Section 5

### Section 5: Alternative Non-invasive Cardiac Procedures

The ACC/AHA guidelines recommend that stress imaging preferentially be performed rather than an exercise treadmill test in all of the following except?

a. prior revascularization.

b. left bundle branch block.

c. elderly patients (≥70 years).

d. ventricular pre-excitation.

c. Patients who have undergone prior revascularization already have an established diagnosis and treatment for an abnormal study is often based on location and severity of ischemia, thereby providing a rationale for imaging use. Ventricular pre-excitation is often associated with an abnormal ECG response (false positive) and left bundle branch block makes exercise ECG uninterpretable with regards to the detection of myocardial ischemia. For elderly patients with an interpretable ECG, routine ECG exercise testing is preferred.

A 57-year-old man with a history of atypical chest pain exercises 12 min on a Bruce protocol achieving 90% of his maximum predicted heart rate with a normal blood pressure response. Exercise symptoms included non-limiting angina. The electrocardiogram demonstrates 1 mm of horizontal ST-segment depression at peak exercise. Based on this exercise treadmill test, the patient's estimated annual cardiovascular mortality is which of the following?

a. 0.25%.

b. 1.25%.

c. 5%.

d. 10%.

b. This patient's functional capacity is quite good, therefore not placing him in a high-risk category, with 5% or 10% annual mortality. However, his risk is not negligible (0.25%).

Which of the following statements regarding standard exercise treadmill testing (ETT) and exercise SPECT imaging is false?

a. ETT is as effective as exercise SPECT for risk stratification in patients with a normal electrocardiogram.

b. Annual cardiovascular mortality in patients with a low-risk Duke treadmill score is <1%.

c. The charge for an ETT is five to seven times higher than an exercise SPECT study.

d. Exercise SPECT is the appropriate first test in patients at low clinical risk with a normal resting electrocardiogram who are able to exercise.

d. Based on the appropriate use criteria and clinical practice guidelines, routine ECG stress testing (without imaging) is recommended for patients at low clinical risk who are able to exercise and have an interpretable electrocardiogram.

The addition of ECHO imaging to treadmill stress testing can be beneficial due to which of the ...

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