Stress testing PRIOR to Discharge!!!

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Dr. Fischer says that everyone should get a stress test prior to discharge (provided they are asymptomatic of course) ... my question is: since the need for this sterss is seeing who should be cathed, would patients who ALREADY had a cath be stressed prior to discharge?!!?

 

[Fuzuli]

Dr. Fischer says that everyone should get a stress test prior to discharge (provided they are asymptomatic of course) ... my question is: since the need for this sterss is seeing who should be cathed, would patients who ALREADY had a cath be stressed prior to discharge?!!?

You're right, if the patient had received catheterization, stress test is not required for risk stratification.

A 50 year old man presents to ED with acute substernal chest pain that radiates to his left harm. He used his sublingual nitroglycerin, but his pain isn't relieved. His EKG shows 3 mm ST elevations in leads V2-4. His cTn-I and CK-MB is highly elevated. A diagnosis of anterior STEMI is made and ACS protocol is initiated. Primary PCI is performed within 90 minutes of arrival, which shows >%90 obstruction in LAD and LCx.

For this patient, stress testing for post-MI risk stratification is not required.

A 50 year old man presents to ED with acute substernal chest pain that radiates to his left harm. He used his sublingual nitroglycerin, but his pain isn't relieved. His EKG shows 3 mm ST elevations in leads V2-4. His cTn-I and CK-MB is highly elevated. A diagnosis of anterior STEMI is made and ACS protocol is initiated. Standard dose reteplase is given to the patient and he's admitted to coronary ICU. After 3 days, his health improves and becomes symptom-free; his EKG shows 1 mm ST elevation in V3 and his cTn-I levels return to normal. What is the best next step for this patient?

a) Obtain CK-MB levels
b) Perform coronary catheterization
c) Perform echocardiography
d) Repeat EKG
e) Discharge the patient with appropriate doses of ASA, clopidogrel, propranolol, atorvastatin, losartan and amlodipine

Since no catheterization was performed for this patient, the best next step would be to perform echocardiography. LV EF is a very powerful indicator of future coronary events.

You performed echocardiography for the patient mentioned above. He has a EF of 0.33. What is the best next step?

a) Repeat EKG
b) Perform catheterization
c) Perform standard exercise stress test
d) Perform stress myocardial perfusion nuclear imaging
e) Perform stress echocardiography

Since <%40 of LVEF is corrolated with poor prognosis, catheterization is warranted for this patient.

You performed echocardiography for the original patient. He has a EF of 0.45. What is the best next step?

a) Repeat EKG
b) Perform catheterization
c) Perform standard exercise stress test
d) Perform stress myocardial perfusion nuclear imaging
e) Perform stress echocardiography

Since he has no high risk symptoms, signs or comorbid conditions (angina, S3, VT, syncope, stroke, etc), the next step would be to perform stress test. He has no EKG contraindications and he has no medical condition that would prevent him from exercising, standard exercise stress test is appropriate.

If he had high-risk features, catheterization would have been appropriate.

 

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A 50 year old man presents to ED with acute substernal chest pain that radiates to his left harm. He used his sublingual nitroglycerin, but his pain isn't relieved. His EKG shows 3 mm ST elevations in leads V2-4. His cTn-I and CK-MB is highly elevated. A diagnosis of anterior STEMI is made and ACS protocol is initiated. Standard dose reteplase is given to the patient and he's admitted to coronary ICU. After 3 days, his health improves and becomes symptom-free; his EKG shows 1 mm ST elevation in V3 and his cTn-I levels return to normal. What is the best next step for this patient?

a) Obtain CK-MB levels
b) Perform coronary catheterization
c) Perform echocardiography
d) Repeat EKG
e) Discharge the patient with appropriate doses of ASA, clopidogrel, propranolol, atorvastatin, losartan and amlodipine

Why not get a CK-MB just to make sure that they returned to baseline?

by the way, echocardiography to assess EF POST MI is never mentioned by Dr. Fischer at all!!!! and from what i understood of you is the following:

IF cath was not done initially, we first check the ejection fraction to determine whether it is above 40 (the threshold to say this person can tolerate exrcise), if EF was above 40, we check for the existence of other risk factors that might have been instigated by the MI (angina, S3, VT, syncope, stroke, as you have elucidated) ... If all of that is negative, then its a go for EXERCISE Stressing, if ANY of those is positive, we move straight to catheterization.

This raises, however, a concern: why did you check echo?? does this mean that we should check the EF on any person that we want to do stress on? i suspect thats not the case, and for the sake of USMLE step 2, dont you agree that checking EF post MI to determine whether stressing should be done might be too detailed for the test? I mean, sometimes, if you know A LOT you might lose a question because the examiner dont expect you to know this step (for example the new change from ABC to CAB in trauma!!!!! I sincerely would stick to ABC on the exam lol

 

[Fuzuli]

Why not get a CK-MB just to make sure that they returned to baseline?

If his cTn-I levels are normal, then his CK-MB levels are bound to be normal as well (it takes troponins longer to return to normal level [generally up to a week]). CK-MB has no value in risk stratification (it's used for evaluation of re-infarction), so I put it there as a distraction 🙂

by the way, echocardiography to assess EF POST MI is never mentioned by Dr. Fischer at all!!!!

That is indeed interesting. Echocardiography is one of the cornerstones of post-MI risk stratification. Because you've written that Dr. Fischer doesn't mention this, I take a look at the guidelines:

Class I
1. Echocardiography should be used in patients with STEMI not undergoing LV angiography to assess baseline LV function, especially if the patient is
hemodynamically unstable. (Level of Evidence: C)

From: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

7. A noninvasive test (echocardiogram or radionuclide angiogram) is recommended to evaluate LV function in patients with definite ACS who are not scheduled for coronary angiography and left ventriculography. (Level of Evidence: B)

From: ACC/AHA Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

IF cath was not done initially, we first check the ejection fraction to determine whether it is above 40 (the threshold to say this person can tolerate exrcise), if EF was above 40, we check for the existence of other risk factors that might have been instigated by the MI (angina, S3, VT, syncope, stroke, as you have elucidated) ... If all of that is negative, then its a go for EXERCISE Stressing, if ANY of those is positive, we move straight to catheterization. This raises, however, a concern: why did you check echo?? does this mean that we should check the EF on any person that we want to do stress on?

That's true, however the order may change. For instance, you have to schedule a catheterization if your patient has a high-risk score, even before performing an echocardiography. Ultimately, it depends on the question and the given choices. If there's anything in the question stem that would indicate high-risk (signs, symptoms, comorbidities, EF<%40), go directly to catheterization.

suspect thats not the case, and for the sake of USMLE step 2, dont you agree that checking EF post MI to determine whether stressing should be done might be too detailed for the test? I mean, sometimes, if you know A LOT you might lose a question because the examiner dont expect you to know this step (for example the new change from ABC to CAB in trauma!!!!! I sincerely would stick to ABC on the exam lol

Yes, but it isn't like that. For example, STEMI guideline is from 2004. And LV EF is a major predictor of future risk. Ultimately, it depends on the question stem. Suppose that they ask a question where there's a patient without any high-risk factors and who had a normal stress test. He still needs to have an echocardiography, since his EF may be lower than %40. Would you choose to discharge a patient without high-risk factors and a normal stress test, but without an echo? I wouldn't.

Hope this helps.

 

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Suppose that they ask a question where there's a patient without any high-risk factors and who had a normal stress test. He still needs to have an echocardiography, since his EF may be lower than %40. Would you choose to discharge a patient without high-risk factors and a normal stress test, but without an echo? I wouldn't.

Man, its like you are reading my mind!!! this is bizarre and a bit scary ...

So you think that in this patient (in the quote) should undergo Cath IF his EF is below 40 EVEN THOUGH his stress is totally normal AND he doesnt have any high risk factors (s3, VT, syncope etc) ...??? I argue that logically its not necessary... since EF depends on how powerful the heart contracts, and this doesnt necessarily follows a pathology in the coronaries that should be investigated by cath ... I dont know whether I am able to express my doubt here coherently

 

[Fuzuli]

Man, its like you are reading my mind!!! this is bizarre and a bit scary ...

So you think that in this patient (in the quote) should undergo Cath IF his EF is below 40 EVEN THOUGH his stress is totally normal AND he doesnt have any high risk factors (s3, VT, syncope etc) ...???

I argue that logically its not necessary... since EF depends on how powerful the heart contracts, and this doesnt necessarily follows a pathology in the coronaries that should be investigated by cath ... I dont know whether I am able to express my doubt here coherently

Yes, EF <%40 alone is an indication for catheterization. I'm quoting from AHA/ACC guideline: "It is reasonable to perform routine PCI in patients with LV EF <%40, CHF or serious ventricular arrhythmias (Level of Evidence: C)"

If you have time, check out the guidelines at http://www.cardiosource.org/

 

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Lets hope that these recommendations are considered to be required by cardiologists and not step 2 takers .... otherwise, I am doomed!!