Abstract 126: Cardiac Stress Testing: Optimizing Outcomes Through Dual Physician-Patient Education

Background: Even though cardiovascular (CV) tests, which are used to assess coronary arterial disease (CAD) are included in medical guidelines, cardiologists have limited ability to adequately perform appropriate testing modalities. In parallel, many patients have concerns or anxiety related to CV testing, and are not proactively educated on how to prepare for their procedure. Goals: To determine if an online parallel physician-patient education interventions could improve performance of cardiologists related to CV stress testing, and patient knowledge about the procedure. Methods: An online CME activity was developed as a 25-minute roundtable discussion with 3 leading experts on criteria for appropriate use of stress testing and preparing physicians to communicate the risks and benefits of testing modalities to their patients. The activity included a transcript of the discussion and a downloadable slide deck to reinforce key recommendations. Participant responses to questions were collected after the education (post-assessment) and compared with each user’s baseline data (pre-assessment) using a 2-tailed paired T-test to provide P values for assessing the impact of education. The CME activity also included a link to a patient/caregiver education module, developed in parallel to educate patients and their caregivers about cardiac stress testing. Patient/caregiver responses post-education compared to pre-education were also assessed to measure improvement in knowledge. Results: A total of 312 of cardiologists who participated in the CME activity and answered all pre- and post-assessment questions were included in the analysis. In addition, 3458 patients preparing for a stress test, 640 family members, 116 caregivers, and 3299 other participants interested in the topic of CV testing who completed the patient/caregiver education module and the pre- and post-education questions were included in the assessment. Post-education, significant improvements were observed (Table). Conclusion: This study demonstrated that both knowledge/competence of cardiologists on evidence-based practices as well as the understanding of patient/caregivers on CV testing can be improved using a dual approach to education.

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Comparison of Preoperative Assessment of Patient’s Metabolic Equivalents (METs) Estimated from History versus Measured by Exercise Cardiac Stress Testing

Anesthesiology Research and Practice ◽

10.1155/2018/5912726 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Adam S. Weinstein ◽

Martin I. Sigurdsson ◽

Angela M. Bader

Keyword(s):

Cardiac Failure ◽

Stress Testing ◽

Stress Test ◽

Preoperative Evaluation ◽

Preoperative Assessment ◽

Exercise Stress ◽

Cardiac Stress ◽

Metabolic Equivalents ◽

Cardiac Stress Testing ◽

Cardiac Stress Test

Background. Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient’s functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient’s physical activity, with the goal of providing an estimate of the metabolic equivalents (METs) that the patient can perform without signs of myocardial ischemia or cardiac failure. We sought to compare estimates of patients’ METs between preoperative assessment by medical history with quantified assessment of METs via the exercise cardiac stress test. Methods. A single-center retrospective chart review from 12/1/2005 to 5/31/2015 was performed on 492 patients who had preoperative evaluations with a cardiac stress test ordered by a perioperative anesthesiologist. Of those, a total of 170 charts were identified as having a preoperative evaluation note and an exercise cardiac stress test. The METs of the patient estimated by history and the METs quantified by the exercise cardiac stress test were compared using a Bland–Altman plot and Cohen’s kappa. Results. Exercise cardiac stress test quantified METs were on average 3.3 METS higher than the METs estimated by the preoperative evaluation history. Only 9% of patients had lower METs quantified by the cardiac stress test than by history. Conclusions. The METs of a patient estimated by preoperative history often underestimates the METs measured by exercise stress testing. This demonstrates that the preoperative assessments of patients’ METs are often conservative which errs on the side of patient safety as it lowers the threshold for deciding to order further cardiac stress testing for screening for ischemia or cardiac failure.

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Blood pressure and risk of cognitive impairment. The role of vascular disease in neurodegeneration.

10.21203/rs.2.18666/v1 ◽

2019 ◽

Author(s):

Mar Carmona-Abellan ◽

Malwina Trzeciak ◽

Miriam Recio-Fernandez ◽

Beatriz Echeveste ◽

Laura Imaz ◽

...

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Cognitive Impairment ◽

Cognitive Decline ◽

Stress Testing ◽

Cardiovascular Response ◽

Stress Test ◽

Peak Exercise ◽

Cardiac Stress ◽

Cardiac Stress Testing

Abstract Background: Both cerebral vascular disorders and cognitive decline increase in incidence with age. The role of cerebral vascular disease and hemodynamic changes in the development of cognitive deficits is controversial. The objective of this study was to assess cardiovascular response during cardiac stress testing in neurologically asymptomatic individuals who developed cognitive impairment several years after the cardiac stress testing.Methods: This is a retrospective cohort study of patients who underwent cardiac stress testing between January 2001 and December 2010. Patients were followed up until May 2015 and we selected those who developed cognitive dysfunction including dementia, mild cognitive impairment and subjective cognitive decline, after the stress test. Heart rate and blood pressure both at rest and at peak exercise and the mean R-R interval at rest were recorded. For each patient who developed cognitive impairment, we selected one matched control who did not show cognitive decline by the end of the follow-up period.Results: From this cohort of 7224 patients, 371 developed cognitive impairment; of these, 186 (124 men) met the inclusion criteria and 186 of the other patients were selected as matched controls. During follow-up, cognitive impairment appeared 6.2 ± 4.7 years after the cardiac stress test. These patients who subsequently developed cognitive impairment had significantly lower at-rest systolic, diastolic and mean blood pressure than controls (p<0.05). Further, compared with controls, their maximum heart rate was significantly higher at peak exercise and both systolic and diastolic blood pressures increased significantly more during exercise. Conclusion: The results from this study suggest that differences in cardiovascular response to stress are present in the preclinical phase of cognitive decline, serving as a potential risk factor for cognitive impairment. These findings challenge the potential use of blood pressure and heart rate variability at rest and during cardiac stress assessment as a risk factor for cognitive impairment.

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The ECG in cardiac stress testing: a valuable, but unappreciated source of clues

American Journal of Critical Care ◽

10.4037/ajcc1998.7.4.320 ◽

1998 ◽

Vol 7 (4) ◽

pp. 320-327

Author(s):

LG Futterman ◽

L Lemberg

Keyword(s):

Emergency Department ◽

Clinical Features ◽

Stress Testing ◽

Stress Test ◽

Exercise Stress Test ◽

Accurate Diagnosis ◽

Exercise Stress ◽

Cardiac Stress ◽

Cardiac Stress Testing ◽

Ecg Abnormalities

The ECG exercise stress test is a very potent aid to the clinical diagnosis of CAD. Thorough knowledge of the ECG abnormalities and clinical features related to the stress test are required for an accurate diagnosis. The ECG exercise stress test is not a substitute for clinical acumen. Proper evaluation of the stress test is a clinical art of the skilled clinician. ECG exercise stress testing can be done efficiently and effectively by trained emergency department physicians. As a result, the diagnosis of CAD can be greatly accelerated.

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Relation of abnormal cardiac stress testing with outcomes in patients undergoing renal transplantation

PLoS ONE ◽

10.1371/journal.pone.0260718 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0260718

Author(s):

Kelsey Anderson ◽

Chirag Bavishi ◽

Dhaval Kolte ◽

Reginald Gohh ◽

James A. Arrighi ◽

...

Keyword(s):

Renal Transplantation ◽

Renal Transplant ◽

Stress Testing ◽

Stress Test ◽

Major Adverse Cardiovascular Events ◽

Cardiac Stress ◽

Cardiac Stress Testing ◽

Artery Disease ◽

Test Result

Cardiovascular risk stratification is often performed in patients considered for renal transplantation. In a single center, we sought to examine the association between abnormal stress testing with imaging and post-renal transplant major adverse cardiovascular events (MACE) using multivariable logistic regression. From January 2006 to May 2016 232 patients underwent renal transplantation and 59 (25%) had an abnormal stress test result. Compared to patients with a normal stress test, patients with an abnormal stress test had a higher prevalence of dyslipidemia, diabetes mellitus, obesity, coronary artery disease (CAD), and heart failure. Among those with an abnormal result, 45 (76%) had mild, 10 (17%) moderate, and 4 (7%) severe ischemia. In our cohort, 9 patients (3.9%) had MACE at 30-days post-transplant, 5 of whom had an abnormal stress test. The long-term MACE rate, at a median of 5 years, was 32%. After adjustment, diabetes (OR 2.37, 95% CI 1.12–5.00, p = 0.02), CAD (OR: 3.05, 95% CI 1.30–7.14, p = 0.01) and atrial fibrillation (OR: 5.86, 95% CI 1.86–18.44, p = 0.002) were independently associated with long-term MACE, but an abnormal stress test was not (OR: 0.83, 95% CI 0.37–1.92, p = 0.68). In conclusion, cardiac stress testing was not an independent predictor of long-term MACE among patients undergoing renal transplant.

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Blood Pressure and Risk of Cognitive Impairment: The Role of Vascular Disease in Neurodegeneration

Brain Sciences ◽

10.3390/brainsci11030385 ◽

2021 ◽

Vol 11 (3) ◽

pp. 385

Author(s):

Mar Carmona-Abellan ◽

Malwina Trzeciak ◽

Miriam Recio Fernández ◽

Beatriz Echeveste ◽

Laura Imaz ◽

...

Keyword(s):

Blood Pressure ◽

Heart Rate ◽

Cognitive Impairment ◽

Cognitive Decline ◽

Stress Testing ◽

Cardiovascular Response ◽

Stress Test ◽

Peak Exercise ◽

Cardiac Stress ◽

Cardiac Stress Testing

(1) Background: Both cerebral vascular disorders and cognitive decline increase in incidence with age. The role of cerebral vascular disease and hemodynamic changes in the development of cognitive deficits is controversial. The objective of this study was to assess the cardiovascular response during cardiac stress testing in neurologically asymptomatic individuals who developed cognitive impairment several years after previous cardiac stress testing. (2) Methods: This was a retrospective cohort study of patients who underwent cardiac stress testing between January 2001 and December 2010. Patients were followed up until May 2015, and we selected those who developed cognitive dysfunction including dementia, mild cognitive impairment, and subjective cognitive decline, after the stress test. Heart rate and blood pressure both at rest and at peak exercise, and the mean R-R interval at rest were recorded. For each patient who developed cognitive impairment, we selected one matched control who did not show cognitive decline by the end of the follow-up period. (3) Results: From the cohort of 7224 patients, 371 developed cognitive impairment; of these, 186 (124 men) met the inclusion criteria, and 186 of the other patients were selected as matched controls. During follow-up, cognitive impairment appeared 6.2 ± 4.7 years after the cardiac stress test. These patients who had subsequently developed cognitive impairment had significantly lower at-rest systolic, diastolic, and mean blood pressure than controls (p < 0.05). Further, compared with controls, their maximum heart rate was significantly higher at peak exercise. (4) Conclusion: The results from this study suggest that differences in cardiovascular response to stress might be present in individuals who develop cognitive decline. These findings challenge the possibility of assessing blood pressure and heart rate variability at rest and during cardiac stress as potential risk factors associated with cognitive impairment.

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Abstract 12972: Reduction of Unnecessary Radiation Exposure for Cardiovascular Patients by Adoption of a Stress-First Protocol for Nuclear-Based Cardiac Stress Testing

Circulation ◽

10.1161/circ.130.suppl_2.12972 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Robert J Russo ◽

Jordan Allem ◽

Heather S Costa ◽

Patricia D Silva

Keyword(s):

Radiation Exposure ◽

Stress Testing ◽

Stress Test ◽

Total Radiation ◽

Stress Tests ◽

Cardiac Stress ◽

Cardiovascular Patients ◽

Cardiac Stress Testing ◽

Nuclear Stress Testing ◽

Unnecessary Radiation

Background: In 2010, the FDA issued the Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging. The purpose of this study was to determine the total radiation exposure for cardiovascular patients and the relative contribution of nuclear-based cardiac stress testing. Method: The electronic medical record was reviewed to identify all patients who underwent cardiac stress testing in 1 institution over a 10-year period. The type and number of all radiation-based diagnostic tests were identified, and a hospital-determined or published radiation dose was used to calculate each patient’s gender-specific total annualized radiation exposure expressed in mSv. Therapeutic radiation-based procedures were excluded. Results: Between 2003 and 2012, a total of 50,737 patients underwent 88,108 stress tests, 501,239 diagnostic radiology exams, and 17,194 diagnostic coronary angiograms, with 177,957 patient years of follow-up. Mean age at first stress test was 60±14 years, 56% of the patients were men, and the total number of stress tests per patient was 1.8±1.4 (range 1-18). When patients undergoing a nuclear-based stress test (PET-Rb/SPECT) at any time were compared to those who never had a nuclear-based stress test, 0.8±0.6 vs 0.7±0.4 total stress tests/year were performed, respectively (p<.001), with a total radiation exposure (including stress tests, all radiology exams, and diagnostic coronary angiography) of 16.2±18.5 vs. 6.0±15.5 mSv/patient-year (p<.001), and an aggregate total radiation exposure from diagnostic angiography of 16 vs. 11%. For patients undergoing a nuclear-based stress test at any time, the total aggregate radiation exposure from nuclear stress testing was 37% (for both men and women). If a stress-first/stress-only protocol was adopted, which would decrease isotope exposure by 75% as a result of administering only a single dose of isotope, using an institutional normal test rate of 57% over the study period, the aggregate radiation exposure from radiation-based testing dropped to 25% for the group. Conclusion: Adoption of a stress-first/stress-only protocol for nuclear-based cardiac stress tests results in a significant reduction in unnecessary radiation exposure for patients undergoing cardiac stress testing.

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A Precision Medicine Approach to Stress Testing Using Metabolomics and Microribonucleic Acids

10.1101/2020.02.06.936757 ◽

2020 ◽

Author(s):

Alexander T. Limkakeng ◽

Laura-Leigh Rowlette ◽

Ace Hatch ◽

Andrew B. Nixon ◽

Olga Ilkayeva ◽

...

Keyword(s):

Myocardial Ischemia ◽

Precision Medicine ◽

Error Rate ◽

Stress Testing ◽

Stress Test ◽

Small Sample ◽

Integrated Analysis ◽

Cardiac Stress ◽

Cardiac Stress Testing ◽

Delta Model

ABSTRACTBackgroundAcute coronary syndrome (ACS) is a growing global health problem, and precision medicine techniques hold promise for the development of diagnostic indicators of ACS. In this pilot, we sought to assess the utility of an integrated analysis of metabolomic and microRNA data in peripheral blood to distinguish patients with abnormal cardiac stress testing from matched controls.MethodsWe used prospectively collected samples from emergency department (ED) patients placed in an ED-based observation unit who underwent stress testing for ACS. We isolated microRNA and quantified metabolites from plasma collected before and after stress testing in patients with myocardial ischemia on stress testing versus those with normal stress tests. The combined metabolomic and microRNA data were analyzed jointly for case (ischemia) and 1:1 matched control patients in a supervised, dimension-reducing discriminant analysis. Two integrative models were implemented: a baseline model utilizing data collected prior to stress-testing (T0) and a stress-delta model, which included the difference between post-stress test (T1) and pre-stress test (T0).ResultsSeven case patients with myocardial ischemia on ED cardiac stress testing (6 females, 85% Caucasian, mean Thrombolysis In Myocardial Infarction Score=3, 4 patients ultimately received percutaneous coronary intervention) were 1:1 age and sex-matched to controls. Several metabolites and microRNAs were differentially expressed between cases and controls. Integrative analysis of the baseline levels of metabolites and microRNA expression showed modest performance for distinguishing cases from controls with an overall error rate of 0.143. The stress-delta model showed worse performance for distinguishing cases from controls, with an overall error rate of 0.500.ConclusionsGiven our small sample size, results are hypothesis-generating. However, this pilot study shows a potential method for a precision medicine approach to cardiac stress testing in patients undergoing workup for ACS.

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The early identification of psychosis: can lessons be learnt from cardiac stress testing?

Psychopharmacology ◽

10.1007/s00213-015-4143-3 ◽

2015 ◽

Vol 233 (1) ◽

pp. 19-37 ◽

Cited By ~ 4

Author(s):

Swapnil Gupta ◽

Mohini Ranganathan ◽

Deepak Cyril D’Souza

Keyword(s):

Early Identification ◽

Stress Testing ◽

Cardiac Stress ◽

Cardiac Stress Testing

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Abstract TP165: Cardiac Screening Does not Improve One-year Mortality Among Patients With Cerebrovascular Disease

Stroke ◽

10.1161/str.47.suppl_1.tp165 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Jason J Sico ◽

Fitsum Baye ◽

Laura J Myers ◽

John Concato ◽

Linda S Williams ◽

...

Keyword(s):

High Risk ◽

Cerebrovascular Disease ◽

Stress Testing ◽

Cerebrovascular Event ◽

Mortality Benefit ◽

Cardiac Stress ◽

Cardiac Screening ◽

All Cause Mortality ◽

Cardiac Stress Testing ◽

One Year

Introduction: Guidelines recommend the use of cardiac stress testing to screen for occult coronary heart disease (CHD) among patients with ischemic stroke/TIA who have a ‘high risk’ Framingham Cardiac Risk score (FCRS). It is unclear whether implementation of this guideline confers a mortality benefit among patients with cerebrovascular disease. Hypothesis: We assessed the hypothesis that cardiac stress testing would be associated with lower odds of one-year all-cause mortality. Methods: Administrative data from a sample of 11,306 Veterans admitted to 134 Veterans Health Administration (VHA) facilities with a stroke or TIA in fiscal year 2011 were analyzed. Patients were excluded (n=6915) on the basis of: prior CHD history, receipt of cardiac stress testing within 18-months prior to cerebrovascular event, death within 90 days of discharge, being discharged to hospice, transferred to a non-VHA acute care facility, or missing/unknown race. A FCRS was calculated for each patient; a score of ≥ 20% was classified as ‘high risk’ of having CHD. Administrative data were used to identify whether cardiac stress testing was performed within 90-days after the cerebrovascular event. Logistic regression was used to assess whether cardiac stress testing was associated with one-year all-cause mortality. Results: Of the 4391 eligible patients, 62.8% (2759) had FCRS ≥ 20%, with 4.5% (n=123) of these patients receiving cardiac stress testing within 90 days of discharge. After adjusting for sociodemographic characteristics and medical comorbidities, FCRS ≥ 20% was associated with one-year mortality (aOR=2.18; CI 95 :1.59, 3.00), however, receipt of stress testing was not (aOR=0.59; CI 95 :0.26, 1.30). Conclusion: Cardiac screening did not confer a one-year all-cause mortality benefit among patients with cerebrovascular disease. Additional work is needed to assess outcomes among patients with cerebrovascular disease who are at ‘high risk’ for CHD.

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