Stress testing and noninvasive coronary imaging: What’s the best test for my patient?

Matta, Milad; Harb, Serge C.; Cremer, Paul; Hachamovitch, Rory; Ayoub, Chadi

doi:10.3949/ccjm.88a.20068

Cited by 4 publications

(4 citation statements)

References 53 publications

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“…Moreover, the high negative predictive value (NPV) and positive predictive value (PPV) of CCTA are well-documented in the literature. The high diagnostic accuracy of CCTA allows for the rapid exclusion of significant CAD and reduces the need for more invasive testing [ 13 ]. The ability of CCTA to provide detailed anatomical information about coronary arteries is a significant advantage over traditional stress tests, which often require multiple steps and prolonged observation.…”

Section: Discussionmentioning

confidence: 99%

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit

Williams,

Van Ligten,

Tomlinson

et al. 2024

Cureus

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This study was designed to analyze the departmental changes in transitioning the Emergency Department (ED)-run Observation Medicine Unit's routine noninvasive cardiac evaluation from the traditional standard-of-care procedures to coronary computed tomography angiography (CCTA). While the routine use of CCTA for the evaluation of chest pain has been deemed feasible and safe, provider confidence appears apprehensive, and ordering patterns appear reluctant to change. We conducted a retrospective analysis of data from two risk-matched cohorts of ED patients who presented with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic electrocardiogram (ECG) changes or positive troponin. Endpoints included length of stay, major adverse cardiovascular event (MACE) rates at 28 days, recidivism rate, and downstream findings on coronary catheterization. The adoption of CCTA led to a significant reduction in the length of stay for patients in the ED-run Observation Medicine Unit. Provider and nursing education initiatives were crucial in overcoming initial resistance and improving the implementation of CCTA. Post-education, there was a marked increase in the volume of CCTA performed and a decrease in the length of stay, enhancing overall departmental throughput. The results suggest that CCTA offers a reliable and efficient diagnostic alternative to traditional noninvasive tests, with high diagnostic accuracy contributing to faster decision-making and reduced need for invasive procedures. Continuous education for providers and nursing staff was essential to ensure adherence to the new protocol and improve clinical outcomes. Transitioning to CCTA for routine noninvasive cardiac evaluation in the ED-run Observation Medicine Unit demonstrated significant efficiency and diagnostic accuracy benefits. Successful implementation requires targeted educational efforts to ensure competency and confidence among healthcare providers. The findings support the integration of CCTA into standard clinical practice for the evaluation of chest pain in the emergency setting, with future research needed to validate these results in broader patient populations and assess long-term outcomes.

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Section: Discussionmentioning

confidence: 99%

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit

Williams,

Van Ligten,

Tomlinson

et al. 2024

Cureus

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“…Coronary artery disease (CAD) remains the leading cause of mortality in the United States and across the world [ 1 ]. Noninvasive diagnostic testing (either exercise or pharmacological) is preferred and plays an important role in the diagnosis of cardiovascular disorders [ 2 ]. In addition to providing predictive value [ 2 ], the exercise stress test is inexpensive, widely accessible, and reasonably safe [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

“…Noninvasive diagnostic testing (either exercise or pharmacological) is preferred and plays an important role in the diagnosis of cardiovascular disorders [ 2 ]. In addition to providing predictive value [ 2 ], the exercise stress test is inexpensive, widely accessible, and reasonably safe [ 3 ]. In this case report, we highlight the case of a patient who experienced Takotsubo syndrome/cardiomyopathy (TTS) during an exercise stress echocardiography.…”

Section: Introductionmentioning

confidence: 99%

Treadmill Exercise Stress Test-Induced Takotsubo Cardiomyopathy: A Case Report and Review of Literature

Singh¹,

Singh²

2023

Cureus

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Noninvasive stress testing is routinely indicated and preferable in the diagnosis of coronary artery disease. We present the case of a patient who developed Takotsubo syndrome/cardiomyopathy (TTS) as a result of an exercise stress echocardiography, as well as a literature review of comparable cases. An abnormal stress test necessitated coronary angiography, which revealed nonobstructive coronaries with apical left ventricular ballooning and a decreased ejection fraction (EF), both of which are concerning for TTS. The patient was medically managed with metoprolol and lisinopril, with improvement in the EF on the follow-up echocardiogram.

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“…In patients with known coronary syndromes or a high pre-test probability of CAD, invasive coronary angiography is performed. Electrocardiographic exercise stress testing followed by potential non-invasive imaging [coronary computed tomography angiography (CTA)] is warranted in patients with clinical symptoms and suspected cardiac cause ( 4 ).…”

Section: Introductionmentioning

confidence: 99%

Magnetocardiography at rest predicts cardiac death in patients with acute chest pain

Wessel,

Kim,

Joung

et al. 2023

Front. Cardiovasc. Med.

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IntroductionSudden cardiac arrest is a major cause of morbidity and mortality worldwide and remains a major public health problem for which better non-invasive prediction tools are needed. Primary preventive therapies, such as implantable cardioverter defibrillators, are not personalized and not predictive. Most of these devices do not deliver life-saving therapy during their lifetime. The individual relationship between fatal arrhythmias and cardiac function abnormalities in predicting cardiac death risk has rarely been explored.MethodsWe retrospectively analyzed the measurements at rest for 191 patients with acute chest pain (ACP) magnetocardiographically. Our recently introduced analyses are able to detect inhomogeneities of the depolarization and repolarization. Moreover, electrically silent phenomena—intracellular ionic currents as well as vortex currents—can be measured and quantified. All included ACP patients were recruited in 2009 at Yonsei University Hospital and were followed up until 2022.ResultsDuring half of the follow-up period (6.5 years), 11 patients died. Out of all the included nine clinical, eight magnetocardiographical, and nine newly introduced magnetoionographical parameters we tested in this study, three parameters revealed themselves to be outstanding at predicting death: heart rate-corrected QT (QTc) prolongation, depression of repolarization current IKr + IKs, and serum creatinine (all significant in Cox regression, p < 0.05). They clearly predicted cardiac death over the 6.5 years duration (sensitivity 90.9%, specificity 85.6%, negative predictive accuracy 99.4%). Cardiac death risk was more than ninefold higher in patients with low repolarization reserve and QTc prolongation in comparison with the remaining patients with ACP (p < 0.001). The non-parametric Kaplan–Meier statistics estimated significantly lower survival functions from their lifetime data (p < 0.001).DiscussionTo the best of our knowledge, these are the first data linking magnetocardiographical and magnetoionographical parameters and subsequent significant fatal events in people, suggesting structural and functional components to clinical life-threatening ventricular arrhythmogenesis. The findings support investigation of new prevention strategies and herald those new non-invasive techniques as complementary risk stratification tools.

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Stress testing and noninvasive coronary imaging: What’s the best test for my patient?

Cited by 4 publications

References 53 publications

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit

Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit

Treadmill Exercise Stress Test-Induced Takotsubo Cardiomyopathy: A Case Report and Review of Literature

Magnetocardiography at rest predicts cardiac death in patients with acute chest pain

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