • Ins labs 4/12 - Chol 171, ratio 3.4, HDL = 48. LDL 104 • Meds – Vytorin, Lisinopril • History of hypertension, hyperlipidemia, OSA treated with CPAP • Family history – non contributory

39. Medical case - #4 APS: 1/11/11 – Asymptomatic, resting ekg read as previous inferior myocardial infarction 1/17/11 – treadmill to 10 METS, stopped due to MPHR, no symptoms, normal BP response. NSSTW changes on tracings, SPECT scan => normal wall motion and thickness, mild inferior defect, can not exclude attenuation. 1/18/11 - Cath => 20 – 30% LM lesion, can not exclude catheter induced spasm, 30 – 40% mid – LAD lesion, 90% distal LAD lesion with collateral flow. MD notes “no significant CAD, continue with clinical treatment”

40. Cardiac Catheterization

41. Coronary Artery Catherization Favorable Factors • Diagnostic gold standard. • Invasive • Bleeding • Arterial damage • Infection • Also, can be therapeutic • Stent • Percutaneous Transluminal Coronary Angiography • Rate of progression • Hard to predict • Evidence of regression • Satins • ACE inhibitor • Exercise

42. Coronary Artery Stenosis

43. CAD Significance over 50% plaque obstruction coupled with  typical  angina symptoms at the bifurcation of 2 major (e.g.,LAD and Circumflex) or a major and second-level (LAD and obtuse marginal ) vessel. 20 mm or greater in length in that it usually impedes flow reserve regardless caliber. the report of “no flow-limiting lesions” has to be taken into context with risk factors and symptoms. lesions < 50%, more significance for women than men, as women are more prone to coronary artery spasm diffuse small lesions are fairly innocuous only in the elderly or at any age if risk factors are meticulously controlled.  lesions as they appear on cath are smaller when actually seen, so the presence of symptoms are important to assess the significance.

44. Catheterization

45. Medical case - #4 - Solution 70 male with stable CAD per MD notes, good control of blood pressure and lipids.  The cath is equivocal for LM disease.  Definite mid-LAD obstruction and a significant distal lesion.  Assuming the reason there is no obstruction to blood flow is due to collateralization, as otherwise a lesion that size would obstruct proximal flow.MD is continuing with clinical treatment only and doesn’t note CAD as significant. Moderate risk of disease

46. Summary Look at the likelihood of disease being present: Consider the history, symptoms and risk factors to develop a sense of whether or not disease is present. And if so, what disease it is it? Look at the studies: Does one appear better quality? Full versus sparse descriptions, etc. A better quality testing labs? Referral center versus private office? What about the tests? One is very positive while the other may be more ambiguous. Draw a conclusion: No risk factors and the negative tests are more accurate, while the positive tests are more likely false positive Many risk factors and the positive tests are more accurate, while the negative tests are more likely to be false negative Consider the probability of disease being present. It may not be what you think!

47. Questions