Appropriate Use in Nuclear Cardiology and Multimodality Imaging

Wael A. Jaber

QUESTIONS

1. Which of the following abnormality on the electrocardiogram (ECG) makes the ECG uninterpretable for the purpose of exercise stress testing?

A. Deep T-wave inversions in anterior leads

B. Right bundle-branch block with left axis deviation

C. Preexcitation with Wolf-Parkinson-White syndrome (WPW)

D. Wide right bundle-branch block

View Answer

1. ANSWER: C. Only WPW with preexcitation is considered an abnormality that renders the exercise ECG uninterpretable. Other abnormalities that make the ECG uninterpretable are ventricular pacing, left bundle-branch block, digoxin use, and baseline ST segment changes >0.10 mV.

REFERENCE:

Patel MR, Bailey SR, Bonow RO, et al. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012;59(22):1995-2027. doi:10.1016/j.jacc.2012.03.003.

2. In calculating the pretest probability for coronary artery disease (CAD) prior to ordering diagnostic testing, which of the following statements is true?

A. Low pretest probability is defined as <10%.

B. High pretest probability is defined as >75%.

C. Angina type is not part of the calculation.

D. Age > 50 results in an intermediate or high probability.

View Answer

2. ANSWER: A. Based on multiple validated risk models, guidelines recommend putting patients into three pretest risk for CAD categories. These models define risk as:

High: >90% pretest probability.

Intermediate: between 10% and 90% pretest probability.

Low: between 5% and 10% pretest probability.

Very low: <5% pretest probability.

Age > 60 puts all patients, males and females, in the intermediate/high pretest probability category.

Angina characteristics are one of the elements used to calculate risk.

REFERENCES:

Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350-1358.

Morise AP, Haddad WJ, Beckner D. Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease. Am J Med. 1997;102:350-356.

Pryor DB, Shaw L, McCants CB, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med. 1993;118:81-90.

3. The global coronary artery disease (CAD) risk score is most often used to define risk in which of the following?

A. Patient presenting with acute ST elevation myocardial infarction

B. Patient presenting with unstable angina

C. Asymptomatic patient—10-year risk for myocardial infarction or CAD death

D. Asymptomatic patient—1-year risk for myocardial infarction or CAD death

View Answer

3. ANSWER: C. The global CAD risk is applied to asymptomatic individuals to identify the risk of myocardial infarction or CAD death over 10 years.

Low global CAD risk is defined by an age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%.

Intermediate risk is defined as a 10-year CAD risk from 10% to 20%.

High risk is defined as a 10-year CAD risk of >20%. CAD equivalents such as diabetes mellitus and peripheral arterial disease can also define a high-risk group.

REFERENCES:

Diamond GA. A clinically relevant classification of chest discomfort. J Am Coll Cardiol. 1983;1:574-575.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.

4. Which of the following active cardiac conditions requires diagnostic evaluation and treatment prior to nonemergent noncardiac surgery?

A. Stable angina

B. History of heart failure in past 5 years

C. Severe aortic or mitral regurgitation

D. High-grade atrioventricular block on ECG

View Answer

4. ANSWER: D. Active cardiac conditions are defined as unstable angina, decompensated heart failure, advanced AV block, symptomatic bradycardia, symptomatic ventricular arrhythmias, supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 beats/min at rest), newly recognized ventricular tachycardia, severe aortic stenosis (mean pressure gradient >40 mm Hg), aortic valve area <1 cm² or symptomatic, or symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF).

Stable angina, heart failure or regurgitating valve lesions are not considered active cardiac issues that should be addressed prior to a noncardiac surgery.

REFERENCES:

Bikkina M, Larson MG, Levy D. Prognostic implications of asymptomatic ventricular arrhythmias: the Framingham Heart Study. Ann Intern Med. 1992;117:990-996.

Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54:e13-e118.

Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30:2631-2671.

Zipes DP, Jalife J, eds. Cardiac Electrophysiology: From Cell To Bedside. 2nd ed. Philadelphia, PA: W. B. Saunders Company, 1995.

5. In assessing symptomatic patients with low pretest probability for CAD, the following imaging modality is considered rarely appropriate.

A. Stress echocardiography

B. CT calcium scoring

C. Stress myocardial perfusion imaging

D. CT coronary angiography

View Answer

5. ANSWER: B. Adding an imaging modality to standard treadmill testing is considered appropriate even in symptomatic patient with low pretest likelihood of CAD. However, this is only appropriate when the ECG is uninter-pretable. Calcium scoring in this population is considered rarely appropriate.

Refer to pages 16 and 17 for relevant definitions, in particular Table A and text for age, sex, symptom presentation, and risk factors relevant to each pre-test probability category

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
1.	Low pre-test probability of CAD ECG interpretable AND able to exercise	A	R	M	R	R	R	R
2.	Low pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	M	R	M	R
3.	Intermediate pre-test probability of CAD ECG interpretable AND able to exercise	A	A	A	M	R	M	R
4.	Intermediate pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	A	R	A	M
5.	High pre-test probability of CAD ECG interpretable AND able to exercise	M	A	A	A	R	M	A
6.	High pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	A	R	M	A
Copyright © The American College of Cardiology. All rights reserved.

REFERENCE:

Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.009.

6. In symptomatic patients presenting for evaluation of possible coronary artery disease, invasive coronary angiography is deemed appropriate care in patients with:

A. High pretest likelihood of disease.

B. Intermediate pretest likelihood of disease and uninterpretable ECG.

C. Intermediate pretest likelihood of disease and are unable to exercise.

D. Intermediate pretest likelihood of disease and high calcium score.

View Answer

6. ANSWER: A. The current Multimodality Imaging Appropriate Use Criteria consider invasive coronary angiography appropriate only for symptomatic patients with high pretest likelihood of disease. Patients with intermediate risk consider a noninvasive imaging modality appropriate before proceeding with invasive coronary angiography. CT calcium scoring is deemed rarely appropriate in symptomatic patients.

Refer to pages 16 and 17 for relevant definitions, in particular Table A and text for age, sex. symptom presentation, and risk factors relevant to each pre-test probability category

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
1.	Low pre-test probability of CAD ECG interpretable AND able to exercise	A	R	M	R	R	R	R
2.	Low pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	M	R	M	R
3.	Intermediate pre-test probability of CAD ECG interpretable AND able to exercise	A	A	A	M	R	M	R
4.	Intermediate pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	A	R	A	M
5.	High pre-test probability of CAD ECG interpretable AND able to exercise	M	A	A	A	R	M	A
6.	High pre-test probability of CAD ECG uninterpretable OR unable to exercise		A	A	A	R	M	A
Copyright © The American College of Cardiology. All rights reserved.

REFERENCE:

7. In a 62-year-old asymptomatic male with low global risk for CAD, which of the following maybe appropriate care?

A. CT calcium scoring.

B. Stress ECG.

C. Stress RNI or echocardiography.

D. Testing is not appropriate.

View Answer

7. ANSWER: D. Testing is not considered appropriate in asymptomatic patients with low risk. Stress ECG and calcium scoring may be appropriate care in the intermediate-risk group. In these patients, addressing the modifiable risk factors should be the target of interventions.

Asymptomatic (Without Symptoms or Ischemic Equivalent) Refer to pages 17 and 18 for relevant definitions

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
7.	Low global CHD risk Regardless of ECG interpretability and ability to exercise	R	R	R	R	R	R	R
8.	Intermediate global CHD risk ECG interpretable and able to exercise	M	R	R	R	M	R	R
9.	Intermediate global CHD risk ECG interpretable OR unable to exercise		M	M	R	M	R	R
10.	High global CAD risk ECG interpretable and able to exercise	A	M	M	M	M	M	M
11.	High global CAD risk ECG uninterpretable OR unable to exercise		M	M	M	M	M	M

REFERENCE:

8. A 65-year-old female, smoker with a history of hypertension presents for evaluation prior to gallbladder surgery. She denies any cardiac symptoms, and she reports that she walks few miles a day as a mail carrier. Her ECG shows normal sinus rhythm with a right bundle-branch block. Prior to proceeding with gallbladder surgery, you recommend which of the following?

A. Exercise stress ECG since she is able to walk on treadmill

B. Pharmacologic stress testing (myocardial perfusion imaging or echocardiography) given baseline ECG abnormalities

C. Treadmill stress test with myocardial perfusion imaging or echocardiography since ECG is till interpretable

D. No testing

View Answer

8. ANSWER: D. Diagnostic testing is not indicated in this patient since she has no active unstable cardiac condition such as unstable angina decompensated heart failure, electric instability, or severe stenotic valve lesions. Furthermore, she has no high-risk clinical features such as history of CAD, prior heart failure, cerebrovascular disease, diabetes, or peripheral vascular disease.

9. A 42-year-old male presents with dyspnea on exertion, LBBB, and newly diagnosed left ventricular systolic dysfunction with an EF of 32%. What is the most appropriate way to work up this patient?

A. No testing

B. Exercise ECG

C. Calcium scoring

D. Invasive coronary angiography

View Answer

9. ANSWER: A. In patients with newly diagnosed left ventricular systolic dysfunction, the current appropriate use criteria consider noninvasive imaging, CT coronary angiography, or invasive coronary angiography appropriate care. Given the documented left ventricular dysfunction, determination of the cause is essential. With an LBBB, the exercise ECG is rarely appropriate care, and a calcium score alone does not provide useful diagnostic or management information.

Refer to pages 18 and 19 for relevant definitions

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
Newly Diagnosed Heart Failure (Resting LV Function Previously Assessed but No Prior CAD Evaluation)
12.	Newly diagnosed systolic heart failure	M	A	A	A	R	A	A
13.	Newly diagnosed diastolic heart failure	M	A	A	A	R	M	M
Evaluation of Arrhythmias Without Ischemic Equivalent (No Prior Cardiac Evaluation)
14.	Sustained VT	A	A	A	A	R	M	A
15.	Ventricular Fibrillation	M	A	A	A	R	M	A
16.	Exercise induced VT or nonsustained VT	A	A	A	A	R	M	A
17.	Frequent PVCs	A	A	A	M	R	M	M
18.	Infrequent PVCs	M	M	M	R	R	R	R
19.	New-onset atrial fibrillation	M	M	M	R	R	R	R
20.	Prior to initiation of anti-arrhythmia therapy in high global CAD risk patients	A	A	A	A	R	M	R
Syncope Without Ischemic Equivalent
21.	Low global CAD Risk	M	M	M	R	R	R	R
22.	Intermediate or High Global CAD Risk	A	A	A	M	R	M	R

REFERENCE:

10. A 73-year-old obese female with hypertension, diabetes, and a sedentary life style is being evaluated for femoral-iliac bypass surgery. Her baseline ECG was normal, and she was referred for treadmill ECG stress test. She exercised for 3.5 METs before reaching 100% of the maximal age-predicted heart rate. Your advice for this patient is:

A. Proceed with surgery since this is a low-risk procedure.

B. Perform CT coronary angiography.

C. Perform pharmacologic echocardiography or myocardial perfusion imaging.

D. Perform invasive coronary angiography.

View Answer

10. ANSWER: C. The AUC for Multimodality Imaging prior to noncardiac surgery utilizes two parameters to make decisions on need for diagnostic testing: risk of surgery and patient functional class. In high-risk procedures such as vascular surgery and liver or kidney transplant, it is considered appropriate care to proceed with a stress test combined with an imaging modality. In this patient who was unable to achieve at least 4 METs, pharmacologic stress is preferred. Angiographic definition of coronary anatomy by CT or invasive coronary angiography is rarely appropriate.

Poor or Unknown Functional Capacity (<4 METs)
Refer to pages 12 and 13 for relevant definitions

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
73.	Low-risk surgery ≥1 clinical risk factor	R	R	R	R	R	R	R
74.	Intermediate-risk surgery ≥1 clinical risk factor	M	M	M	M	R	R	R
75.	Vascular surgery ≥1 clinical risk factor	M	A	A	M	R	R	R
76.	Kidney transplant	M	A	A	M	R	R	M
77.	Liver transplant	M	A	A	M	R	R	M

REFERENCE:

11. A 63-year-old female patient underwent coronary artery bypass and graft surgery (CABG×4) 7 weeks ago. She presents for scheduled evaluation and reports no symptoms. She wants to join a cardiac rehabilitation program. Which of the following is appropriate care?

A. Stress myocardial perfusion imaging to identify residual ischemia

B. CT coronary angiography to insure graft patency

C. Stress ECG to determine functional capacity

D. No testing indicated

View Answer

11. ANSWER: C. The AUC for Multimodality Imaging consider only stress ECG appropriate care. In the absence of symptoms, noninvasive imaging and invasive imaging are rarely appropriate care. The stress ECG will provide useful information on heart rate goals and blood pressure control on medical management and set targets for rehabilitation.

Prior to the Initiation of Cardiac Rehabilitation (As a Stand-Alone Indication): Able to Exercise

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Diagnostic Coronary Angiography
78.	No prior revascularization	A	R	R	R	R	R	R

REFERENCE:

12. An 83-year-old male presents for evaluation prior to open cholecystectomy. He lives on the third floor of an apartment building and uses the stairs at least twice a day without symptoms. He has a history of hypertension and hypercholesterolemia. His baseline ECG shows normal sinus rhythm with first-degree AV block. His physical exam is unremarkable. What do you recommend prior to surgery?

A. No testing

B. Stress ECG

C. Stress RNI

D. Laparoscopic cholecystectomy

View Answer

12. ANSWER: A. The patient has a reasonable exercise capacity, >4 METs, and no clinical high-risk markers such as diabetes, heart failure, prior CAD, or peripheral vascular disease. A stress ECG or RNI is rarely appropriate care. In the absence of risk, there is no need to perform laparoscopic surgery if that is considered optimal care by the surgeons.

Moderate-to-Good Functional Capacity (≥4 METs) OR No Clinical Risk Factors
Refer to pages 12 and 13 for relevant definitions

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
71.	Any surgery	R	R	R	R	R	R	R

REFERENCE:

13. A 58-year-old female is scheduled for a hysterectomy for uterine bleeding and significant anemia. She had CABG 9 months earlier, had completed cardiac rehabilitation, and is symptom free. Her ECG shows normal sinus rhythm with T-wave changes. What is the best recommendation?

A. Perform a stress ECG.

B. Perform CT angiography.

C. Perform stress MPI.

D. Perform surgery.

View Answer

13. ANSWER: D. This is a patient who is asymptomatic <1 year post revascularization. The AUC for Multimodality Imaging recommend no further testing prior to any type of surgery.

Asymptomatic AND <1 Year Post Any of the Following: Normal CT or Invasive Angiogram, Normal Stress Test for CAD, or Revascularization
Refer to pages 12 and 13 for relevant definitions

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
72.	Any surgery	R	R	R	R	R	R	R

REFERENCE:

14. A 67-year-old female presents with new onset of dyspnea on mild exertion 3 years after PCI to the LAD and LCX. She suspects her dyspnea is related to weight gain after recent bilateral knee surgery. Her ECG shows normal sinus rhythm and is unchanged from prior ECGs showing 0.5 mm ST changes in leads 2, 3, and AVF. What is the most appropriate next step?

A. Exercise ECG

B. Pharmacologic stress RNI

C. Exercise stress echo

D. Weight loss program

View Answer

14. ANSWER: B. Symptomatic patients with angina or an anginal equivalent any time post PCI need diagnostic testing with a very sensitive test. Thus, imaging studies are appropriate care. Even if such patients are asymptomatic >2 years post PCI, stress testing with imaging may be appropriate care as PCI seldom achieves complete revascularization and progression of stenosis is likely. In this symptomatic patient, recent bilateral knee surgery limits exercise capacity, and the stress ECG, which already has a lower sensitivity, is not possible and the exercise stress echo is limited. Although a weight loss program may be helpful, it is not sufficient in the presence of worsening symptoms in a patient with known CAD.

Pharmacologic stress RNI has high sensitivity and with limited exercise capacity is the most appropriate care for this patient.

Symptomatic (Ischemic Equivalent)

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
64.	Evaluation of ischemic equivalent	M	A	A	A	R	M	A

REFERENCE:

15. A 71-year-old male presents for follow-up 8 months post PCI of the RCA for an acute ST elevation myocardial infarction. He had >50% lesions in the first diagonal and a large second obtuse. He is asymptomatic. What is the most appropriate care for this patient?

A. Stress RNI to assess residual myocardial ischemia

B. CT coronary angiography

C. Invasive coronary angiography and PCI

D. Consideration surgical revascularization

View Answer

15. ANSWER: A. This patient had incomplete revascularization by PCI at the time of an acute presentation. A stress RNI will allow assessment of the presence and amount of ischemia in the diagonal and obtuse marginal arteries and determine the need for revascularization or continued maximal medical management. CT coronary angiography in an elderly patient may be limited by calcification and will require invasive coronary angiography for PCI. Invasive coronary angiography and PCI may not be necessary if the lesions are not flow liming at the time of angiography.

Since there were no critical lesions in the left anterior descending artery or the left main artery, there is no justification for surgical revascularization without doing another test.

Asymptomatic (Without Ischemic Equivalent)

Indication Text		Exercise ECG	Stress RNI	Stress Echo	Stress CMR	Calcium Scoring	CCTA	Invasive Coronary Angiography
65.	Incomplete revascularization Additional revascularization feasible	M	A	A	M	R	R	R
66.	Prior left main coronary stent	M	M	M	M	R	M	M
67.	<5 years after CABG	R	R	R	R	R	R	R
68.	≥5 years after CABG	M	M	M	M	R	R	R
69.	<2 years after PCI	R	R	R	R	R	R	R
70.	≥2 years after PCI	M	M	M	M	R	R	R

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Nov 8, 2018 | Posted by drzezo in CARDIOLOGY | Comments Off

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