DOCSLIB.ORG

Cardiac Stress Testing

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Cardiac Stress Testing Quality Challenges and Pitfalls in the Evaluation of Patients with Suspected Heart Disease Joseph A. Ladapo, MD, PhD Assistant Professor of Medicine Department of Population Health NYU School of Medicine Disclosures: K23 HL116787 Award from National Heart, Lung, and Blood Institute; Consultant for CardioDx, Inc Overview • Health and economic burden of coronary artery disease (CAD) • Pitfalls in care of patients suspected of having CAD • Approaches to improve quality of care • Introduction to Corus CAD, a gene expression test for CAD 2 1 Coronary Artery Disease (CAD) is a Major Public Health Challenge Epidemiology • 15.4 million adults in the US live with CAD • 6.4% of adults overall; 7.9% of men and 5.1% of women Mortality Myocardial infarction • Accounts for over 386,000 deaths • Nearly one million new or recurrent annually (1 in 6 of all deaths) heart attacks each year • More than half of sudden cardiac • Early diagnosis is important deaths occur in people with no prior because treatment & preventive history of heart disease practices significantly reduce morbidity and mortality National Health Interview Survey, 2010; Go, Circulation 20133 Healthcare Utilization and Costs Attributable to CAD are Substantial Healthcare utilization and costs • CAD costs $195.2 billion in direct and indirect costs annually (2009) • In 2006, Medicare spent $11.7 billion on inpatient care for CAD • By 2030, medical costs for CAD (real 2010$) projected to increase ≈100% Ambulatory care Hospital care • In 2009, there were over 14 million • 1.3 million hospital admissions with ambulatory care visits with CAD as the CAD listed as the first diagnosis first-listed diagnosis • 954,000 percutaneous coronary interventions (PCIs), 397,000 cardiac bypass surgeries, 1.03 million diagnostic cardiac catheterizations National Health Interview Survey, 2010; Go, Circulation 20134 2 Cardiac Stress Testing Source of picture: American College of Cardiology, CardioSmart website Primary Care Physicians Routinely Manage Patients With Suspected or Diagnosed CAD ~4M Stable, Symptomatic Patients Suggestive of Coronary Disease Annually Diagnostic Tools Clinical Factors Primary Care EKG Treadmill Stress Echo Often Repeat Cardiology Nuclear Imaging Testing CT Angiography Invasive Obstructive CAD is not found in Angiography ~60% patients1 ~$4.5B annual expenditures2 1 Patel et al, N Engl J Med 2010;362:886-95; COMPASS study. 2 IMV Market Reports 6 3 Ambulatory Care: Cardiac Stress Tests In Patients Without CAD, From 1993 To 2010 5,000,000 4,000,000 3,000,000 2,000,000 Any cardiac stress test No. of Tests Stress imaging 1,000,000 Avg. Avg. annual annual cost in cost in - 1993-1995 2008-2010 All cardiac $820M $2.0B stress tests Stress $550M $1.9B imaging 7 Source: Ladapo et al, Annals of Internal Medicine 2014 Opportunities For Quality Improvement Presentation Title Goes Here 8 4 Despite Wide Array of Available Tests for Working Up CAD, Patients Routinely Encounter… 1. Diagnostic uncertainty 2. Unnecessary testing and procedures 3. Unnecessary radiation exposure 9 Challenges to Clinical Care: Diagnostic Uncertainty Presentation Title Goes Here 10 5 Uncertainty About How to Interpret Diagnostic Test Results is Common • Bayes’ theorem defines how pretest disease risk and diagnostic test performance can be used to guide interpretation of test results Missed or Correctly misdiagnosed identified Reverend Thomas Bayes 11 Stress Test Effectiveness in Diagnosing CAD: Results From Meta-analyses Stress MPI Stress ECHO Sens Spec # studies Sens Spec # studies Garber et 88% 77% 10 76% 88% 6 al Fleischma 87% 64% 27 85% 77% 24 nn et al Mowatt et 76% 65% 10 --- al* Mowatt et 92% 74% 4 --- al** *includes or **excludes patients with prior myocardial infarction Garber, Annals 1999; Fleischmann, JAMA 1998; Mowatt, HTA 2004 12 6 Physicians Interpret Test Results in a Bayesian Manner Stress MPI example • Most frequently performed imaging stress test • Sensitivity = 87%, Specificity = 64% Normal test result Abnormal test result • With a pretest probability of 20%, • With a pretest probability of 20%, post-test probability of CAD is 5% post-test probability of CAD is after a normal test result 38% after an abnormal test result • With a pretest probability of 60%, • With a pretest probability of 60%, post-test probability of CAD is 23% post-test probability of CAD is after a normal test result 78% after an abnormal test result 13 Referral Bias also Influences Diagnostic Accuracy and Test Interpretation Referral bias Biases clinical • Sometimes called “verification bias” or “workup bias” decision-making • Occurs because higher-risk patients are preferentially referred to cardiac catheterization • Bayesian methods needed to adjust • Because it biases test diagnostic test performance for referral performance, it may also bias clinical decision-making • Studies of stress test performance do not adjust Most studies do for this phenomenon so not account for estimates of sensitivity and referral specificity biased Begg, Biometrics 1983 14 7 Presentation Title Goes HereLadapo et al, JAHA 2013 15 Cardiac Catheterization Referral Rates After Normal Exercise ECHO or MPI Results Referral rates are low after a normal study • Range of ~1% to 5% generally Homogenous • Geographic location and patient characteristics vary but little variation in referral rates Ladapo et al, JAHA 2013 16 8 Cardiac Catheterization Referral Rates After Abnormal Exercise ECHO or MPI Results Referral rates higher after an abnormal test • Range of ~20% to 50% generally Heterogeneity • Significant variation in referral rates Ladapo et al, JAHA 2013 17 Observed vs. True Diagnostic Performance of Exercise ECHO 99% 100% 91% 81% 80% 60% 40% 40% 20% 0% Sensitivity Specificity Observed performance True performance True performance = observed performance after adjustment for referral18 9 Observed vs. True Diagnostic Performance of Exercise MPI 97% 100% 91% 80% 67% 60% 44% 40% 20% 0% Sensitivity Specificity Observed performance True performance True performance = observed performance after adjustment for referral19 Challenges to Clinical Care: Unnecessary Testing and Procedures Presentation Title Goes Here 20 10 Unnecessary Testing is Common Our Threshold for Testing Patients is Falling • 39,515 patients undergoing stress MPI between 1991- 2009 at Cedars Sinai • Incidence of abnormal scans fell from 41%→9% • Incidence of ischemic scans fell from 30%→5% • Only 3% of patients who did not have typical angina and could exercise had an abnormal scan Rozanski, JACC 2013 21 Unnecessary Procedures are Common Cardiac Catheterization Frequently Performed Needlessly • 398,978 patients in American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) • Noninvasive cardiac testing performed in 84% of patients prior to catheterization • Only 1 in 3 patients were found to have obstructive coronary disease • No coronary artery disease was reported in 39% of patients Patel, NEJM 2010 22 11 Inappropriate Imaging is Common What is appropriate imaging? • Imaging that provides (1) accurate information, (2) influences behavior, and (3) yields benefits that outweigh risks • In general, imaging in intermediate to high-risk patients is appropriate (diabetics, AAA, PVD, angina/ischemic equiv., ECG uninterpretable) • Number of inappropriate cardiac imaging stress tests in patients evaluated for CAD has risen • Primary care doctors fare worse than cardiologists Presented at American College of Cardiology 63rd Annual Scientific Session, March 23 2014 in Washington, DC Challenges to Clinical Care: Unnecessary Radiation Presentation Title Goes Here 24 12 25 Unnecessary Radiation Exposure is a Growing Problem Potential harms related to radiation exposure are poorly understood • Stress MPI accounts for 22% of cumulative effective radiation from medical sources • One MPI ≈ 1,000 chest x-rays ≈ 10-15 mSv • Persons at risk for repeated radiation exposure, such as healthcare workers and the nuclear industry, typically restricted to max 100 mSv every 5 years Columbia University Medical Center Medicare population • 1,097 consecutive patients, 8-10 years of • Between 1993-2001, 34% of enrollees follow-up underwent repeat testing • Multiple MPIs performed in 424 patients (39%) • Median cumulative effective dose from MPI US nonelderly population was 29 mSv • Median cumulative effective dose from • 952,420 adults in 5 US markets (2005-2007) medical sources was 64 mSv • Among patients undergoing cardiac imaging, mean cumulative dose 16.4 mSv (1.5-190 mSv) • MPI accounted for 74% of cumulative dose Fazel, NEJM 2009; Einstein, JAMA 2010; Gerber, Circulation 2009; Lucas, Circulation 2006; Chen, JACC 201026 13 Improving Quality Of Care Presentation Title Goes Here 27 Improving Quality of Care: Reducing Unnecessary Testing Appropriate use criteria • Growing physician awareness of appropriate use criteria for diagnostic testing in patients suspected of having CAD • ACC and United Healthcare registry reported that 34% of stress MPIs were inappropriate or of uncertain appropriateness Insurer policies and regulation Patient/Professional education • Prior authorization by radiology benefits managers • Informed decision-making • Reductions in reimbursement • Medicare released national coverage • Shared decision-making decision requesting more evidence for coronary CT angiography (CTCA) • Professional society scrutiny …Impact on health is unknown and needs to be studied Shaw, JACC: CV Imaging 2010; Gibbons, JACC 2008 28 14 Improving Quality of Care: Comparative Effectiveness Research
Load more

Recommended publications
  • ICD-10 and Cardiology Steven M
    ICD-10-CM and Cardiology Steven M. Verno, CMBSI, CEMCS, CMSCS, CPM-MCS Page 1 of 24 ICD-10 and Cardiology Steven M. Verno, CMBSI, CEMCS, CMSCS, CPM-MCS Note: ICD-9-CM and ICD-10 are owned and copyrighted by the World Health Organization. The codes in this guide were obtained from the US Department of Health and Human Services, NCHS website. This guide does not contain ANY legal advice. This guide shows what specific codes will change to when ICD-9-CM becomes ICD-10-CM. This guide does NOT discuss ICD-10-PCS. This guide does NOT replace ICD-10-CM coding manuals. This guide simply shows a practice what ICD-10-CM will look like within their specialty. The intent is to show that ICD-10 is not scary and it is not complicated. This guide is NOT the final answer to coding issues experienced in a medical practice. This guide does NOT replace proper coding training required by a medical coder and a medical practice. Images or graphics were obtained from free public domain internet websites and may hold copyright privileges by the owner. This guide was prepared for Free. If you paid for this, demand the return of your money! If the name of the original author, Steve Verno, has been replaced, it is possible that you have a thief on your hands. Page 2 of 24 For the past thirty-one (31) years, we have learned and used ICD-9-CM when diagnosis coding for our providers. ICD stands for International Classification of Diseases.
    [Show full text]
  • Perioperative Stress Testing: the New High Risk Paradigm
    medigraphic Artemisaen línea E A NO D NEST A ES Mexicana de IC IO EX L M O G O I ÍA G A E L . C C O . C Revista A N A T Í E Anestesiología S G S O O L C IO I S ED TE A ES D M AN EXICANA DE PROFESORES EXTRANJEROS Vol. 32. Supl. 1, Abril-Junio 2009 pp S198-S206 Perioperative stress testing: The new high risk paradigm Marc A. Rozner, PhD, MD* * Professor of Anesthesiology and Perioperative Medicine. Professor of Cardiology The University of Texas MD Anderson Cancer Center. Houston, TX [email protected] INTRODUCTION Each scenarios (i.e.; should have been tested but was not; did not need the test but was tested anyway, got tested For sometime, anesthesiologists have been asked to assist and intervention) is accompanied by financial and medi- in the assignment of risk for an operative procedure, espe- cal complication issues that are beyond the scope of this cially the patient with cardiac disease. For most of these talk. It is important to keep in mind that every medical test patients, the preoperative assessment involves a decision and procedure has a potential downside – a significant about getting a stress test and dealing with the results. But aspect to the patient with a positive stress test who has a there is little data to support this practice, and recent events stroke during the follow-up, clean cardiac catheterization. suggesting that mechanical coronary artery intervention In their Guideline Update for exercise testing, the ACC / actually increases perioperative risk of MI and death have AHA quote a rate for myocardial infarction and / or death muddied the perioperative water.
    [Show full text]
  • Surgical Treatment of Giant Saphenous Vein Graft Aneurysm: a Case Report
    Successful Surgical Treatment of Giant Saphenous Vein Graft Aneurysm: A Case Report SalahEldien Altarabsheh MD*, Salil Deo MD**, Lyle Joyce MD** ABSTRACT A 72 year-old-male patient who had coronary artery bypass grafting twice in the past, presented with shortness of breath. Coronary angiography showed a giant saphenous vein graft aneurysm, surgical excision of the aneurysm with bypass of the right coronary artery using new vein conduit was performed. The pathophysiology, clinical presentation, diagnostic modalities and therapeutic options will be discussed in light of this case. Key words: Saphenous Vein Graft, Giant Aneurysm, Coronary Artery Bypass Grafting, Coronary Artery Disease JRMS June 2012; 19(2): 76-78 Introduction located in the middle part of the vein graft and dye Coronary Artery Bypass Grafting (CABG) is a swirled in the aneurysmal sac without any flow into widely used surgical therapy for coronary artery the distal coronary circulation (Fig. 1A). The other disease. Great saphenous vein is the traditional grafts were patent with no obvious major pathology conduit used in this procedure. Saphenous Vein Graft identified. A contrast enhanced Computed Aneurysms (SVGA) is rare and usually found Tomogram (CT) scan of the chest measured the incidentally. SGVA should be considered as a aneurysm to be 6.4 x 4.3 cm in cross-section. There possibility in any patient presenting with a was significant mass effect on the right atrium (RA) mediastinal mass after CABG, as early diagnosis and and superior vena cava (SVC) as depicted in (Fig. intervention may avert fatal complications. We report 1B). Additionally, a preoperative Transthoracic a case of a giant SVGA which was successfully Echocardiogram (TTE) showed preserved left treated by surgical excision and coronary ventricular function with severe calcific aortic valve revascularization.
    [Show full text]
  • Download PDF File
    Cardiology Journal 2008, Vol. 15, No. 1, pp. 4–16 Copyright © 2008 Via Medica REVIEW ARTICLE ISSN 1897–5593 Early repolarization variant: Epidemiological aspects, mechanism, and differential diagnosis Andrés Ricardo Pérez Riera1, Augusto Hiroshi Uchida2, Edgardo Schapachnik3, Sérgio Dubner4, Li Zhang5, Celso Ferreira Filho6 and Celso Ferreira7 1Electro-Vectorcardigraphic Section, ABC Medical School, ABC Foundation, Santo André, São Paulo, Brazil 2Electrocardiology Service, Heart Institute (InCor) of the University of São Paulo Medical School, São Paulo, Brazil 3Department of Chagas Disease, Dr. Cosme Argerich Hospital, Buenos Aires, Argentina 4Arrhythmias and Electrophysiology Service, Clinical y Maternidad Suizo Argentina, Buenos Aires, Argentina 5LDS Hospital and University of Utah School of Medicine, SALT Lake City UT, USA 6Cardiology Division, ABC School of Medicine, ABC Foundation and School of Medicine of Santo Amaro, UNISA, São Paulo, Brazil 7Cardiology Division, ABC School of Medicine, ABC Foundation, Santo André, São Paulo, Brazil Abstract Early repolarization variant (ERV or ERPV) is a enigmatic electrocardiographic phenom- enon, characterized by prominent J wave and ST-segment elevation in multiple leads. Recently, there has been renewed interest in ERV because of similarities to the arrhythmogenic Brugada syndrome (BrS). Not much is known about the epidemiology of ERV and several studies have reported that this condition is associated with a good prognosis. Both syndromes exhibit some similarities including the ionic underlying mechanism, the analogous responses to changes in heart rate and autonomic tone, sympathicomimetics (isoproterenol test) as well as in sodium channel and beta-blockers. These observations raise the hypothesis that ERV may be not as benign as traditionally believed. Additionally, there are documents showing that ST-segment height in the man is greatly influenced by central sympathetic nervous activity, both at baseline and during physiologic and pharmacological stress.
    [Show full text]
  • Chapter Xi Medicine Evaluation and Management Services Cpt Codes 90000 - 99999 for National Correct Coding Initiative Policy Manual for Medicare Services
    CHAP11-CPTcodes90000-99999 Revision Date: 1/1/2021 CHAPTER XI MEDICINE EVALUATION AND MANAGEMENT SERVICES CPT CODES 90000 - 99999 FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, prospective payment systems, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein. Table of Contents Chapter XI ................................................. XI-3 Medicine Evaluation and Management Services CPT Codes 90000 - 99999 ..................................................... XI-3 A. Introduction .........................................XI-3 B. Therapeutic or Diagnostic Infusions/Injections and ...XI-3 Immunizations ............................................XI-3 C. Psychiatric Services .................................XI-8 D. Biofeedback .........................................XI-10 E. Dialysis ............................................XI-10 F. Gastroenterology ....................................XI-11 G. Ophthalmology .......................................XI-12 H.
    [Show full text]
  • Icd-9-Cm (2010)
    ICD-9-CM (2010) PROCEDURE CODE LONG DESCRIPTION SHORT DESCRIPTION 0001 Therapeutic ultrasound of vessels of head and neck Ther ult head & neck ves 0002 Therapeutic ultrasound of heart Ther ultrasound of heart 0003 Therapeutic ultrasound of peripheral vascular vessels Ther ult peripheral ves 0009 Other therapeutic ultrasound Other therapeutic ultsnd 0010 Implantation of chemotherapeutic agent Implant chemothera agent 0011 Infusion of drotrecogin alfa (activated) Infus drotrecogin alfa 0012 Administration of inhaled nitric oxide Adm inhal nitric oxide 0013 Injection or infusion of nesiritide Inject/infus nesiritide 0014 Injection or infusion of oxazolidinone class of antibiotics Injection oxazolidinone 0015 High-dose infusion interleukin-2 [IL-2] High-dose infusion IL-2 0016 Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Pressurized treat graft 0017 Infusion of vasopressor agent Infusion of vasopressor 0018 Infusion of immunosuppressive antibody therapy Infus immunosup antibody 0019 Disruption of blood brain barrier via infusion [BBBD] BBBD via infusion 0021 Intravascular imaging of extracranial cerebral vessels IVUS extracran cereb ves 0022 Intravascular imaging of intrathoracic vessels IVUS intrathoracic ves 0023 Intravascular imaging of peripheral vessels IVUS peripheral vessels 0024 Intravascular imaging of coronary vessels IVUS coronary vessels 0025 Intravascular imaging of renal vessels IVUS renal vessels 0028 Intravascular imaging, other specified vessel(s) Intravascul imaging NEC 0029 Intravascular
    [Show full text]
  • Exercise / Pharmacologic / Stress Echo)
    CARDIAC STRESS TEST (EXERCISE / PHARMACOLOGIC / STRESS ECHO) A diagnostic procedure used to measure the heart’s ability to respond to external stress in a controlled clinical environment. At Chinatown Cardiology, P.C., heart stimulation is either provided by exercising on a treadmill or injection of intravenous vasodilators such as adenosine or dobutamine. The latter is usually used when you have medical problems that prevent you from being able to complete the necessary exercise; this is called a pharmacologic stress test. Stress tests are useful in comparing the coronary circulation of a patient while at rest with the patient’s circulation during maximum exercise capacity. Findings will show any abnormal blood flow to the heart’s muscle tissue and provide information about the patient’s physical condition or symptoms. Oftentimes, stress tests can help diagnose coronary heart disease (CHD), a condition in which plaque builds up in the coronary artery. These arteries supply oxygen­rich blood to your heart. Plaque buildup causes narrowed arteries (incomplete perfusion) and blood clot formation (arterial blockage). Blocked arteries may cause chest pain or angina. Stress echocardiography or exercise echocardiogram: This non­invasive test consists of a stress test accompanied by an echocardiogram. The echocardiogram is performed both before (baseline) and after (peak heart rate) the exercise. Structural differences and wall motion are compared. Ischemia of one or more coronary arteries could cause wall motion abnormalities, indicating coronary artery disease. Nuclear stress test: Commonly known as “myocardial perfusion imaging.” This procedure utilizes the distribution of an intravenous dose of radiotracer (Tc­99m Sestamibi or Thallous Chlordie 201) to capture images of the blood flow using a special camera.
    [Show full text]
  • A Long-Term Outcomes Study to Assess Statin Residual Risk Reduction with Epanova in High Cardiovascular Risk Patients with Hypertriglyceridemia (STRENGTH)
    Statistical Analysis Plan Study Code D5881C00004 Edition Number Version 5.0 Date 22 April 2020 A Long-Term Outcomes Study to Assess STatin Residual Risk Reduction with EpaNova in HiGh Cardiovascular Risk PatienTs with Hypertriglyceridemia (STRENGTH) 1 Statistical Analysis Plan Study Code D5881C00004 Edition Number Version 5.0 Date 22 April 2020 A Long-Term Outcomes Study to Assess STatin Residual Risk Reduction with EpaNova in HiGh Cardiovascular Risk PatienTs with Hypertriglyceridemia (STRENGTH) Study Statistician Redacted Date Redacte Redact , IQVIA Redacted 20124 Milano Italy 2 Statistical Analysis Plan Study Code D5881C00004 Edition Number Version 5.0 Date 22 April 2020 A Long-Term Outcomes Study to Assess STatin Residual Risk Reduction with EpaNova in HiGh Cardiovascular Risk PatienTs with Hypertriglyceridemia (STRENGTH) Global Product Statistician Redacted Date Senior Statistician Biometrics, Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D AstraZeneca 3 Redacted Statistical Analysis Plan Study Code D5881C00004 Edition Number Version 5.0 Date 22 April 2020 TABLE OF CONTENTS PAGE TITLE PAGE ............................................................................................................................ 1 SIGNATURE OF STUDY STATISTICIAN ........................................................................... 2 SIGNATURE OF GLOBAL PRODUCT STATISTICIAN .................................................... 3 TABLE OF CONTENTS ........................................................................................................
    [Show full text]
  • Stress Test Brochure
    Preparing for a Stress Electrocardiogram Care Management Services When You Come to Take the Test Please check in at the Outpatient Registration desk at Greene County Medical Center in Jefferson on: Day: _______________________ Date: _______________________ Time: _______________________ Do you have other questions? You may direct any other questions or Hours: concerns you may have regarding your Monday - Friday upcoming cardiac stress test to the staff: 8 a.m. - 4:30 p.m. Cardiac Management 515-386-0469 (515) 386-0469 FAX: (515) 386-2017 Greene County Medical Center 1000 West Lincolnway Jefferson, IA 50129 gcmchealth.com PS-GCMC-016 11-2014 What is a stress What happens during the test? Preparing for the Test electrocardiogram (ECG)? The exercise ECG test will be performed in If you take a beta blocker or any other An exercise ECG test allows doctors to the Cardiac Management department of the medication listed here, DO NOT take them the learn how well the heart functions when medical center. A trained technician will place night before or the morning of the test. It is a it is made to work harder. This test can several electrodes on your chest to allow good idea to check with your doctor first if you help detect heart problems that may recording of the ECG during exercise. The are on a heart medication not listed here. He not be apparent at rest. The exercise electrodes are connected by wires to an ECG or she may want you to hold that medication ECG test is done while you walk on machine.
    [Show full text]
  • Coronary Disease in Emergency Department Chest Pain Patients with Recent Negative Stress Testing
    Original research Coronary Disease in Emergency Department Chest Pain Patients with Recent Negative Stress Testing Jonathan Walker, DO York Hospital, Department of Emergency Medicine, York, PA Michael Galuska, MD David Vega, MD Supervising Section Editor: Shahram Lotfipour, MD, MPH Submission history: Submitted July 10, 2009; Revision Received February 12, 2010; Accepted April 7, 2010 Reprints available through open access at http://escholarship.org/uc/uciem_westjem Background: Cardiac stress tests for diagnosis of coronary artery disease (CAD) are incompletely sensitive and specific. Objective: We examined the frequency of significant CAD in patients presenting to the emergency department (ED) with chest pain who have had a recent negative or inconclusive (<85% of predicted maximum heart rate) cardiac stress test. Methods: This was a retrospective chart review of patients identified from ED and cardiology registries at the study hospital. We included patients presenting to the ED with a chief complaint of chest pain, with a negative cardiac stress test in the past three years as the last cardiac test, and hospital admission. One-hundred sixty-four patients met the inclusion criteria. Their admission was reviewed for diagnosis of CAD by positive serum troponin, percutaneous coronary intervention, or positive stress test while an inpatient. Results: Of 164 patients, 122 (74.4%, 95% CI 67.7, 81.1) had a negative stress test prior to the index admission, while 42 (25.6%, 95% CI 18.9, 32.3) had otherwise normal but inconclusive stress tests. Thirty-four (20.7%, 95% CI 14.4,27.0) of the included patients were determined to have CAD. Twenty-five of the 122 patients (20.5%, 95% CI 13.3, 27.7) had negative pre-admission stress tests and nine of 42 patients (21.4%, 95% CI 9.0, 33.8) had inclusive stress tests of CAD.
    [Show full text]
  • Cardiac Stress Test 8
    Cardiac Stress Test 8. You will then return to the camera room to have a second 20 minute picture performed. You will be For the success of the scan and for your safety, tell Date: ______________________________________ You have been scheduled for a Cardiac Stress Test, positioned under the same Gamma Camera and a the nurse or technologist if you which involves the use of a small amount of second set of pictures of your heart will be taken. Are pregnant or breastfeeding (or if there is radioactive material. The level of radioactivity used 9. This entire procedure takes between 4 and 5 hours. any chance of pregnancy). Time: is extremely low and has no side effects. In some cases a separate set of images 24 hours Have had a Cardiac Stress Test before (or ______________________________________ later may be necessary. other tests pertaining to your symptoms). You will be positioned next to a special detector 10. Your referring physician will receive a written Have had a Cardiac Catheterization, called a Gamma Camera. The camera does not report from the Cardiac Stress Test 48 hours after Angioplasty or Bypass Surgery. produce any radiation. It will be placed close to your your test is complete. Are taking any medications. heart. Have had a recent Barium Study or x-rays Patient Preparation: using contrast. Patient Information: Are unable to hold your left arm above you Place: Please follow the following preparation prior to your head. Goshen Hospital 1. Please report to Goshen Hospital 15 minutes prior Cardiac Stress Test: 200 High Park Ave. to your scheduled test time.
    [Show full text]
  • IHE Cardiology Technical Framework Supplement Stress Testing Workflow
    Integrating the Healthcare Enterprise 5 IHE Cardiology Technical Framework Supplement 10 Stress Testing Workflow (STRESS) 15 Trial Implementation 20 Date: August 29, 2013 Author: IHE Cardiology Technical Committee Email: [email protected] 25 Copyright © 2013: IHE International, Inc. IHE Cardiology Technical Framework Supplement – Stress Testing Workflow (STRESS) ______________________________________________________________________________ Foreword This is a supplement to the IHE Cardiology Technical Framework 5.0. Each supplement undergoes a process of public comment and trial implementation before being incorporated into the volumes of the Technical Frameworks. 30 This supplement is submitted for trial implementation as of August 29, 2013 and may be available for testing at subsequent IHE Connectathons. The supplement may be amended based on the results of testing. Following successful testing it will be incorporated into the Cardiology Technical Framework. Comments are invited and may be submitted at http://www.ihe.net/Cardiology_Public_Comments. 35 This supplement describes changes to the existing technical framework documents and where indicated amends text by addition (bold underline) or removal (bold strikethrough), as well as addition of large new sections introduced by editor’s instructions to “add new text” or similar, which for readability are not bolded or underlined. “Boxed” instructions like the sample below indicate to the Volume Editor how to integrate the 40 relevant section(s) into the relevant Technical Framework volume: Replace section X.X by the following: General information about IHE can be found at: www.ihe.net. 45 Information about the IHE Cardiology domain can be found at: http://www.ihe.net/IHE_Domains. Information about the organization of IHE Technical Frameworks and Supplements and the process used to create them can be found at: http://www.ihe.net/IHE_Process and http://www.ihe.net/Profiles.
    [Show full text]