Tailoring Cardiac stress testing. When and how to use Exercise, Vasodilators and Inotropes.

Raffaele GiubbiniChair and Nuclear Medicine UnitUniversity and Spedali Civili

Brescia - Italy

Provocative Stress Tests

AtropineAtropineAtropineAtropineAtropineAtropineAtropineAtropine

PharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacological

The right test for a specific PtThe right test for a specific PtThe right test for a specific PtThe right test for a specific PtThe right test for a specific PtThe right test for a specific PtThe right test for a specific PtThe right test for a specific Pt

49% of vasodilators + 49% of vasodilators + 49% of vasodilators + 49% of vasodilators + 49% of vasodilators + 49% of vasodilators + 49% of vasodilators + 49% of vasodilators + exerciseexerciseexerciseexerciseexerciseexerciseexerciseexercise

58% of vasodilators + 58% of vasodilators + 58% of vasodilators + 58% of vasodilators + 58% of vasodilators + 58% of vasodilators + 58% of vasodilators + 58% of vasodilators + exerciseexerciseexerciseexerciseexerciseexerciseexerciseexercise

SR UnderwoodSR UnderwoodECNC SurveyECNC Survey

20052005200520052005200520052005

20072007200720072007200720072007

Test Temporal Trend

N= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yrN= 1550/1600 pts/yr

Please consider:Please consider:Please consider:Please consider:Please consider:Please consider:Please consider:Please consider:••Clinical InstabilityClinical InstabilityClinical InstabilityClinical InstabilityClinical InstabilityClinical InstabilityClinical InstabilityClinical Instability

•• CHFCHFCHFCHFCHFCHFCHFCHF•• Concomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditysConcomitant endocarditys or pericarditys

••Recent MI Recent MI Recent MI Recent MI Recent MI Recent MI Recent MI Recent MI (<4 (<4 (<4 (<4 (<4 (<4 (<4 (<4 daysdaysdaysdaysdaysdaysdaysdays))))))))••Left main diseaseLeft main diseaseLeft main diseaseLeft main diseaseLeft main diseaseLeft main diseaseLeft main diseaseLeft main disease••Recent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmiasRecent history of malignant arrhytmias••Severe obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow tracktSevere obstruction of LV outflow trackt••Severe hypertensionSevere hypertensionSevere hypertensionSevere hypertensionSevere hypertensionSevere hypertensionSevere hypertensionSevere hypertension••Aortic DissectionAortic DissectionAortic DissectionAortic DissectionAortic DissectionAortic DissectionAortic DissectionAortic Dissection••Severe systemic diseasesSevere systemic diseasesSevere systemic diseasesSevere systemic diseasesSevere systemic diseasesSevere systemic diseasesSevere systemic diseasesSevere systemic diseases••Aortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosisAortic stenosis or moderate severe mitral stenosis

Choice of a provocative TestChoice of a provocative Test

Consider Rest EKGConsider Rest EKGConsider Rest EKGConsider Rest EKGConsider Rest EKGConsider Rest EKGConsider Rest EKGConsider Rest EKG1)1)1)1)1)1)1)1)PMPMPMPMPMPMPMPM2)2)2)2)2)2)2)2)LBBBLBBBLBBBLBBBLBBBLBBBLBBBLBBB3)3)3)3)3)3)3)3)Repolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalitiesRepolarization abnormalities

yesyesyesyesyesyesyesyes

Pharmacological Pharmacological Pharmacological Pharmacological Pharmacological Pharmacological Pharmacological Pharmacological Stress TestStress TestStress TestStress TestStress TestStress TestStress TestStress Test

NONONONONONONONO

Unable to exercise, Unable to exercise, Unable to exercise, Unable to exercise, Unable to exercise, Unable to exercise, Unable to exercise, Unable to exercise, NeurologicalNeurologicalNeurologicalNeurologicalNeurologicalNeurologicalNeurologicalNeurological-------- Orthopedic Orthopedic Orthopedic Orthopedic Orthopedic Orthopedic Orthopedic Orthopedic limitationslimitationslimitationslimitationslimitationslimitationslimitationslimitations yesyesyesyesyesyesyesyes

NONONONONONONONO

Diagnostic Accuracy of Exercise 201Tl SPECT in Patients with Conduction Abnormalities

TawaraharaTawarahara et al, Am J et al, Am J CardiolCardiol 19921992SpecificitySpecificity

0

20

40

60

80

100

NormalsNormals RBBBRBBB RBBB+LFB RV PacingRBBB+LFB RV Pacing LBBBLBBB

94%94%

30%30%44%44%50%50%

86%86%

Stress Perfusion Scintigraphy in LBBB:“False Positive” Septal Defects

VaduganathanVaduganathan, JACC 1996;28:543, JACC 1996;28:543

p <0.001p <0.00146%46%

11%11% 8%8%0

10

20

30

40

50

ExerciseExercise (n.206)(n.206)AdenosineAdenosine (n.127)(n.127)DobutamineDobutamine (n.50)(n.50)

Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise Is the pt able to exercise >85% PMHR?>85% PMHR?>85% PMHR?>85% PMHR?>85% PMHR?>85% PMHR?>85% PMHR?>85% PMHR?

NONONONONONONONO1)1)1)1)1)1)1)1)HypertensionHypertensionHypertensionHypertensionHypertensionHypertensionHypertensionHypertension2)2)2)2)2)2)2)2)BetaBetaBetaBetaBetaBetaBetaBeta--------blockersblockersblockersblockersblockersblockersblockersblockers3)3)3)3)3)3)3)3)AntiAntiAntiAntiAntiAntiAntiAnti--------arrythm.arrythm.arrythm.arrythm.arrythm.arrythm.arrythm.arrythm.4)4)4)4)4)4)4)4)AnamnesisAnamnesisAnamnesisAnamnesisAnamnesisAnamnesisAnamnesisAnamnesis5)5)5)5)5)5)5)5)COPDCOPDCOPDCOPDCOPDCOPDCOPDCOPD

yesyesyesyesyesyesyesyesErgomethryErgomethryErgomethryErgomethryErgomethryErgomethryErgomethryErgomethry

Submaximal stress testSubmaximal stress testdiagnostic implicationsdiagnostic implications

748888

98 88

Iskandrian, 1989Iskandrian, 1989

Pharmacological TestPharmacological TestPharmacological TestPharmacological TestPharmacological TestPharmacological TestPharmacological TestPharmacological TestIIIIIIII°° Choice: VasodilatorsChoice: VasodilatorsChoice: VasodilatorsChoice: VasodilatorsChoice: VasodilatorsChoice: VasodilatorsChoice: VasodilatorsChoice: Vasodilators

1)1)1)1)1)1)1)1)AdenosinAdenosinAdenosinAdenosinAdenosinAdenosinAdenosinAdenosin2)2)2)2)2)2)2)2)dypiridamoledypiridamoledypiridamoledypiridamoledypiridamoledypiridamoledypiridamoledypiridamole3)3)3)3)3)3)3)3)(A2a(A2a(A2a(A2a(A2a(A2a(A2a(A2a--------selective selective selective selective selective selective selective selective agonists)agonists)agonists)agonists)agonists)agonists)agonists)agonists)

CONSIDERCONSIDERCONSIDERCONSIDERCONSIDERCONSIDERCONSIDERCONSIDERAbsolute Contraindications: Absolute Contraindications: Absolute Contraindications: Absolute Contraindications: Absolute Contraindications: Absolute Contraindications: Absolute Contraindications: Absolute Contraindications: AsthmaAsthmaAsthmaAsthmaAsthmaAsthmaAsthmaAsthmaAVB IIAVB IIAVB IIAVB IIAVB IIAVB IIAVB IIAVB II°°, sick sinus syndrome, sick sinus syndrome, sick sinus syndrome, sick sinus syndrome, sick sinus syndrome, sick sinus syndrome, sick sinus syndrome, sick sinus syndromeSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgSystolic Pressure < 90 mmHgRelative Contraindications:Relative Contraindications:Relative Contraindications:Relative Contraindications:Relative Contraindications:Relative Contraindications:Relative Contraindications:Relative Contraindications:Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 Xantines Absumtions in the last 12 hourshourshourshourshourshourshourshoursIIIIIIII°° AVBAVBAVBAVBAVBAVBAVBAVBSinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm) Sinus Bradicardia (< 40 bpm)

yesyesyesyesyesyesyesyes

NONONONONONONONO

TESTTESTTESTTESTTESTTESTTESTTEST

22222222°° ChoiceChoiceChoiceChoiceChoiceChoiceChoiceChoiceDobutamineDobutamineDobutamineDobutamineDobutamineDobutamineDobutamineDobutamine

yesyesyesyesyesyesyesyesNONONONONONONONOTESTTESTTESTTESTTESTTESTTESTTEST

ConsiderConsiderConsiderConsiderConsiderConsiderConsiderConsiderEmodynamically significat LV outflow Emodynamically significat LV outflow tract obstructiontract obstructionModerateModerate--severe aortic stenosissevere aortic stenosisAtrial Tachiarrythmia with uncontrolled Atrial Tachiarrythmia with uncontrolled ventricular responseventricular responseHistory of ventricular tachicardiaHistory of ventricular tachicardiaUncontrolled hypertension by drugsUncontrolled hypertension by drugsAortic dissection or aortic aneurismAortic dissection or aortic aneurismBeta blockers therapyBeta blockers therapy

Evaluate again physical Evaluate again physical Evaluate again physical Evaluate again physical Evaluate again physical Evaluate again physical Evaluate again physical Evaluate again physical exercise stress test optionexercise stress test optionexercise stress test optionexercise stress test optionexercise stress test optionexercise stress test optionexercise stress test optionexercise stress test option

Modify medication Modify medication Modify medication Modify medication Modify medication Modify medication Modify medication Modify medication regimenregimenregimenregimenregimenregimenregimenregimen

Postpone evaluationPostpone evaluationPostpone evaluationPostpone evaluationPostpone evaluationPostpone evaluationPostpone evaluationPostpone evaluation

Strenght of exercise stress testStrenght of exercise stress testMore physiologicalMore physiologicalAdditional information:Additional information:

Exercise toleranceExercise toleranceHaemodynamic (BP, Haemodynamic (BP,

chronotropic chronotropic modulation, etc.)modulation, etc.)ArrythmiasArrythmiasSymptomsSymptoms

Exercise StressTestExercise StressTestExercise StressTestExercise StressTestExercise StressTestExercise StressTestExercise StressTestExercise StressTest

Submaximal testSubmaximal testSubmaximal testSubmaximal testSubmaximal testSubmaximal testSubmaximal testSubmaximal test

Stop exerciseStop exerciseStop exerciseStop exerciseStop exerciseStop exerciseStop exerciseStop exerciseRevaluate pharmacological Revaluate pharmacological Revaluate pharmacological Revaluate pharmacological Revaluate pharmacological Revaluate pharmacological Revaluate pharmacological Revaluate pharmacological

stress teststress teststress teststress teststress teststress teststress teststress test

AtropineAtropineAtropineAtropineAtropineAtropineAtropineAtropine

Atropine Administration in Stress TestingFrom 1997: From 1997: From 1997: From 1997: From 1997: From 1997: From 1997: From 1997:

•• Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):Atropine in 37% (0.5 mg):�� 38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%38.6% exercise tests (MPHR 72%��85%)85%)85%)85%)85%)85%)85%)85%)�� 36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%36.1% pharmacological tests (MPHR 63%��78%)78%)78%)78%)78%)78%)78%)78%)•• # Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)# Exercise tests: from 31% (1996) to 57% (2008)•• Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts Significant Side effects: 7 pts �� 2 urinary retention2 urinary retention2 urinary retention2 urinary retention2 urinary retention2 urinary retention2 urinary retention2 urinary retention�� 4 high HR response in AF4 high HR response in AF4 high HR response in AF4 high HR response in AF4 high HR response in AF4 high HR response in AF4 high HR response in AF4 high HR response in AF�� 1 PSVT1 PSVT1 PSVT1 PSVT1 PSVT1 PSVT1 PSVT1 PSVT

Atropine (0.5-1 mg iv)Augmentation in Exercise Sestamibi SPECT

Max age-pred.

HR

70

75

80

85

90

95

100

Exercise Exercise +Atropine

p <0.01p <0.01

Atropine in Patients with Submaximal Exercise Test

De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003De Lorenzo et al; JNC 2003 47/717 (7%) patients with 47/717 (7%) patients with <85% MPHR<85% MPHRAtropine 0.6Atropine 0.6--1.2 mg1.2 mg

P<0..001P<0..001 P<0.001P<0.001

Contraindications to atropine Contraindications to atropine ��GlaucomaGlaucoma��Obstructive Uropathy, prostatic hypertrophyObstructive Uropathy, prostatic hypertrophy��Atrial fibrillation with uncontrolled HRAtrial fibrillation with uncontrolled HR��Previous adverse reactionPrevious adverse reaction��Driving precautionDriving precaution

A difficult Pt…. Pt with COPD

Limited exercise tolerance……. But:Limited possibilities for pharmacological stress test:

Asthmatic Component adenosine/dypiridamoleArryithmias dobutamineTeophilline derivatives adenosine/dypiridamoleeB2-agonist dobutamine

Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Consider Exercise stressTest Er+Atropine Er+Atropine Er+Atropine Er+Atropine Er+Atropine Er+Atropine Er+Atropine Er+Atropine (O2 support)(O2 support)(O2 support)(O2 support)(O2 support)(O2 support)(O2 support)(O2 support)

A difficult choiceA difficult choiceA difficult choiceA difficult choiceA difficult choiceA difficult choiceA difficult choiceA difficult choice……………………................

Diagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPIDiagnostic Accuracy of MPI

Leppo, J Nucl Cardiol 1996Leppo, J Nucl Cardiol 1996

Biokynetic of TalliumBiokynetic of Tallium--201 after stress in 201 after stress in normalsnormals

Stress Tests

ExerciseExerciseExerciseExerciseExerciseExerciseExerciseExerciseDypiridamoleDypiridamoleDypiridamoleDypiridamoleDypiridamoleDypiridamoleDypiridamoleDypiridamole AdenosineAdenosineAdenosineAdenosineAdenosineAdenosineAdenosineAdenosine

AtropineAtropineAtropineAtropineAtropineAtropineAtropineAtropine

DobutamineDobutamineDobutamineDobutamineDobutamineDobutamineDobutamineDobutamine

Limitations of Vasodilator Stress Testing

•• Increased Splanchnic Increased Splanchnic Increased Splanchnic Increased Splanchnic Increased Splanchnic Increased Splanchnic Increased Splanchnic Increased Splanchnic Uptake of TracerUptake of TracerUptake of TracerUptake of TracerUptake of TracerUptake of TracerUptake of TracerUptake of Tracer

•• Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Unable to Evaluate the Efficacy of MedicationsEfficacy of MedicationsEfficacy of MedicationsEfficacy of MedicationsEfficacy of MedicationsEfficacy of MedicationsEfficacy of MedicationsEfficacy of Medications

•• Lack of Exercise DataLack of Exercise DataLack of Exercise DataLack of Exercise DataLack of Exercise DataLack of Exercise DataLack of Exercise DataLack of Exercise Data•• Side EffectsSide EffectsSide EffectsSide EffectsSide EffectsSide EffectsSide EffectsSide Effects

Symptoms Associated with Adenosine/Dipyridamole Infusion��VasodilationVasodilationVasodilationVasodilationVasodilationVasodilationVasodilationVasodilation FlushingFlushingFlushingFlushingFlushingFlushingFlushingFlushing

HeadacheHeadacheHeadacheHeadacheHeadacheHeadacheHeadacheHeadacheNauseaNauseaNauseaNauseaNauseaNauseaNauseaNauseaDizzinessDizzinessDizzinessDizzinessDizzinessDizzinessDizzinessDizziness

��Activation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersActivation of Peripheral Respiratory CentersDyspneaDyspneaDyspneaDyspneaDyspneaDyspneaDyspneaDyspnea

��Activation of NociceptorsActivation of NociceptorsActivation of NociceptorsActivation of NociceptorsActivation of NociceptorsActivation of NociceptorsActivation of NociceptorsActivation of NociceptorsChest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)Chest Pain (without ischemia)

Adenosine and Noncardiac SymptomsEffects of Combined Exercise

P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001

P=.01P=.01P=.01P=.01P=.01P=.01P=.01P=.01

P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001P<.0001P=.002P=.002P=.002P=.002P=.002P=.002P=.002P=.002

(134)(134)(134)(134)(134)(134)(134)(134) (128)(128)(128)(128)(128)(128)(128)(128) (145)(145)(145)(145)(145)(145)(145)(145)

Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995

Association of Exercise Reduces Adenosine/Dipyridamole Side

EffectsHemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse Hemodynamic response to exercise reverse hypotension and vasodilationhypotension and vasodilationhypotension and vasodilationhypotension and vasodilationhypotension and vasodilationhypotension and vasodilationhypotension and vasodilationhypotension and vasodilationCatecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, Catecholamine drive reduces splanchnic, cerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationcerebral and skin vasodilationPsychologic componentPsychologic componentPsychologic componentPsychologic componentPsychologic componentPsychologic componentPsychologic componentPsychologic component

Combined TestExtent of Ischemia

CandellCandellCandellCandellCandellCandellCandellCandell--------Riera et al, JACC Riera et al, JACC Riera et al, JACC Riera et al, JACC Riera et al, JACC Riera et al, JACC Riera et al, JACC Riera et al, JACC 19971997199719971997199719971997 Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995

Association of Exercise to Adenosine Stimulation Improves Images Quality

Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995Pennel et al, JACC 1995

Combined TestExercise+Ado/dip

1)1)1)1)1)1)1)1) No physical limitation to No physical limitation to No physical limitation to No physical limitation to No physical limitation to No physical limitation to No physical limitation to No physical limitation to exersiseexersiseexersiseexersiseexersiseexersiseexersiseexersise

2)2)2)2)2)2)2)2) No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to ergomethryergomethryergomethryergomethryergomethryergomethryergomethryergomethry

3)3)3)3)3)3)3)3) No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to No contraindications to Ado/dipAdo/dipAdo/dipAdo/dipAdo/dipAdo/dipAdo/dipAdo/dip

Intracenter ExperienceThe Physician Performing the Stress Test

Main SubspecialityOperator A EchographyOperator B Clinical/General

CardiologistOperator C Exercise/functional

EvaluationOperator D Dedicated Nuclear

Cardiologist

PharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacologicalPharmacological ExerciseExerciseExerciseExerciseExerciseExerciseExerciseExercise

% MPI Positive% MPI Positive% MPI Positive% MPI Positive% MPI Positive% MPI Positive% MPI Positive% MPI Positive % ECG Positive% ECG Positive% ECG Positive% ECG Positive% ECG Positive% ECG Positive% ECG Positive% ECG Positive

Take home messages:Take home messages:�� MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still MPI combined with Exercise stress test is still the 1the 1the 1the 1the 1the 1the 1the 1°° choice procedurechoice procedurechoice procedurechoice procedurechoice procedurechoice procedurechoice procedurechoice procedure�� When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately When Exercise stress test cannot be adequately performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful performed, Pharmacological testing is an useful alternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificityalternative with good sensitivity and Specificity�� The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored The choice of the test must be tailored according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.according to pt needs and carachteristics.�� Hybrid tests should be consideredHybrid tests should be consideredHybrid tests should be consideredHybrid tests should be consideredHybrid tests should be consideredHybrid tests should be consideredHybrid tests should be consideredHybrid tests should be considered

Thanks!Thanks!Thanks!Thanks!Thanks!Thanks!Thanks!Thanks!