Bacterial infections kill several persons globally, effective diagnosis of bacterial infections continues to be minimal requirement in effective management of infected patients-
FATIGUE IS A STIMULUS FOR ADAPTATION CHANGES AND MEDICOBIOLOGICAL MEANS ARE REQUIRED TO OPTIMIZE RECOVERY
Definition of operative dentistry , procedures done in it and types of operative procedures and recent concepts-
Slide 1 : ACC Heart Failure GuidelinesSlide Deck Based on the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult January 2006
Slide 2 : Supported by Medtronic, Inc. Medtronic, Inc. was not involved in the development of this slide deck and in no way influenced its contents.
Slide 3 : William T. Abraham, MD, FACC, FAHA Marshall H. Chin, MD, MPH, FACP Arthur M. Feldman, MD, PhD, FACC, FAHA Gary S. Francis, MD, FACC, FAHA Theodore G. Ganiats, MD Mariell Jessup, MD, FACC, FAHA Marvin A. Konstam, MD, FACC Sharon Ann Hunt, MD, FACC, FAHA, Chair Donna M. Mancini, MD Keith Michl, MD, FACP John A. Oates, MD, FAHA Peter S. Rahko, MD, FACC, FAHA Marc A. Silver, MD, FACC, FAHA Lynne Warner Stevenson, MD, FACC, FAHA Clyde W. Yancy, MD, FACC, FAHA ACC/AHA 2005 Guideline Update for the Management of Patients With Chronic Heart Failure in the Adult Writing Committee Members
Slide 4 : Applying Classification of Recommendations and Level of Evidence
Slide 5 : Applying Classification of Recommendations and Level of Evidence
Slide 6 : Applying Classification of Recommendations and Level of Evidence
Slide 7 : Applying Classification of Recommendations and Level of Evidence
Slide 8 : Heart Failure is a Major and Growing Public Health Problem in the U.S. Approximately 5 million patients in this country have HF Over 550,000 patients are diagnosed with HF for the first time each year Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year In 2001, nearly 53,000 patients died of HF as a primary cause
Slide 9 : Heart Failure is Primarily a Condition of the Elderly The incidence of HF approaches 10 per 1000 population after age 65 HF is the most common Medicare diagnosis-related group More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare
Slide 10 : Guideline Scope Document focuses on : Prevention of HF Diagnosis and management of chronic HF in the adult
Slide 11 : Definition of Heart Failure HF is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
Slide 12 : “Heart Failure” vs. “Congestive Heart Failure” Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.”
Slide 13 : Causes of HF in Western World For a substantial proportion of patients, causes are: Coronary artery disease Hypertension Dilated cardiomyopathy
Slide 14 :
Slide 15 : Stages of Heart Failure At Risk for Heart Failure: STAGE A High risk for developing HF STAGE B Asymptomatic LV dysfunction Heart Failure: STAGE C Past or current symptoms of HF STAGE D End-stage HF
Slide 16 : Stages of Heart Failure Designed to emphasize preventability of HF Designed to recognize the progressive nature of LV
Slide 17 : Stages of Heart Failure COMPLEMENT, DO NOT REPLACE NYHA CLASSES NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease) Stages - progress in one direction due to cardiac remodeling
Slide 18 :
Slide 19 :
Slide 20 :
Slide 21 :
Slide 22 : Stage A Patients at High Risk for Developing Heart Failure
Slide 23 : Stage A Therapy Recommended Therapies to Reduce Risk Include: Treating known risk factors (hypertension, diabetes, etc.) with therapy consistent with contemporary guidelines Avoiding behaviors increasing risk (i.e., smoking excessive consumption of alcohol, illicit drug use) Periodic evaluation for signs and symptoms of HF Ventricular rate control or sinus rhythm restoration Noninvasive evaluation of LV function Drug therapy – Angiotensin Converting Enzyme Inhibitors (ACEI) Angiotensin Receptor Blockers (ARBs)
Slide 24 : Stage A Therapy In patients at high risk for developing HF, systolic and diastolic hypertension should be controlled in accordance with contemporary guidelines. In patients at high risk for developing HF, lipid disorders should be treated in accordance with contemporary guidelines. Using Therapy Consistent with Contemporary Guidelines
Slide 25 : Stage A Therapy In patients at high risk for developing HF who have known atherosclerotic vascular disease, healthcare providers should follow current guidelines for secondary prevention. For patients with diabetes mellitus (who are all at high risk for developing HF), blood sugar should be controlled in accordance with contemporary guidelines. Using Therapy Consistent with Contemporary Guidelines
Slide 26 : Stage A Therapy Thyroid disorders should be treated in accordance with contemporary guidelines in patients at high risk for developing HF. Using Therapy Consistent with Contemporary Guidelines
Slide 27 : Stage A Therapy Patients at high risk for developing HF should be counseled to avoid behaviors that may increase the risk of HF (e.g., smoking, excessive alcohol consumption, and illicit drug use). Avoiding Behaviors That Increase Risk
Slide 28 : Stage A Therapy Healthcare providers should perform periodic evaluation for signs and symptoms of HF in patients at high risk for developing HF. Periodic Evaluation for Signs and Symptoms
Slide 29 : Stage A Therapy Ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias who are at high risk for developing HF. Ventricular Rate Control or Sinus Rhythm Restoration I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIb IIa IIb III IIb III B III
Slide 30 : Stage A Therapy Healthcare providers should perform a noninvasive evaluation of LV LV
Slide 31 : Stage A Therapy ACEI can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. Angiotensin Converting Enzyme Inhibitors (ACEI)
Slide 32 : Stage A Therapy ARBs can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors. Angiotension Receptor Blockers (ARBs)
Slide 33 : Stage A Therapy Routine use of nutritional supplements solely to prevent the development of structural heart disease should not be recommended for patients at high risk for developing HF. Therapies NOT Recommended
Slide 34 : Stage B Patients with Asymptomatic LV
Slide 35 : Stage B Therapy Recommended Therapies: General Measures as advised
for Stage A Drug therapy for all patients ACEI or ARBs Beta-Blockers ICDs in appropriate patients Coronary revascularization in appropriate patients Valve replacement or repair in appropriate patients
Slide 36 : Stage B Therapy All Class I recommendations for Stage A should apply to patients with cardiac structural abnormalities who have not developed HF. (Levels of Evidence: A, B, and C as appropriate) Patients who have not developed HF symptoms should be treated according to contemporary guidelines after an acute MI. General Measures
Slide 37 : Stage B Therapy Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI. ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF. Angiotensin Converting Enzyme Inhibitors (ACEI)
Slide 38 : Stage B Therapy An ARB should be administered to post-MI patients without HF who are intolerant of ACEIs and have a low LVEF. ACEIs or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF. ARBs can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs. Angiotensin Receptor Blockers (ARBs)
Slide 39 : Stage B Therapy Beta-blockers and ACEIs should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. Beta-blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms. Beta-Blockers
Slide 40 : Stage B Therapy Placement of an ICD is reasonable in patients with ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are NYHA functional class I on chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. Placement of an ICD might be considered in patients without HF who have nonischemic cardiomyopathy and an LVEF less than or equal to 30% who are in NYHA functional class I with chronic optimal medical therapy and have a reasonable expectation of survival with good functional status for more than 1 year. Internal Cardioverter Defibrillator (ICD)
Slide 41 : Stage B Therapy Coronary revascularization should be recommended in appropriate patients without symptoms of HF in accordance with contemporary guidelines (see ACC/AHA Guidelines for the Management of Patients With Chronic Stable Angina). Coronary Revascularization
Slide 42 : Stage B Therapy Valve replacement or repair should be recommended for patients with hemodynamically significant valvular stenosis or regurgitation and no symptoms of HF in accordance with contemporary guidelines. Valve Replacement/Repair
Slide 43 : Stage B Therapy Digoxin should not be used in patients with low EF, sinus rhythm, and no history of HF symptoms, because in this population, the risk of harm is not balanced by any known benefit. Use of nutritional supplements to treat structural heart disease or to prevent the development of symptoms of HF is not recommended. Calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI. Therapies NOT Recommended
Slide 44 : Stage C Patients with Past or Current Symptoms of Heart Failure
Slide 45 : Recommended Therapies: General measures as advised for Stages A and B Drug therapy for all patients Diuretics for fluid retention ACEI Beta-blockers Drug therapy for selected patients Aldosterone Antagonists ARBs Digitalis Hydralazine/nitrates ICDs in appropriate patients Cardiac resynchronization in appropriate patients Exercise Testing and Training Stage C Therapy (Reduced LVEF with Symptoms)
Slide 46 : Measures listed as Class I recommendations for patients in stages A and B are also appropriate for patients in Stage C. (Levels of Evidence: A, B, and C as appropriate) Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs). General Measures Stage C Therapy (Reduced LVEF with Symptoms)
Slide 47 : Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention. Diuretics Stage C Therapy (Reduced LVEF with Symptoms)
Slide 48 : ACEIs are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. Angiotensin Enzyme Converting Inhibitors (ACEIs) Stage C Therapy (Reduced LVEF with Symptoms)
Slide 49 : ARBs approved for the treatment of HF are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACEI- intolerant (see full text guidelines for information regarding patients with angioedema). ARBs are reasonable to use as alternatives to ACEIs as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications. Angiotensin Receptor Blockers (ARBs) Stage C Therapy (Reduced LVEF with Symptoms)
Slide 50 : The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patientswith current or prior symptoms of HF and reduced LVEF. ARBs (cont’d) Stage C Therapy (Reduced LVEF with Symptoms)
Slide 51 : Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be less than or equal to 2.5 mg/dL in men or less than or equal to 2.0 mg/dL in women and potassium should be less than 5.0 mEq/L. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. Aldosterone Antagonists Stage C Therapy (Reduced LVEF with Symptoms)
Slide 52 : Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. Beta-Blockers Stage C Therapy (Reduced LVEF with Symptoms)
Slide 53 :
Slide 54 :
Slide 55 : Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. Digitalis Stage C Therapy (Reduced LVEF with Symptoms)
Slide 56 : The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACEI and beta- blocker for symptomatic HF and who have persistent symptoms. A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACEI or ARB because of drug intolerance, hypotension, or renal insufficiency. Hydralazine and Isosorbide Dinitrate Stage C Therapy (Reduced LVEF with Symptoms)
Slide 57 : An ICD is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. Implantable Cardioverter- Defibrillators (ICDs) Stage C Therapy (Reduced LVEF with Symptoms)
Slide 58 : ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with nonischemic cardiomyopathy who have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. Placement of an ICD is reasonable in patients with LVEF of 30% to 35% of any origin with NYHA functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year. ICDs (cont’d) Stage C Therapy (Reduced LVEF with Symptoms)
Slide 59 : Patients with LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 120 ms, should receive cardiac resynchronization therapy unless contraindicated. Cardiac Resynchronization Stage C Therapy (Reduced LVEF with Symptoms)
Slide 60 : Maximal exercise testing with or without measurement of respiratory gas exchange is recommended to facilitate prescription of an appropriate exercise program for patients presenting with HF. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. Exercise Testing and Training Stage C Therapy (Reduced LVEF with Symptoms)
Slide 61 : Unproven/Not Recommended Drugs and Interventions for HF Nutritional Supplements Hormonal Therapies Intermittent Intravenous Positive Inotropic Therapy Stage C Therapy (Reduced LVEF with Symptoms)
Slide 62 : Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for Stage D). Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF. Unproven/Not Recommended Drugs and Interventions Stage C Therapy (Reduced LVEF with Symptoms)
Slide 63 : Calcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF. Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. Routine combined use of an ACEI, ARB, and aldosterone antagonist is not recommended for patientswith current or prior symptoms of HF and reduced LVEF. Unproven/Not Recommended Drugs and Interventions Stage C Therapy (Reduced LVEF with Symptoms)
Slide 64 : Recommended Therapies for Routine Use: Treating known risk factor (hypertension) with therapy consistent with contemporary guidelines Ventricular rate control for all patients Drugs for all patients - Diuretics Drugs for appropriate patients – ACEI ARBs Beta-Blockers Digitalis Coronary revascularization in selected patients Restoration/maintenance of sinus rhythm in appropriate patients Stage C Therapy (Normal LVEF with Symptoms)
Slide 65 : Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms Incorrect diagnosis of HF Inaccurate measurement of LVEF Primary valvular disease Restrictive (infiltrative) cardiomyopathies Amyloidosis, sarcoidosis, hemochromatosis Pericardial constriction Episodic or reversible LV systolic dysfunction Severe hypertension, myocardial ischemia HF associated with high metabolic demand (high-output states) Anemia, thyrotoxicosis, arteriovenous fistulae Chronic pulmonary disease with right HF Pulmonary hypertension associated with pulmonary vascular disorders Atrial myxoma Diastolic dysfunction of uncertain origin Obesity
Slide 66 : Physicians should control systolic and diastolic hypertension in patients with HF and normal LVEF, in accordance with published guidelines. Treating known risk factors - Hypertension Stage C Therapy (Normal LVEF with Symptoms)
Slide 67 : Physicians should control ventricular rate in patients with HF and normal LVEF and atrial fibrillation. Ventricular Rate Control Stage C Therapy (Normal LVEF with Symptoms)
Slide 68 : Physicians should use diuretics to control pulmonary congestion and peripheral edema in patients with HF and normal LVEF. Diuretics Stage C Therapy (Normal LVEF with Symptoms)
Slide 69 : Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function. Coronary Revascularization Stage C Therapy (Normal LVEF with Symptoms)
Slide 70 : Restoration and maintenance of sinus rhythm in patients with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms. Restoration/Maintenance of Sinus Rhythm Stage C Therapy (Normal LVEF with Symptoms)
Slide 71 : The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF. Angiotensin Enzyme Converting Inhibitors (ACEIs) Stage C Therapy (Normal LVEF with Symptoms)
Slide 72 : The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF. Angiotensin Receptor Blockers (ARBs) Stage C Therapy (Normal LVEF with Symptoms)
Slide 73 : The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF. Beta-Blockers Stage C Therapy (Normal LVEF with Symptoms)
Slide 74 : The usefulness of digitalis to minimize symptoms of HF in patients with HF and normal LVEF is not well established. Digitalis Stage C Therapy (Normal LVEF with Symptoms)
Slide 75 : Stage D Patients with Refractory End-Stage HF
Slide 76 : Stage D Therapy Recommended Therapies Include: Control of fluid retention Referral to a HF program for appropriate pts Discussion of options for end-of-life care Informing re: option to inactivate defibrillator Device use in appropriate patients Surgical therapy – Cardiac transplantation Mitral valve repair or replacement Other Drug Therapy – Positive inotrope infusion as palliation in appropriate patients
Slide 77 : Stage D Therapy Meticulous identification and control of fluid retention is recommended in patients with refractory end-stage HF. Control of Fluid Retention
Slide 78 : Stage D Therapy Referral of patients with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful. Referral to an HF Program
Slide 79 : Stage D Therapy Options for end-of-life care should be discussed with the patient and family when severe symptoms in patients with refractory end-stage HF persist despite application of all recommended therapies. Discussion of Options for End-of-Life Care
Slide 80 : Stage D Therapy Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate defibrillation. Inform on option to inactivate defibrillation
Slide 81 : Stage D Therapy Referral for cardiac transplantation in potentially eligible patients is recommended for patients with refractory end-stage HF. The effectiveness of mitral valve repair or replacement is not established for severe secondary mitral regurgitation in refractory end-stage HF. Surgical Therapy
Slide 82 : Stage D Therapy Consideration of an LV
Slide 83 : Stage D Therapy Continuous intravenous infusion of a positive inotropic agent may be considered for palliation of symptoms in patients with refractory end-stage HF. Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF. Medical Therapy
Slide 84 : Stage D Therapy Partial left ventriculectomy is not recommended inpatients with nonischemic cardiomyopathy and refractory end-stage HF. Routine intermittent infusions of positive inotropic agents are not recommended for patients with refractory end-stage HF. Therapies NOT Recommended
Slide 1 : How to Perform and Interpret an Exercise Test V. Froelicher, MD Professor of Medicine Stanford University VA Palo Alto HCS
Slide 2 : Key Points of Exercise Testing Manual SBP measurement (not automated) most important for safety Adjust to clinical history (couch potatoes) No Age predicted Heart Rate Targets The BORG Scale of Perceived Exertion METs not Minutes Fit protocol to patient (RAMP) Avoid HV and cool down walk Use standard ECG analysis/ 3 minute recovery/ use scores Heart rate recovery Expired Gas Analysis?
Slide 3 : BORG SCALE
Slide 4 : Symptom-Sign Limited Testing Endpoints – When to stop! Dyspnea, fatigue, chest pain Systolic blood pressure drop ECG--ST changes, arrhythmias Physician Assessment Borg Scale (17 or greater)
Slide 5 : How to read an Exercise ECG Good skin prep PR isoelectric line Not one beat Three consistent complexes Averages can help Garbage in, garbage out Three minute recovery
Slide 6 : Types of Exercise Isometric (Static) weight-lifting pressure work for heart, limited cardiac output, proportional to effort Isotonic (Dynamic) walking, running, swimming, cycling Flow work for heart, proportional to external work Mixed
Slide 7 : Oxygen Consumption During Dynamic Exercise Testing There are Two Types to Consider: Myocardial (MO2) Internal, Cardiac Ventilatory (VO2) External, Total Body
Slide 8 : Myocardial (MO2) Coronary Flow x Coronary a - VO2 difference Wall Tension (Pressure x Volume, Contractility, Stroke Work, HR) Systolic Blood Pressure x HR Angina and ST Depression usually occurs at same Double Product in an individual ** Direct relationship to VO2 is altered by beta-blockers, training,...
Slide 9 : Problems with Age-Predicted Maximal Heart Rate Which Regression Formula? (2YY - .Y x Age) Big scatter around the regression line poor correlation [-0.4 to -0.6] One SD is plus/minus 12 bpm Confounded by Beta Blockers A percent value target will be maximal for some and sub-max for others Borg scale is better for evaluating Effort Do Not Use Target Heart Rate to Terminate the Test or as the Only Indicator of Effort or adequacy of test
Slide 10 : Myocardial (MO2) Systolic Blood Pressure x HR SBP should rise > 40 mmHg Drops are ominous (Exertional Hypotension) Diastolic BP should decline
Slide 11 : Ventilatory (VO2) Cardiac Output x a-VO2 Difference VE x (% Inspired Air Oxygen Content - Expired Air Oxygen Content) External Work Performed ****Direct relationship with Myocardial O2 demand and Work is altered by beta-blockers, training,...
Slide 12 : VO2 THE FICK EQUATION VO2 = C.O. x C(a-v)O2 C(a-v)O2 ~ k then, VO2 ~ C.O.
Slide 13 : What is a MET? Metabolic Equivalent Term 1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2 /Kg/min Actually differs with thyroid status, post exercise, obesity, disease states But by convention just divide ml O2/Kg/min by 3.5
Slide 14 : Key MET Values (part 1) 1 MET = "Basal" = 3.5 ml O2 /Kg/min 2 METs = 2 mph on level 4 METs = 4 mph on level < 5METs = Poor prognosis if < 65; limit immediate post MI; cost of basic activities of daily living
Slide 15 : Key MET Values (part 2) 10 METs = As good a prognosis with medical therapy as CABS 13 METs = Excellent prognosis, regardless of other exercise responses 16 METs = Aerobic master athlete 20 METs = Aerobic athlete
Slide 16 : Calculation of METs on the Treadmill METs = Speed x [0.1 + (Grade x 1.8)] + 3.5 3.5 Calculated automatically by Device! Note: Speed in meters/minute conversion = MPH x 26.8 Grade expressed as a fraction
Slide 17 : METs---not Minutes (Report Exercise Capacity in METs) Can compare results from any mode or Testing Protocol Can Optimize Test by Individualizing for Patient Can adjust test to 8-10 minute duration (aerobic capacity--not endurance) Can use prognostic power of METs
Slide 18 : Estimated vs Measured METs All Clinical Applications based on Estimated Estimated Affected by: Habituation (Serial Testing) Holding on Deconditioning and Disease State Measured Requires a Mouthpiece and Delicate Equipment Measured More Accurate and Permits measurement of Gas Exchange Anaerobic Threshold and Other Mxments (VE/VCO2) Prognostic in CHF and Transplantation
Slide 19 : WORK TREADMILL WORK TIME RAMP TIME WORK
Slide 20 : Why Ramp? Started with Research for AT and ST/HR but clinicaly helpful Individualized test Using Prior Test, history or Questionnaire Linear increase in heart rate Improved prediction of METs Nine-minute duration for most patients Requires special Treadmill controller or manual control by operator
Slide 21 : Should Heart Rate Drop in Recovery be added to ET? Long known as a indicator of fitness: perhaps better for assessing physical activity than METs Recently found to be a predictor of prognosis after clinical treadmill testing Does not predict angiographic CAD Studies to date have used all-cause mortality and failed to censor
Slide 22 : Heart Rate Drop in Recovery Probably not more predictive than Duke Treadmill Score or METs Studies including censoring and CV mortality needed Should be calculated along with Scores as part of all treadmill tests
Slide 23 : Heart Rate Drop in Recovery vs METs 10 to 15% increase in survival per MET Can be increased by 25% by a training program What about Heart Rate Recovery???
Slide 24 :
Slide 25 :
Slide 26 : Diagnosis vs Prognosis Maximal Heart Rate vs METs
Slide 27 : AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing Diagnosis CAD Prognosis with symptoms/CAD After MI Using Ventilatory Gas Analysis Special Groups
Slide 28 : AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing Special Groups: Pre- and Post-Revascularization Women Asymptomatic Pre-surgery Valvular Heart Disease Cardiac Rhythm Disorders
Slide 29 : The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test Class I (Definitely appropriate) - Adult males or females (including RBBB or < 1mm resting ST depression) with an intermediate pre-test probability of coronary artery disease based on gender, age and symptoms (specific exceptions are noted under Class II and III below). Class IIa (Probably appropriate) - Patients with vasospastic angina.
Slide 30 : Pre Test Probability of Coronary Disease by Symptoms, Gender and Age
Slide 31 : Diagnostic Use, continued: Class IIb (Maybe appropriate) – Patients taking Digoxin with less than 1 mm resting ST depression. Patients with ECG criteria for left ventricular hypertrophy with less than 1 mm ST depression. Patients with a high pre-test probability of coronary artery disease by age, symptoms and gender. Patients with a low pre-test probability of CAD by age, symptoms and gender.
Slide 32 : Diagnostic Use, continued: Class III (Not appropriate) - 1. To use the ST segment response in the diagnosis of coronary artery disease in patients who demonstrate the following baseline ECG abnormalities: pre-excitation (WPW) syndrome; electronically paced ventricular rhythm; more than one millimeter of resting ST depression; LBBB 2. To use the ST segment response in the diagnosis of coronary artery disease in MI patients
Slide 33 : Comparison of Tests for Diagnosis of CAD
Slide 34 : Males Choose only one per group <40=low prob 40-60= intermediate probability >60=high probability
Slide 35 : Women Choose only one per group <37=low prob 37-57= intermediate probability >57=high probability
Slide 36 : The ACC/AHA Guidelines for the Prognostic Use of the Standard Exercise Test Indications for Exercise Testing to Assess Risk and prognosis in patients with symptoms or a prior history of coronary artery disease: Class I. Should be used: Patients undergoing initial evaluation with suspected or known CAD. Specific exceptions are noted below in Class IIb. Patients with suspected or known CAD previously evaluated with significant change in clinical status.
Slide 37 : Prognostic Use, continued: Class IIb. Maybe Appropriate for: Patients who demonstrate the following ECG abnormalities: Pre-excitation (WPW) syndrome; Electronically paced ventricular rhythm; More than one millimeter of resting ST depression; and LBBB. Patients with a stable clinical course who undergo periodic monitoring to guide management
Slide 38 : Prognostic Use, continued: Class IIa. Probably Appropriate: None Class III. Should not be used for prognostication: Patients with severe comorbidity likely to limit life and/or consideration for revascularization procedures
Slide 39 : Endpoints for Prediction of Prognosis Why is this even an issue?? Confusion All-cause certainly best for interventional studies CV mortality more appropriate outcome for CV tests
Slide 40 : DUKE Treadmill Score for Stable CAD METs - 5 X [mm E-I ST Depression] - 4 X [Treadmill Angina Index] ******Nomogram******* E-I = Exercise Induced
Slide 41 : Duke Treadmill Score (uneven lines, elderly?)
Slide 42 : “All-comers” prognostic score SCORE = (1=yes, 0=no) METs<5 + Age>65 + History of CHF + History of MI or Q wave a=0, b=1, c=2, d=more than 2
Slide 43 : But Can Physicians do as well as the Scores? 954 patients - clinical/TMT reports Sent to 44 expert cardiologists, 40 cardiologists and 30 internists Scores did better than all three but was most similar to the experts
Slide 44 : Key Points of Exercise Testing Manual SBP measurement (not automated) most important for safety Adjust to clinical history (couch potatoes) No Age predicted Heart Rate Targets The BORG Scale of Perceived Exertion METs not Minutes Fit protocol to patient (RAMP) Avoid HV and cool down walk Use standard ECG analysis/ 3 minute recovery/ use scores Heart rate recovery Expired Gas Analysis?
Slide 45 : What is the most important prognostic measurement from the exercise test? 1. BORG scale estimate 2. ST depression 3. Exercise time 4. Exercise capacity Question 1
Slide 46 : What is the most appropriate indicator of a maximal effort? 1. BORG scale 2. ST depression 3. Heart rate 4. Exercise capacity Question 2
Slide 47 : All references are available as pdf files on www.cardiology.org along with scores and sample report generator
Slide 48 : Thank you
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