Overview

The goal of cardiac testing is to help stratify

patients thought to be at risk for symptomatic
coronary artery disease, specifically for short-term
complications such as myocardial infarction (MI)
or sudden cardiac death. Risk stratification of chest
pain patients in the emergency department (ED) or
other outpatient settings also includes interpretation
of the history, physical examination, ECG, and,
when indicated, cardiac biomarkers. Cardiac testing
encompasses diagnostic coronary angiography
(invasive) or a variety of noninvasive tests.This
article focuses on the noninvasive testing
modalities and their role in risk-stratifying ED
patients and other outpatients. The tests reviewed
include exercise stress testing; pharmacologic
stress testing; myocardial perfusion imaging; stress
echocardiography; and cardiac CT, MRI, and
positron emission tomography (PET) scanning.
These noninvasive tests can be performed in an
outpatient setting, in a physician's office, in a
hospital, or in an observation unit, as well as for
admitted inpatients.

An understanding of these tests is important to for
2 primary reasons. First, patients frequently present
that have undergone prior noninvasive testing.
Knowing the value and limitations of that testing
can be valuable in the care of such patients.
Second, with the recent expansion of observation
medicine, it has become the responsibility of
emergency physicians to choose and utilize the
results of noninvasive cardiac testing in many
hospitals. Noninvasive cardiac testing is an
important adjunct to the broader scheme used to
risk stratify chest pain patients. Use of cardiac
biomarkers alone without additional noninvasive
testing has not been shown to confer a low-enough
risk to safely discharge a large proportion of
emergency department chest pain patients.[1, 2, 3]

Explicitly or implicitly physicians use a Bayesian
model to interpret results of cardiac tests. They
generate a pretest probability of disease for an
individual patient based on history, ECG,
laboratory results, and other clinical factors. Then
by using the sensitivity and specificity of a given
test for the population of interest, a post-test
probability is calculated which can guide decision
making. In day-to-day practice, this is performed
Prezentare general
Scopul de testare cardiace este de a ajuta stratifica
pacientii considerati a fi la risc pentru boal
arterial coronarian simptomatic , n special
pentru complicatii pe termen scurt , cum ar fi
infarct miocardic (IM ) sau de moarte subita de
cauza cardiaca . Stratificare a riscului de pacienti
cu durere in piept in departamentul de urgenta ( ED
) sau alte ambulatoriu include, de asemenea,
interpretarea de istorie , examenul fizic , ECG , i ,
atunci cnd este indicat , biomarkerilor cardiaci .
Testarea cardiace cuprinde angiografia coronariana
de diagnostic ( invazive ), sau o varietate de articol
tests.This neinvaziv se concentreaz asupra
modalitilor de testare neinvaziv si rolul lor la
pacientii ED risc - stratificare i alte ambulatoriu .
Testele analizate includ testarea exercitiu de stres ,
teste de stres farmacologic , imagini perfuziei
miocardic , ecocardiografia de stres , si cardiace CT
, RMN , iar cu emisie de pozitroni ( PET ) de
scanare . Aceste teste noninvazive pot fi efectuate
n ambulatoriu , n biroul unui medic , ntr- un
spital , sau ntr- o unitate de observare , precum i
pentru inpatients admise .

O nelegere a acestor teste este important s se
pentru 2 motive principale . n primul rnd ,
pacienii prezint frecvent , care au fost supuse
unor teste nainte de neinvaziv . Cunoscnd
valoarea i limitrile de testare care pot fi valoroase
n ngrijirea acestor pacieni . n al doilea rnd , cu
extinderea recent a medicinei observaie , aceasta
a devenit responsabilitatea de medici de urgenta a
alege i de a utiliza rezultatele testelor cardiace
neinvaziv in mai multe spitale . Testarea cardiac
neinvaziv este un adjuvant important pentru
schema de mai larg utilizat pentru risc stratificarea
pacientii cu durere in piept . Utilizarea
biomarkerilor cardiaci singur, fr teste
suplimentare neinvaziv nu a fost demonstrat pentru
a conferi un risc sczut suficient s-i ndeplineasc
n condiii de siguran o mare parte din
departamentul de urgenta pacientii cu durere in
piept [ 1 , 2 , 3 ] .

n mod explicit sau implicit, medicii utilizeaza un
model de Bayesian pentru a interpreta rezultatele
testelor cardiace . Ele genereaz o probabilitate pre-
test de boal pentru un anumit pacient pe baza
istoricului , ECG , rezultatele de laborator , i de
ali factori clinice . Apoi, folosind sensibilitatea i
more qualitatively than quantitatively. In addition,
this process is reflected in diagnostic protocols for
chest pain.

This article discusses the physiology, technique,
interpretation, and utility of the most common
noninvasive cardiac tests.

Exercise Tolerance Test
Test physiology and technique
Physical exercise places stress on the
cardiopulmonary system. The physiologic response
to exercise stress increases myocardial oxygen
demand in response to increased heart rate and
systolic blood pressure. The ECG response and
development of angina in response to exercise
closely correlates with myocardial ischemia due to
obstructive coronary artery disease. Exercise
capacity is reduced by myocardial ischemia but is
also influenced by many other factors. The goal of
exercise testing in the setting of acute chest pain is
typically to evaluate for coronary ischemia and not
for exercise capacity per se. A typical clinical
paradigm anticipates discharge to home of patients
with a negative initial evaluation (H+P, ECG, chest
radiograph, negative cardiac biomarkers), and a
negative exercise test.

Multiple protocols exist for exercise tolerance tests.
A bicycle ergometer or treadmill is most often
used. The goal is to increase workload
incrementally to induce ischemia or until a
predetermined workload is reached. One common
protocol is to have the patient start walking on a
treadmill and then to increase the treadmill speed
and gradient until the patient experiences
symptoms or ECG changes, the heart rate or blood
pressure reaches preset limits, or the patient reaches
a predetermined metabolic workload.

Multiple studies have validated the safety and
efficacy of exercise testing in low-risk chest pain
patients. Low risk, in this context, is defined as
patients presenting with chest pain who remain
pain-free during a 6- to 12-hour period of
observation and have normal initial and repeat
cardiac biomarker levels.[4] It is also assumed that
other serious diagnoses such as pulmonary
embolism or aortic dissection are not present.
Studies have also reported on the safety and
efficacy of "immediate" exercise testing in low-risk
specificitatea unui anumit test pentru populaia de
interes , o probabilitate post- test este calculat,
care poate ghida de luare a deciziilor . n practica
de zi cu zi , aceasta se realizeaz mai calitativ dect
cantitativ . In plus , acest proces se reflect n
protocoalele de diagnostic pentru dureri n piept .

Acest articol discut despre fiziologia , tehnica ,
interpretare , i utilitatea cele mai comune teste
cardiace neinvazive .

Exercitarea Toleranta de testare
Fiziologie de testare i tehnic
Exerciii fizice locuri de stres pe sistemul
cardiorespirator . Rspunsul fiziologic de a exercita
stres crete necesarul de oxigen miocardic , ca
raspuns la cresterea ritmului cardiac si a tensiunii
arteriale sistolice . Rspunsul ECG i dezvoltarea
de angina pectorala , ca raspuns la exercitarea
strns legtur cu ischemie miocardic din cauza
bolii coronariene obstructive . Capacitatea de efort
este redus cu ischemie miocardic , dar este , de
asemenea, influenat de muli ali factori . Scopul
testului de efort n stabilirea de durere toracica
acuta este de obicei pentru a evalua pentru ischemie
coronarian i nu de capacitatea de exerciiu n sine
. O paradigm clinic tipic anticipeaza descrcarea
de gestiune a pacientilor la domiciliu cu o evaluare
initiala negativ ( H + P , EKG , radiografie toracica
, biomarkerilor cardiaci negativi ) , i un test de
efort negativ .

Exist protocoale multiple pentru testele de
toleranta la efort . O bicicleta ergometrica sau
banda de alergat este cel mai des folosit . Scopul
este de a crete volumul de munc treptat pentru a
induce ischemie sau pn cnd se ajunge la un
volum predeterminat . Un protocol comun este de a
avea la nceput pacientul mers pe jos pe o banda de
alergat i apoi pentru a crete viteza de banda de
alergat i de pant pn pacientul prezint
simptome sau modificri ECG , rata inimii sau
tensiune arterial atinge limite prestabilite , sau ce
pacientul ajunge la un volum de munc metabolice
predeterminat .

Multiple studii au validat siguranta si eficacitatea
de testul de efort la pacientii cu durere in piept cu
risc sczut . Risc sczut , n acest context , este
definit ca pacienii care se prezint cu durere in
piept care rmn fr durere n timpul unei 6 - . La
patients who have normal initial ECG findings and
initial biomarker levels and are not serially
evaluated prior to stress testing.[5]

Certain patients do not benefit from exercise
electrocardiography; this group includes patients
with resting ECG abnormalities (left bundle-branch
block, paced rhythm, preexcitation syndromes, or
1 mm ST depressions at rest), inability to
exercise, and others. Test interpretation may be
compromised in patients taking certain medications
such as digoxin, beta-blockers, certain calcium
channel blockers, and other antihypertensive
medications. Other tests, such as nuclear cardiac
scanning, may be useful in this subgroup. In
addition, clinicians should be familiar with
contraindications to stress testing prior to ordering
or performing the test. Contraindications include
the following.

Acute MI
Sustained ventricular arrhythmias, SVT, high-grade
heart block
Wellens syndrome (highly correlated with CAD
and sudden death), shown in the image
belowClassic Wellens syndrome T-wave changes.
This ECG
Classic Wellens syndrome T-wave changes. This
ECG represents a patient after becoming pain free
secondary to medications. Notice the deep T waves
in V3-V5 and slight biphasic T wave in V6 in this
chest pain free ECG. The patient had negative
cardiac enzyme levels and later had a stent placed
in the proximal left anterior descending (LAD)
artery.
Aortic stenosis (hemodynamically significant)*
Severe hypertension*
Serious coexisting illness (eg, pneumonia, DKA)
Symptomatic CHF
Active venous thromboembolic disease (DVT, PE)
Pericarditis, myocarditis, endocarditis
*May be candidates for pharmacologic stress
testing

Test interpretation
Exercise tolerance test (ETT) results are centered
on the ST response, with ST depression greater
than or equal to 1 mm signifying a positive test
result. The probability and severity of coronary
artery disease is related directly to the amount of
depression and to the down-slope of the ST
perioada de 12 de ore de observaie i au valori
normale iniiale i repetate biomarker cardiace [ 4 ]
De asemenea, se presupune c alte diagnostice
grave , cum ar fi embolie pulmonara sau disectie
aortica nu sunt prezente . Studiile au raportat , de
asemenea, cu privire la sigurana i eficacitatea
testului de efort " imediat " la pacientii cu risc
scazut , care au constatari ECG iniiale normale i
nivelurile iniiale biomarker si nu sunt evaluate n
serie nainte de teste de stres . [ 5 ]

Unii pacieni nu beneficiaz de exercitarea
electrocardiografie , acest grup include pacienti cu
anomalii ECG de repaus ( stnga bloc de ramur ,
ritmul alert , sindroame preexcitatie , sau 1 mm
depresiuni ST n repaus ) , incapacitatea de a-i
exercita , i altele . Interpretarea testului poate fi
compromis la pacienii care iau anumite
medicamente , cum ar fi digoxina , beta - blocante ,
blocante ale canalelor de calciu anumite , i alte
medicamente antihipertensive . Alte teste , cum ar
fi scanarea cardiace nuclear , pot fi utile n acest
subgrup . n plus , medicii trebuie s fie familiarizat
cu contraindicaii pentru testul de stres nainte de a
comanda sau de efectuarea testului . Contraindicaii
includ urmtoarele .

IM acut
Aritmii ventriculare susinute , SVT , bloc cardiac
de grad nalt
Sindromul Wellens ( foarte corelat cu CAD i
moarte subit ) , se arat n imaginea de
belowClassic sindromul Wellens modificrile undei
T . acest ECG
Classic Wellens sindrom modificrile undei T .
Aceasta ECG reprezint un pacient dup ce durere
gratuit secundar de medicamente . Observai undele
T adnci n V3 - V5 i uoar und T bifazic n V6
n acest piept durere ECG . Pacientul a avut un
nivel de enzime cardiace negative, i mai trziu a
avut un stent plasat n segmentul proximal anterior
descendent arterei ( LAD ) .
Stenoza aortica ( hemodinamic semnificativ ) *
Hipertensiune arterial sever *
Boli coexistente grave ( de exemplu , pneumonie ,
DKA )
ICC simptomatic
Boal tromboembolic venoas activ ( TVP , PE )
Pericardita , miocardita , endocardita
* Poate fi candidai pentru teste de stres
farmacologic
segment. Severity of coronary artery disease and
prognosis is correlated with the lower workload at
which ST-segment depression occurs.

ST-segment elevation in patients with no Q waves
on the resting ECG is a rare finding, which
signifies significant ischemia. ST-segment
elevation in leads with previous Q waves appears to
be related to the presence of dyskinetic areas or
ventricular aneurysms, which does not signify
acute ischemia.

Clinical responses
Patients are instructed to terminate the test for
significant chest pain, as chest pain consistent with
angina constitutes a positive test. Chest pain
becomes more predictive of coronary artery disease
if it is associated with ST depression. Signs of poor
perfusion, such as a drop in skin temperature or
peripheral cyanosis and symptoms of
lightheadedness or vertigo, may indicate inadequate
cardiac output.

Exercise capacity
Exercise capacity frequently is reported in
metabolic equivalents of task (METs). METs
indicate units equivalent to the metabolic
equivalent of resting oxygen uptake while sitting.
An exercise capacity of 5 METs or less is
associated with a poor prognosis in patients
younger than 65 years. In patients with CAD,
exercise capacity of at least 10 METs signifies a
good prognosis with medical therapy, similar to
that of coronary artery bypass surgery. An exercise
capacity of 13 METs indicates a good prognosis
even with an abnormal exercise ECG response.[6]

Hemodynamic responses
Systolic blood pressure at peak exertion is
considered a clinically useful estimation of the
inotropic capacity of the heart. A drop of systolic
blood pressure below that at rest is associated with
increased risk in patients with a prior myocardial
infarction (MI) or myocardial ischemia. Heart rate
response to exercise can be affected by left
ventricular dysfunction, ischemia, cardioactive
drugs, or autonomic dysfunction. Chronotropic
incompetence, defined as failure to achieve 80% of
the age-predicted maximum exercise heart rate,
was associated with an 84% increase in all-cause
mortality over 2 years in a 1996 Cleveland Clinic

interpretarea testului
Exercitarea toleran de testare ( ETT ) Rezultatele
sunt centrate perspunsul ST , cu depresie ST mai
mare sau egal cu 1 mm semnificnd un rezultat
pozitiv. Probabilitatea i severitatea bolii
coronariene este legat direct de cantitatea de
depresie i de declivitate al segmentului ST .
Severitatea bolii coronariene si prognosticul este
corelat cu volumul de munc inferior la care apare
depresia de segment ST .

Supradenivelare de segment ST la pacienii care nu
au unde Q pe ECG de repaus este o constatare rar ,
care semnific ischemie semnificativ .
Supradenivelare de segment ST n derivaiile cu
valuri anterioare Q pare a fi legat de prezena
zonelor dyskinetic sau anevrisme ventriculare , care
nu semnifica ischemie acut .

rspunsurile clinice
Pacientii sunt instruiti pentru a termina testul de
dureri in piept semnificative , precum dureri n
piept n concordan cu angin constituie un test
pozitiv . Dureri n piept devine mai mult de
predictie a bolii coronariene n cazul n care acesta
este asociat cu depresia ST . Semne de perfuzie
srace , cum ar fi o scdere a temperaturii pielii sau
cianoza periferica si simptome de vertij ameeli sau
, poate indica debitul cardiac inadecvat .

capacitate de exercitiu
Capacitate de exercitiu frecvent este raportat in
echivalent metabolice ale sarcinii ( Mets ) . Mets
indica uniti echivalente cu echivalentul
metabolice de repaus consumului de oxigen n timp
ce edinei . O capacitate de exercitiu de 5 Mets sau
mai puin este asociata cu un prognostic slab la
pacientii mai tineri de 65 de ani . La pacienii cu
CAD , capacitatea de efort de cel puin 10 Mets
semnific un prognostic bun cu terapie
medicamentoas , similar cu cea a coronare
bypass chirurgie . O capacitate de exercitiu de 13
Mets indic un prognostic bun chiar i cu un
rspuns anormal ECG de efort . [ 6 ]

de raspunsuri hemodinamice
Tensiunea arterial sistolic la efort vrf este
considerat o estimare clinic util alcapacitii inotrop
alinimii . O scadere a tensiunii arteriale sistolice de
mai jos , care n repaus este asociat cu un risc
Study.[7] The heart rate recovery pattern, or change
in heart rate after the patient stops exercising, also
has prognostic significance, as do changes in blood
pressure, with a slower reversion to the patient's
baseline vital signs associated with higher long-
term mortality.

Test utility
The American College of Cardiology and the
American Heart Association performed a meta-
analysis of the diagnostic accuracy of exercise
stress testing on 147 consecutively published
reports involving 24,045 patients who underwent
coronary angiography and ETT. The results
indicated a mean sensitivity of 68% (range, 23-
100%; standard deviation, 17%) and a mean
specificity of 77% (range, 17-100%; standard
deviation, 17%). When the studies that included
patients with a previous MI were excluded, the
meta-analysis involving 11,691 patients showed a
mean sensitivity of 67% and mean specificity of
72% of exercise stress testing for diagnosing
coronary artery disease.

The few studies that removed workup bias by
having patients agree to undergo both procedures
beforehand showed a sensitivity of 50% and a
specificity of 90%.[8] However, the purpose of
stress testing in the context of the ED evaluation of
chest pain is not to definitively rule coronary artery
disease in or out. Rather, it is a short-term
prognostic tool to aid in the safe disposition of
patients. Studies have shown excellent short-term
(1-6 mo) cardiovascular prognosis for patients
discharged from the ED or observation unit after a
negative exercise test result.[9]

Myocardial Perfusion Imaging
The American College of Radiology guidelines for
imaging state that in patients with active chest pain,
an ECG with no ischemic changes, and an initial
negative troponin result, rest SPECT has been
demonstrated to be the "test of choice." However, it
has been shown to be less sensitive than stress
SPECT imaging if performed after the chest pain
has subsided. Abundant literature describes the use
of SPECT in suspected ACS. The absence of a
perfusion defect on an acute rest study is associated
with a very high negative predictive value for ACS
evaluation. A perfusion defect that becomes
apparent or becomes larger during exercise stress
crescut la pacientii cu infarct miocardic n
antecedente ( IM ) sau ischemie miocardic .
Rspunsul frecvenei cardiace la efort pot fi
afectate de disfuncia ventricular stng , ischemie
, droguri cardioactive , sau cu tulburare vegetativ .
Incompeten cronotrop , definit ca incapacitatea
de a atinge 80 % din varsta a prezis ritmul cardiac
maxim exerciiu , a fost asociat cu o cretere de 84
% a mortalitatii de toate cauzele de peste 2 ani intr-
un 1996 Cleveland Clinic de studiu . [ 7 ] Rata de
model de recuperare a inimii , sau modificarea
ritmului cardiac dupa ce pacientul nu mai exercit ,
de asemenea, are semnificatie de prognostic , cum
fac modificari ale tensiunii arteriale , cu o revenire
mai lent la baz semnele vitale ale pacientului
asociate cu o mortalitate mai mare pe termen lung .

utilitar de testare
Colegiul American de Cardiologie si American
Heart Association efectuat o meta - analiza a
precizie de diagnosticare de testare a stresului
exerciiu la 147 de rapoarte publicate consecutiv
care implica 24045 de pacienti care au suferit
angiografia coronariana si ETT . Rezultatele au
indicat o sensibilitate medie de 68 % ( interval , 23-
100 % ; deviaia standard , 17 % ) i o specificitate
medie de 77 % ( interval , 17-100 % ; deviaia
standard , 17 % ) . Cnd au fost excluse de studii
care au inclus pacieni cu IM anterior ,meta -
analiza care implica 11691 de pacienti au aratat o
sensibilitate medie de 67 % i specificitate de 72 %
din teste de efort pentru diagnosticarea bolii
coronariene spun .

Cele cateva studii care eliminate prtinire workup
de catre pacientii sunt de acord s se supun
ambele proceduri au artat n prealabil o
sensibilitate de 50% i o specificitate de 90 % . [ 8 ]
Cu toate acestea , n scopul de teste de stres n
contextul evalurii ED de durere toracica este nu s
se pronune definitiv boli coronariene sau afar .
Mai degrab , acesta este un instrument de
prognostic pe termen scurt pentru a ajuta la
dispoziie n condiii de siguran a pacienilor .
Studiile au demonstrat pe termen scurt ( 1-6 MO)
prognoza cardiovascular excelent pentru pacientii
evacuate din unitatea de ED sau de observare dupa
un rezultat negativ test de efort . [ 9 ]

Perfuzie miocardica Imaging
Colegiul American de Radiologie linii directoare
or pharmacologic stress defines ischemic
myocardium.[10]

One difficulty that arises is when the
electrocardiographic evidence and myocardial
perfusion imaging on a stress test disagree. Soman
et al studied 473 patients with chest pain, and two
thirds of whom had abnormal ST segment response
to exercise. In this study, normal technetium-99
sestamibi SPECT study results were associated
with an annual mortality rate of 0.2%.[11] When
interpreting stress tests, more importance is
generally placed on the myocardial perfusion
results than the electrocardiographic results.

Test limitations
A technetium-99 sestamibi scan exposes a patient
to approximately 8 millisieverts of radiation. This
is roughly half the radiation exposure from a chest
or abdomen CT. The thallium test exposure is
approximately equal to that of a CT.

Equivocal results can result from poor image
quality. Interference by breast tissue or the
diaphragm can impair image quality in some
patients.

Stress Echocardiography
Test physiology and technique
Another method of detecting coronary artery
disease is to perform echocardiography while the
heart is undergoing exercise or pharmacologically
induced ischemia. Wall motion abnormalities can
be visualized with the technique. The exercise is
performed using a treadmill or a bicycle ergometer.
If a treadmill is used, images are obtained prior to
exercise and then within 60-90 seconds of
completing exercise. Bicycle ergometry has the
advantage of being able to perform the
echocardiogram at different stages of exercise.
Supine ergometry provides the most information
since 4 cardiac views can be obtained. Dobutamine
is the most common pharmacologic agent used in
conjunction with echocardiography. Image quality
can be enhanced by injection of echogenic
microbubbles.

Test interpretation
A positive stress echocardiogram is defined by
stress-induced decrease in regional wall motion,
decreased wall thickening, or regional
pentru stat imagini ca la pacientii cu durere in piept
activ , un ECG cu modificri ischemice , i un
rezultat initial troponinei negativ , restul SPECT a
fost demonstrat a fi " testul de alegere . " Cu toate
acestea , ea sa dovedit a fi mai puin sensibile dect
stres SPECT dac efectuate dup dureri in piept a
disprut . Literaturii abundente descrie utilizarea
SPECT la ACS suspectate . Absena unui defect de
perfuzie pe un studiu de odihn acut este asociat
cu o valoare predictiv negativ foarte mare pentru
evaluarea ACS . Un defect de perfuzie care devine
aparent sau devine mai mare n timpul de efort sau
stres farmacologic definete miocardului ischemic .
[ 10 ]

O dificultate care apare este atunci cnd dovada
electrocardiografice i imagini perfuziei miocardic
pe un test de stres nu sunt de acord . Soman colab
au studiat 473 de pacienti cu dureri in piept , i din
care doua treimi au avut anormale rspuns segment
ST s-i exercite . n acest studiu , normale
techneiu - 99 Sestamibi SPECT Rezultatele
studiului au fost asociate cu o rata de mortalitate
anual de 0,2 % [ 11 ] Cnd interpretarea testelor
de stres , mai important este, n general plasat pe
rezultatele perfuziei miocardice dect rezultatele
electrocardiogramei. .

limitri de testare
Un techneiu - 99 sestamibi scanare expune un
pacient la aproximativ 8 milisievert de radiaii .
Aceasta este aproximativ jumtate din expunerea la
radiatii de la un piept sau CT abdomen . Expunerea
Testul taliu este aproximativ egal cu cea a unui
CT .

Rezultatele nesigure poate duce la calitatea slab a
imaginii . Interferena cu tesutul mamar sau
diafragma poate afecta calitatea imaginii la unii
pacienti .

Ecocardiografia de stres
Fiziologie de testare i tehnic
O alt metod de detectare a bolii coronariene este
de a efectua ecocardiografie , n timp ce inima este
n curs de exercitarea sau ischemie indus
farmacologic . Anomalii de micare de perete pot fi
vizualizate cu tehnica . Exerciiu se realizeaz cu
ajutorul unui banda de alergat sau o bicicleta
ergometrica . n cazul n care se folosete o band
de alergare , imaginile sunt obinute nainte de a
compensatory hyperkinesis. In experienced hands,
this can have a diagnostic accuracy similar to that
of nuclear stress testing. However, results are
operator dependent.[12]

Test utility
Advantages to stress echocardiography are that it is
a faster test to perform than a nuclear stress test
because delayed images are obtained much sooner.
It has no associated radiation exposure. It is less
costly than nuclear stress testing, and therefore
performs well on cost analysis studies. The test can
be more readily performed in an office setting.

In a meta-analysis that included data from 24
studies, Fleischmann et al found that exercise
echocardiography had a sensitivity of 85% and a
specificity of 77% when compared with coronary
angiography. The results were felt to be similar to
those for SPECT imaging.[13]

Test limitations
As stated above, the test is dependent on the
experience of the operator. Obesity, lung disease,
and tachycardia can limit image quality. Up to 10%
of cases have inadequate image quality.

Computed Tomography
Test methodology
Calcium deposits are commonly found in
atherosclerotic coronary plaques. The total amount
of coronary calcium is predictive of future cardiac
events. Cardiac computed tomography (CCT) can
measure the density and extent of calcifications in
coronary artery walls. The technique of CCT was
established with electron beam scanners, but it has
been refined and made more widely available with
the introduction of multidetector scanners. The
technique relies on ECG "gating" to compensate
for cardiac motion. No contrast is used. The
coronary lumen itself is not visualized. A related
technique is cardiac CT angiography (CCTA).
CCTA uses intravenous contrast material to
provide direct visualization of the coronary lumen.
Gating is also used to decrease motion artifact.
CCTA has been shown to have good correlation
with the criterion standard of conventional
coronary angiography.

Coronary CTA techniques are under rapid
development. A low and regular heart rate
exercita i apoi n 60-90 de secunde de la
terminarea exerciiului . Biciclete ergometrie are
avantajul de a fi capabil de a
efectuaecocardiografie la diferite etape de exerciiu
. Ergometrie culcat pe spate ofer cele mai multe
informaii din 4 vizualizri cardiace pot fi obinute .
Dobutamina esteagent farmacologic mai frecvent
utilizat n conjuncie cu ecocardiografie . Calitatea
imaginii poate fi mbuntit prin injectarea de
microbule echogenic .

interpretarea testului
O ecocardiografie de stres pozitiv este definit prin
scaderea stresului indus n micare perete regional ,
scderea ingrosarea peretelui , sau hiperkinezie
compensatorii regionale . n mini cu experien ,
aceasta poate avea o precizie de diagnostic similar
cu cel de testare a stresului nucleare . Cu toate
acestea , rezultatele depind de operator . [ 12 ]

utilitar de testare
Avantaje pentru ecocardiografia de stres sunt c
acesta este un test rapid pentru a efectua dect un
test de stres nuclear , deoarece imaginile ntrziate
se obin mult mai devreme . Ea nu are nici o
expunere la radiaii asociat. Este mai puin
costisitoare dect testele de stres nucleare , i , prin
urmare, funcioneaz bine pe studii de analiz a
costurilor . Testul poate fi efectuat mai uor ntr- un
decor de birou .

ntr-o meta - analiza care a inclus datele de la 24 de
studii , Fleischmann et al constatat c exercitarea
ecocardiografie a avut o sensibilitate de 85 % i o
specificitate de 77% n comparaie cu angiografia
coronariana . Rezultatele s-au considerat a fi
similare cu cele de imagistica SPECT . [ 13 ]

limitri de testare
Aa cum se menioneaz mai sus ,testul este
dependent deexperienaoperatorului . Obezitate,
boli pulmonare , i tahicardie pot limita calitatea
imaginii . Pn la 10 % din cazuri au o calitate
necorespunztoare imaginii .

Tomografia computerizata
metodologia de testare
Depozitele de calciu sunt de obicei gsite n placi
aterosclerotice coronariene . Suma total de calciu
coronariene este de predictie a viitoarelor
evenimente cardiace . Tomografie computerizata
(typically sinus rhythm) is necessary for optimal
imaging, and it is often necessary to administer
beta-blockers to achieve an adequately low heart
rate (approximately 60-65 bpm or less). Studies
have shown that if a patient's heart rate can be
brought below 60 bpm, only about 3% of coronary
segments will be unevaluable by the CCTA, while
at 61-65 bpm, over 21% are unevaluable. Obtaining
optimal images with the least radiation exposure
depends on control of the heart rate.[14]

Test interpretation requires special training and is
usually performed by a radiologist or cardiologist.

Test outcomes and interpretation
The amount of calcium seen in coronary vessels on
CT is usually expressed as an "Agatston score,"
which is based on the area and the density of the
calcified plaques. A typical report provides an
Agatston score for the major coronary arteries as
well as a total Agatston score. A test result is
considered to be positive if any calcification is
detected within the coronary arteries. A positive
test result is nearly 100% specific for atheromatous
coronary plaque but not highly correlated with
obstructive disease. A negative test result has a 96-
100% negative predictive value for obstructive
lesions. Agatston scores of less than 10, 11-99,
100-400, and above 400 have been proposed to
categorize individuals into groups having minimal,
moderate, increased, or extensive amounts of
calcification, respectively.

Conversely, a study by Rosen et al found that
"although there is a significant relationship
between the extent of calcification and mean
degree of stenosis in individual coronary vessels,
16% of the coronary arteries with significant
stenoses had no calcification at baseline."[15]

Calcium scores greater than 1000 have been
associated with significant increases in morbidity
and mortality independent of other risk factors.
Scores greater than 100 are consistent with a high
risk (>2% annually) of a coronary event within 5
years. The amount of calcification can give, to
some extent, an indication of the overall amount of
atherosclerosis. In addition, a greater amount of
calcification and a higher Agatston score increase
the likelihood that coronary angiography will detect
significant coronary artery stenosis. However, there
cardiace ( CCT ) poate msura densitatea i gradul
de calcifications in peretii arterelor coronare .
Tehnica de CCT a fost stabilit cu electroni scanere
fascicul , dar acesta a fost rafinat i puse la
dispoziie pe scar mai larg cu introducerea
scanerelor multidetector . Tehnica se bazeaz pe
ECG " separarea " pentru a compensa miscare
cardiace . Este utilizat nici un contrast . Lumen
coronariene in sine nu este vizualizat . O tehnica
legate este cardiace CT angiografia ( CCTA ) .
CCTA foloseste substanta de contrast intravenos
pentru a oferi vizualizarea directa a lumenului
coronarian . Suprimare a fasciculului este de
asemenea folosit pentru a scdea artefact micare .
CCTA a fost dovedit a avea corelare bun cu
standardul criteriul de angiografia coronariana
conventionale .

Tehnicile coronare CTA sunt n curs de dezvoltare
rapid . O rat sczut i regulat inimii ( de obicei
ritm sinusal ) este necesar pentru imagistica optim
, i este adesea necesar s se administreze beta-
blocante pentru a atinge un ritm cardiac adecvat
sczut ( aproximativ 60-65 bpm sau mai puin ) .
Studiile au artat c, n cazul n care rata de inima
unui pacient poate fi adus sub 60 bpm , doar
aproximativ 3 % din segmente coronariene va fi
unevaluable de CCTA , n timp ce la 61-65 bti pe
minut , peste 21 % sunt unevaluable . Obtinerea de
imagini optime cu cel expunerea la radiatii depinde
de controlul ritmului cardiac . [ 14 ]

Interpretarea testului necesit o pregtire special i
este , de obicei, efectuat de ctre un radiolog sau
cardiolog .

Rezultate ale testelor i interpretare
Cantitatea de calciu observate la vasele coronariene
pe CT este de obicei exprimat ca o " plas Agatston
, " care se bazeaz pe suprafaa idensitatea de placi
calcifiate . Un raport tipic ofer un scor Agatston
pentru arterele coronariene majore , precum i un
scor total Agatston . Un rezultat al testului este
considerat pozitiv dac este detectat oricare
calcifiere n arterele coronare . Un rezultat pozitiv
al testului este de aproape 100 %, specific pentru
coronariana placi ateromatoase , dar nu foarte
corelat cu boli obstructive . Un rezultat negativ are
o valoare predictiva negativa 96-100 % pentru
leziunile obstructive . Scoruri Agatston de mai
puin de 10 , 11-99 , 100-400 , iar peste 400 au fost
is not a 1-to-1 relationship between a high score
and the presence of coronary artery stenosis. In
other words, a positive scan result indicates
atherosclerosis but not necessarily significant
stenosis.[16]

Individuals with Agatston scores greater than 400
have an increased occurrence of coronary
procedures (bypass, stent placement, angioplasty)
and events (myocardial infarction and cardiac
death) within the 2-5 years after the test.
Individuals with very high Agatston scores (>1000)
have a 20% chance of suffering a myocardial
infarction or cardiac death within a year. Even
among elderly patients (>70 y), who frequently
have calcification, an Agatston score greater than
400 was associated with a higher risk of death. In
one study, patients with calcium scores greater than
1000 were found to have a relative risk of death at
5 years of 4.03 (95% confidence interval [CI],
2.52-6.40). However, calcium scores reflect overall
risk and cannot be used to diagnose the presence of
an obstructing lesion.[17]

Test utility
Studies have investigated the use of CCT in the
ED. These studies report a negative predictive
value (NPV) of 97-100%. For example, in one
study, CCT was performed in 192 patients
presenting to the ED with chest pain, with an
average follow-up interval of 50 months. The
negative predictive value of the test was 99%.
Patients with the absence of coronary artery
calcium (CAC) had a 0.6% annual cardiovascular
event rate. In another study of ED chest pain
patients, a negative test result (absence of coronary
calcification) was associated with a very low
adverse event rate over a 7-year follow-up period.
Increasing score quartiles were strongly correlated
with risk (p< 0.001).[18] Another recent study
evaluated 1,031 patients admitted to an observation
unit with CCT. Only 2 events occurred in 625
patients with a calcium score of 0 (0.3%; 95%
confidence interval, 0.04-1.1%).[19]

The absence of detectable calcium has a very high
negative predictive value for ruling out obstructive
coronary artery disease and confers an excellent
long-term prognosis for future cardiac events.
Thus, use in low-risk patients is the most important
application of CCT. A negative predictive value of
propuse pentru a clasifica persoanele n grupuri
care au crescut , sau extinse sume minime ,
moderate , de calcifiere , respectiv .

n schimb , un studiu de Rosen et al constatat c "
dei exist o relaie semnificativ ntre gradul de
calcifiere si gradul de stenoza in vasele coronariene
individuale medie , 16 % din arterele coronariene
cu stenoze semnificative au avut nici o calcifiere la
momentul initial . " [ 15 ]

Scoruri de calciu mai mare de 1000 au fost asociate
cu cresteri semnificative in morbiditatii si
mortalitatii independent de alti factori de risc .
Scoruri mai mari de 100 sunt n concordan cu un
risc ridicat ( > 2 % anual ), a unui eveniment
coronarian termen de 5 ani . Suma de calcifiere pot
da , ntr-o oarecare msur , o indicaie de valoarea
total a aterosclerozei . n plus , o cantitate mai
mare de calcifiere i un scor mai mare Agatston
crete probabilitatea ca angiografia coronariana va
detecta stenoze coronariene semnificative . Cu
toate acestea , nu exist o relaie 1 - la - 1 ntre un
scor mare iprezena stenoza arterei coronare . Cu
alte cuvinte , un rezultat pozitiv scanare indic
ateroscleroza , dar nu neaprat stenoz
semnificativ . [ 16 ]

Persoanele cu scoruri Agatston mai mare de 400 au
o ocuren crescut a procedurilor coronariene ( by-
pass , plasarea de stent , angioplastie ) si
evenimente ( infarct miocardic i deces cardiac ), n
2-5 ani dup ncercare . Persoanele cu scoruri
foarte mari Agatston ( > 1000) au o sansa de 20 %
de a suferi un infarct miocardic sau deces cardiac in
termen de un an . Chiar si in randul pacientilor
varstnici ( > 70 Y ) , care au frecvent calcifiere , un
scor Agatston mai mare de 400 a fost asociat cu un
risc mai mare de deces . ntr-un studiu , pacientii cu
scoruri de calciu mai mare de 1000 s-au dovedit a
avea un risc relativ de deces la 5 ani de 4,03 ( 95 %
interval de incredere [ CI ] , 2.52-6.40 ) . Cu toate
acestea , scorurile de calciu reflecta riscul global i
nu poate fi folosit pentru diagnosticareaprezena
unei leziuni mascheaz [ 17 ] .

utilitar de testare
Studiile au investigatutilizarea CCT nED . Aceste
studii raporteaz o valoare predictiva negativa (
VAN ) de 97-100 % . De exemplu , ntr- un studiu ,
CCT a fost efectuat la 192 pacienti care prezinta la
98% has been reported for coronary chest pain or
myocardial infarction in patients with acute
symptoms and nonspecific ECG results.[20, 21]

As with other noninvasive techniques, CCT cannot
be used to identify or rule out the presence of an
unstable plaque. A problem with the use of CCT is
that calcification is present much more often than
significant stenosis. Most patients with coronary
calcification who go on to conventional invasive
catheter angiography will therefore not have
significant obstructive disease. CCTA may be a
less invasive alternative in these cases, but there are
limitations of the currently available data for
CCTA. These include the fact that most reports
have been based on single-center experiences and
have been conducted with a subset of symptomatic
middle-aged white men who had a high prevalence
of CAD. Multicenter trials and studies with
intermediate-risk populations are warranted.

Cardiac CT angiography (CCTA)
The studies evaluating CCTA are relatively small.
They have found good negative predictive value of
CCTA compared with the criterion standard of
catheter angiography. A normal CCTA study
reliably rules out significant stenosis.

Large outcome-based studies of CCTA in acutely
symptomatic patients are presently lacking. In one
study of CCTA in low-risk ED patients published
in abstract form, CCTA result was considered
negative if no vessel had more than a 50% stenosis
and the calcium score was less than 100. Patients
with a negative study result were discharged. Of
the 407 discharged patients, 402 had 30-day follow
up. None (0%) died from a cardiovascular cause,
needed revascularization, or had an MI. This result
has a 95% confidence interval of 0-0.9%. The
authors concluded that low-risk chest pain patients
with a negative CCTA result can be safely
discharged.[22]

Another representative study of 1,127 low- to
intermediate-risk patients followed for 15 months
showed that there were just 1 in 333 all-cause
deaths in the group with no visualized coronary
plaque.[23]

Further studies in various populations will define
the role of CCTA. However, it appears that enough
ED cu dureri in piept , cu o medie interval de
urmarire de 50 de luni. Valoarea predictiv
negativ atestului a fost de 99 % . Pacienii culipsa
de calciu arterei coronare ( CAC ) au avut o rat de
0,6 % anual eveniment cardiovascular . ntr-un alt
studiu de ED pacientii cu durere in piept , un
rezultat negativ ( lipsa de calcifiere coronariene ) a
fost asociata cu o rata de eveniment advers foarte
sczut pe o perioad de 7 ani de follow - up .
Creterea Cuartilele scor au fost puternic corelate
cu risc ( p < 0,001 ) . [ 18 ] Un alt studiu recent a
evaluat 1031 pacientii admisi la o unitate de
observare , cu CCT . Numai 2 evenimente au avut
loc la 625 de pacienti cu un scor de calciu de zero (
0,3 % , 95 % interval de ncredere , 0.04 - 1.1 % ) .
[ 19 ]

Lipsa de calciu detectabil are o valoare predictiv
negativ foarte mare pentru a exclude boli
coronariene obstructive i confer un prognostic
excelent pe termen lung pentru viitoarele
evenimente cardiace . Astfel , utilizarea la pacientii
cu risc scazut este cea mai important aplicaie a
CCT . O valoare predictiv negativ de 98 % a fost
raportata pentru dureri in piept coronariene sau
infarct miocardic la pacientii cu simptome acute i
rezultatele nespecifice ECG . [ 20 , 21 ]

Ca i n cazul altor tehnici neinvaziv , CCT nu pot
fi utilizate pentru a identifica sau excludeprezena
unei plci instabile . O problem cu utilizarea de
CCT este c calcifiere este prezent mult mai des
dect stenoz semnificativ . Cei mai multi pacienti
cu calcificarea coronariana , care merge pe la
angiografie conventionale cateter invazive , prin
urmare, nu vor avea boala semnificative obstructiva
. CCTA poate fi o alternativa mai putin invazive ,
n aceste cazuri , dar exist limitri ale datelor
disponibile n prezent pentru CCTA . Acestea
includ faptul c cele mai multe rapoarte au fost
bazate pe experiene singur centru i au fost
efectuate cu un subset de simptomatice barbati de
varsta mijlocie albi care au avut o prevalenta
ridicata de CAD . Studii multicentrice i studii cu
populatii cu risc intermediar sunt justificate .

Cardiace CT angiografia ( CCTA )
Studiile de evaluare CCTA sunt relativ mici . Ei au
descoperit bun valoare predictiva negativa a
CCTA , comparativ cu standardul criteriul de
angiografie cateter . Un studiu normala CCTA
evidence exists to allow safe discharge of patients
without acute ECG changes, elevated markers, and
benign CCTA examinations. Of course, this
assumes other serious causes of chest pain have
been considered and excluded as needed.

Future Directions in Testing
Magnetic resonance angiography
Cardiac magnetic resonance angiography (MRA)
allows visualization of coronary vessels without
radiation or contrast dye. With contrast and the
addition of vasodilators or dobutamine, MRA can
be used to assess myocardial viability as well. By
synchronizing image acquisition with the patient's
cardiac cycle, new protocols allow the patient to
breathe during the test. While cardiac MRI/MRA
continues to evolve, it shows promise as the only
imaging modality that can combine angiography
with perfusion and wall motion assessments.

A 2010 publication reported on the use of stress
MRI in an observation unit compared to routine
inpatient care in a group of nonlow-risk patients.
Thirty day outcomes were the same in both the
admitted group and the observation/MRI patients.
Observation/MRI patients had significantly lower
costs ($336-$811; 95% CI).[24]

Carotid intima-media thickness
Carotid artery ultrasonography and measurement of
the intima-media thickness is another area of
investigation. Observational studies have shown
that intima-media thickness is an independent
marker of cardiovascular risk, but whether it is
more accurate than traditional risk factors is
unclear. However, it could prove valuable as a
rapid, low-cost, low-risk test easily obtainable in
the emergency department.

Combined CT studies for chest pain evaluation: the
"triple rule out"
Conceptually, a CT scan with intravenous contrast
can combine imaging of the coronary arteries,
ascending aorta, and pulmonary arteries. This
allows assessment of coronary artery disease,
pulmonary embolism, and disease of the thoracic
aorta (dissection) with a single study. Technical
aspects of the study differ than for CCTA with a
wider field of view and a different protocol for the
administration of intravenous contrast. The
technique involves substantial cost and radiation
fiabil exclude stenoza semnificative .

Studiile mari bazate pe rezultate ale CCTA la
pacientii acut simptomatic sunt n prezent lipsesc .
ntr-un studiu CCTA la pacienii ED cu risc sczut
publicate ntr-o form abstract , rezultatul CCTA a
fost considerat negativ n cazul n care nici o nav
nu a avut mai mult de o stenoza de 50 %, iar scorul
de calciu a fost mai mic de 100 . Pacientii cu un
rezultat negativ studiu au fost evacuate . Dintre cei
407 de pacienti evacuate , 402 au avut 30 de zile de
urmrire . Nici unul ( 0 % ) au murit de la o cauza
cardiovasculare , nevoie de revascularizare , sau a
avut un MI . Acest rezultat are un interval de
ncredere de 95 % de 0-0.9 % . Autorii au
concluzionat ca pacientii cu risc redus durere in
piept , cu un rezultat negativ CCTA pot fi evacuate
n condiii de siguran . [ 22 ]

Un alt studiu reprezentativ de 1127 redus la
pacientii cu risc intermediar urmat timp de 15 luni
au aratat ca au existat doar 1 din 333 de toate
cauzele deceselor n grupul cu nici o placa
coronariene vizualizate. [ 23 ]

Studii suplimentare la diferite populaii va defini
rolul de CCTA . Cu toate acestea , se pare c exist
dovezi suficiente pentru a permite o descrcare n
condiii de siguran a pacienilor fr modificri
acute ECG , markeri crescute , i examene benigne
CCTA . Desigur , acest lucru presupune alte cauze
grave de durere toracic au fost luate n considerare
i excluse dup cum este necesar .

Direcii viitoare n testare
Angiografia prin rezonan magnetic
Cardiace Angiografie prin rezonan magnetic (
MRA ) permite vizualizarea vaselor coronariene
fara radiatii sau substanta de contrast . Cu contrast
iadugarea de vasodilatatoare sau dobutamin ,
MRA poate fi utilizat pentru a evalua viabilitatea
miocardic , de asemenea. Prin sincronizarea
achiziia imaginii cu ciclului cardiac al pacientului ,
noi protocoale permite pacientului s respire n
timpultestului . n timp ce RMN cardiace / ARR
continu s evolueze , se arat promit ca singura
modalitate de imagistica , care pot combina
angiografie cu evalurile de micare perfuzie i
perete .

O publicaie 2010 a raportat cu privire la utilizarea
exposure. This type of evaluation has been called
the "triple rule out (TRO)."

A review of the topic suggests that this approach
may have utility under relatively limited
circumstances.[25] A 2013 study evaluated 100
intermediate-risk patients with acute chest pain. All
had D-dimer testing. Those with a positive D-dimer
result were imaged with a TRO protocol and the
others with CCTA. Sixty of 100 had a negative
CCTA and were discharged. No adverse events
occurred in this group at 90-day follow-up.
Nineteen of 100 had positive CCTA, of which 17
were true positive based on catheter angiography.
A TRO-CCTA protocol was performed in 36
patients because they had elevated D-dimer levels.
Pulmonary embolism was present in 5, pleural
effusion of unknown etiology in 3, severe right-
sided ventricular dysfunction with pericardial
effusion in 1, and an incidental bronchial
carcinoma was diagnosed in 1 patient.[26]

In current practice, this type of imaging exposes
patients to significant radiation but shows promise
in appropriately selected patients. Improved
scanning hardware and imaging algorithms have
shown promise for reducing radiation exposure
without compromising accuracy. To date, no
consensus has been reached on which patients are
most appropriate for TRO imaging.

Cardiac PET scanning for diagnosis of coronary
artery disease
There are 2 specific clinical applications of PET
that have been proposed for the evaluation of
patients with known or suspected coronary artery
disease. Detection of coronary artery disease and
estimation of severity is performed using a PET
perfusion agent at rest and during pharmacologic
vasodilation. The second clinical application of
PET is the assessment of myocardial viability in
patients with coronary artery disease and left
ventricular dysfunction. The most common
approach is to determine whether metabolic activity
is preserved in regions with reduced perfusion as a
marker of glucose utilization and, thus, tissue
viability.

The combined technique of PET/CT of the
coronary arteries was shown in one study to
compare favorably with the criterion standard of
de stres RMN ntr- o unitate de observare ,
comparativ cu grija stationar de rutin ntr- un grup
de pacienti non - risc scazut . Treizeci de rezultatele
zi au fost aceleai att n grupul de recunoscut i de
observare / pacienti RMN . Observare / pacienti
RMN au avut costuri semnificativ mai mici ($ 336
- 811 dolari ; CI 95 % ) . [ 24 ]

Carotidei intima-media grosime
Ecografie artera carotid i msurarea grosimii
intima-media este un alt domeniu de investigare .
Studiile observaionale au artat c grosimea
intima-media este un marker independent de risc
cardiovascular , dar dac acesta este mai precis
dect factorii de risc traditionali este neclar . Cu
toate acestea , s-ar putea dovedi valoroasa ca un
low-cost test rapid , cu risc sczut uor de obinut
n departamentul de urgenta .

Studii combinate CT pentru evaluarea dureri in
piept : "regula triplu afar "
Conceptual , o scanare CT cu substan de contrast
intravenos poate combina imagistica a arterelor
coronare , aorta ascendenta , i arterele pulmonare .
Acest lucru permite evaluarea bolii arterei coronare
, embolie pulmonar , i boala deaortei toracice (
disecie ) , cu un singur studiu . Aspectele tehnice
ale studiului difer dect pentru CCTA cu un cmp
mai larg de vedere i un protocol diferit pentru
administrarea intravenoasa de contrast . Tehnica
presupune costuri substaniale i de expunerea la
radiatii . Acest tip de evaluare a fost numit " de
regula triplu ( ORC ) . "

O revizuire de subiect sugereaz c aceast
abordare ar putea avea utilitate n condiii relativ
limitate [ 25 ] Un studiu 2013 a evaluat 100 de
pacienti cu risc intermediar , cu durere toracica
acuta . . Toate au avut testare D - dimer . Cei cu un
rezultat pozitiv de dimeri D au fost sonda cu un
protocol ORC i ceilali cu CCTA . Saizeci de 100
au avut o CCTA negativ i au fost evacuate . Nu
exista evenimente adverse au aprut n acest grup la
90 de zile de follow - up . Nousprezece de 100 au
avut CCTA pozitiv , dintre care 17 au fost adevrat
pozitive bazate pe angiografie cateter . Un protocol
ORC - CCTA a fost efectuat la 36 de pacieni ,
deoarece acestea au valori crescute ale D - dimer .
Embolie pulmonara a fost prezent la 5 , pleurezie
de etiologie necunoscuta , n 3 , disfuncii severe
ventriculara dreapta fata-verso cu efuziune
catheter coronary angiography. One hundred seven
patients with an intermediate pretest likelihood of
coronary artery disease were enrolled. All patients
underwent PET/CT, and the results were compared
with invasive angiography. PET and CT
angiography alone both demonstrated 97%
negative predictive value, CT angiography alone
was suboptimal in assessing the severity of stenosis
(positive predictive value, 81%). Perfusion imaging
alone could not always separate microvascular
disease from epicardial stenoses, but hybrid
PET/CT significantly improved this accuracy to
98%.[27]

Cardiac Testing in Women
Cardiovascular disease is the leading cause of death
for women in the United States, but a considerable
body of research has demonstrated that women
have different patterns of coronary artery disease
and different responses to cardiac testing than their
male counterparts. Women are more likely to have
nonobstructive or single-vessel disease when
compared with men, which decreases the
diagnostic accuracy of stress testing. For example,
treadmill testing in one meta-analysis was shown to
have a sensitivity and specificity of 61% and 70%,
respectively, for women compared with 72% and
77%, respectively, for men.[28]

Calcium scoring is limited because women tend to
have 3- to 5-fold greater mortality rates for a given
calcium score than men, suggesting that separate
guidelines for interpreting scores in women should
be developed.

SPECT imaging is technically limited in women
because breast tissue and relatively small left
ventricle size can generate false-positive results.
Technetium is less prone to attenuation artifacts
than thallium and thus has higher specificity. The
American Heart Association has recommended that
the exercise tolerance test is still the initial test of
choice for a low-risk or intermediate-risk
symptomatic woman with no contraindications.[29]

Pharmacologic Stress Testing
Test physiology and technique
Pharmacologic stress testing differs from exercise
testing in that it does not rely on the patient's own
ability to increase cardiac oxygen demand. Rather,
the patient can remain at rest while the heart's
pericardic n 1 , i un carcinom bronsic incidental a
fost diagnosticat la 1 pacient . [ 26 ]

n practica curent , acest tip de imagistica expune
pacientii la radiatii semnificative , dar promit
spectacole la pacientii selectate in mod
corespunzator . mbuntirea hardware de scanare
i algoritmi de imagistica au aratat promisiune
pentru reducerea expunerii la radiatii , fara a
compromite precizie . Pn n prezent , nici un
consens a fost atins la care pacientii sunt cele mai
potrivite pentru imagini TRO .

PET cardiace scanare pentru diagnosticul de boala
coronariana
Exist 2 aplicatii clinice specifice de PET , care au
fost propuse pentru evaluarea pacientilor cu boala
coronariana cunoscute sau suspectate . Detectarea
bolii coronariene si estimarea de severitate se
realizeaz cu ajutorul unui agent de perfuzie PET n
repaus i n timpul farmacologic vasodilataie . Al
doilea aplicarea clinica a PET este evaluarea
viabilitii miocardice la pacientii cu boala
coronariana si disfunctie ventriculara stanga .
Abordarea cea mai comun este de a stabili dac
activitatea metabolic este conservat n regiuni cu
perfuzie redus ca un marker de utilizare a glucozei
i , astfel , viabilitatea esutului .

Tehnica combinata de PET / CT a arterelor
coronare a fost demonstrat ntr-un studiu pentru a
compara favorabil cu standardul criteriul de
angiografia coronariana cateter . O suta sapte
pacienti cu un pre-test risc intermediar de boala
coronariana au fost inrolati . Toti pacientii au
suferit PET / CT , iar rezultatele au fost comparate
cu angiografie invazive . PET i CT angiografia
numai att demonstrat 97 % valoare predictiva
negativa , angiografie CT singur a fost suboptim
n evaluarea severitii stenozei ( valoare predictiva
pozitiva , 81 % ) . Imagistica de perfuzie singur nu
a putut ntotdeauna boala separat microvasculare de
stenoze epicardice , dar hibrid PET / CT
mbuntit n mod semnificativ aceast precizie de
98 % . [ 27 ]

Testarea cardiace la femei
Boala cardiovasculara este principala cauza de
deces pentru femeile din Statele Unite , dar un corp
considerabil de cercetare a demonstrat c femeile
au modele diferite de boli coronariene si raspunsuri
response to a drug is measured. The most widely
available pharmacologic agents for stress testing
are dipyridamole (Persantine), adenosine,
regadenoson (Lexiscan), and dobutamine. The
adenosine analog regadenoson has a longer half-life
than adenosine. This allows for simpler bolus
versus continuous administration.

Pharmacologic agents
For patients unable to exercise, pharmacologic
agents are used to stress the myocardium and
produce the characteristic ECG or nuclear imaging
findings. Pharmacologic stress testing is indicated
for patients who would be unable to adequately
perform an exercise stress test. An exercise test is
considered inadequate when a patient cannot reach
85% of predicted maximum heart rate or reach a
workload of 5 metabolic equivalents of task
(METs) for 3 minutes. A pharmacologic test is
preferred over an exercise test in patients with
aortic stenosis, left bundle branch block, a paced
rhythm, recent myocardial infarction, and severe
hypertension, even if they were able to exercise
adequately.[30]

Adenosine, regadenoson (Lexiscan), and
dipyridamole (Persantine) are coronary
vasodilators. In terms of blood flow, normal vessels
are up to 400% more responsive to the vasodilatory
effect than stenotic vessels. This difference in
response leads to differential flow, and perfusion
defects appear in cardiac nuclear imaging or as ST-
segment changes on the ECG.

Contraindications to adenosine include active
asthma, high-grade heart block, and hypotension.
Caffeine or theophylline should be stopped 12
hours before adenosine is given. Regadenoson and
dipyridamole have similar contraindications, but
studies have indicated that regadenoson is
relatively safe in asthma.[31]

Dobutamine is a direct cardiac inotrope and
chromotrope. It consequently increases myocardial
oxygen demand similar to exercise and allows
ischemic areas to become visible on nuclear
scanning or apparent as ST depression on the ECG.

Dobutamine contraindications include
hemodynamically significant left ventricular
outflow tract obstruction, tachyarrhythmias
diferite la testarea cardiace decat omologii lor de
sex masculin . Femeile sunt mai susceptibile de a
avea boala nonobstructive sau un singur vas , in
comparatie cu barbatii , care scade precizia de
diagnostic de testare de stres . De exemplu , testul
de efort ntr- o meta - analiza a fost dovedit a avea
o sensibilitate i specificitate de 61 % i 70 % ,
respectiv , pentru femei n comparaie cu 72 % i
77 % , respectiv , pentru brbai . [ 28 ]

Calciul scoring este limitat, deoarece femeile tind
s aib 3 - la rata de 5 ori mortalitate mai mare
pentru un scor de calciu dat dect brbaii , ceea ce
sugereaz c ar trebui s fie elaborate linii
directoare separate pentru interpretarea scoruri la
femei .

Imagistica SPECT este punct de vedere tehnic
limitat la femei, deoarece tesutul mamar i relativ
mici dimensiuni ventriculului stng poate genera
rezultate fals - pozitive . Techneiu este mai puin
predispus la artefacte de atenuare de taliu i , astfel,
are specificitate mai mare . The American Heart
Association a recomandat ca testul de toleranta la
efort este nc testul iniial de alegere pentru o
femeie simptomatic cu risc sczut sau intermediar
de risc , fr contraindicaii . [ 29 ]

Farmacologic Testarea la stres
Fiziologie de testare i tehnic
Teste de stres farmacologic difer de la testul de
efort n care aceasta nu se bazeaz pe pacientului
capacitatea lor de a crete cererea de oxigen cardiac
. Mai degrab ,pacientul poate s rmn n repaus
timp de rspuns al inimii la un medicament este
msurat . Cele mai disponibile pe scara larga
agenti farmacologic pentru testele de stres sunt
dipiridamol ( Persantine ) , adenozina ,
regadenoson ( Lexiscan ) , i dobutamina .
Regadenoson analog adenozina are un timp de
njumtire mai mare de adenozina . Acest lucru
permite bolus simple versus administrarea continu
.

agenti farmacologic
Pentru pacienii care nu pot s-i exercite , ageni
farmacologici sunt folosite pentru a accentua
miocardului i produce caracteristic ECG sau
rezultatele imagistice nucleare . Teste de stres
farmacologic este indicat pentru pacientii care ar fi
n imposibilitatea de a ndeplini n mod adecvat un
(including prior history of ventricular tachycardia),
uncontrolled hypertension (blood pressure
>200/110 mm Hg), aortic dissection or large aortic
aneurysm. Beta-blockers should be discontinued so
that response to dobutamine will not be attenuated.

Test interpretation
The pharmacologic stress test is interpreted in a
manner similar to the exercise stress test (see
above). Additionally, myocardial perfusion
imaging is advisable in all patients undergoing
pharmacologic stress testing.

Test utility
Pharmacologic stress testing with nuclear imaging
is equivalent to an exercise stress test with nuclear
imaging at detecting coronary artery disease. Note,
however, that since patients undergoing
pharmacologic stress testing tend to have more
comorbidities, the posttest probability of disease is
higher in patients who have undergone a
pharmacologic test. A normal pharmacologic stress
test result confers a 1-2% per year cardiac event
rate, whereas a normal exercise test result with
nuclear imaging has a rate less than 1% per
year.[32]

Test limitations
Theophylline can reduce ischemic changes on the
ECG with vasodilator stress testing. Caffeine has
been reported to have a similar effect. However,
one study demonstrated that one cup of coffee, one
hour prior to stress testing did not attenuate the
results of adenosine nuclear imaging.[33] Calcium
channel blockers, beta-blockers, and nitrates can
also alter perfusion defects on pharmacologic stress
tests and therefore ideally should be withheld for
24 hours prior to pharmacologic stress testing.
Dipyridamole and adenosine can lead to
bronchospasm; they are generally avoided in
patients with severe reactive airway disease or
active wheezing. Dobutamine is safe to use in these
patients.

Summary
Noninvasive cardiac testing is used as part of a
broader scheme of risk stratification for patients
with possible acute coronary syndromes. Many
tests exist, and each has unique advantages and
disadvantages. Patient characteristics and local
resources dictate which of the cardiac tests are
test de efort . Un test de efort este considerat
inadecvat atunci cnd un pacient nu poate ajunge
la 85 % din ritmul cardiac maxim prezis sau de a
ajunge la un volum de 5 echivalente metabolice ale
sarcinii ( Mets ) timp de 3 minute. Un test
farmacologic este preferat de peste un test de efort
la pacientii cu stenoza aortica , bloc de ramur
stng , un ritm alert , infarct miocardic recent , i
hipertensiune arterial sever , chiar dac ei au fost
capabili s-i exercite n mod adecvat . [ 30 ]

Adenozina , regadenoson ( Lexiscan ) , i
dipiridamol ( Persantine ) sunt vasodilatatoare
coronariene . n ceea ce privete fluxul de sange ,
vasele normale sunt de pn la 400% mai receptiv
la efectul vasodilatator dect vasele stenozate .
Aceast diferen de rspuns duce la debitului
diferenial , i defecte de perfuzie apar n imagistica
nucleare cardiace sau ca modificri de segment ST
pe ECG .

Contraindicaii la adenozin includ astm activ , bloc
cardiac de grad nalt , i hipotensiune arterial .
Cafein sau teofilin ar trebui s fie oprit 12 ore
nainte de adenozin este dat . Regadenoson i
dipiridamol au contraindicatii similare , dar studiile
au artat c regadenoson este relativ sigur n astm .
[ 31 ]

Dobutamina este un inotrope cardiace direct i
chromotrope . Este , prin urmare, crete necesarul
de oxigen miocardic similare s-i exercite i
permite zonelor ischemice s devin vizibile pe
scanarea nuclear sau evident ca depresia ST pe
ECG .

Contraindicaii dobutamin includ ventriculului
obstacol hemodinamic semnificativ la stnga ieiri
ale tractului , tahiaritmii ( inclusiv antecedente de
tahicardie ventricular ) , hipertensiune arteriala
necontrolata ( tensiune arterial > 200/110 mm Hg
) , disectie aortica sau anevrism aortic mare . Beta-
blocante trebuie ntrerupt , astfel nct rspunsul la
dobutamin nu vor fi atenuate .

interpretarea testului
Testul de stres farmacologic este interpretat ntr- un
mod similar cutestul de efort ( vezi mai sus ) . n
plus , imagistica perfuziei miocardic este indicat la
toti pacientii supusi testelor de stres farmacologic .

chosen. Variability exists in how well noninvasive
cardiac tests correlate with angiographic findings.
Despite this variability, most of the tests are useful
for determining short-term risk of myocardial
infarction and death.

Noninvasive cardiac tests are improving as new
diagnostic technologies and methods are being
developed. As future studies reveal the true
diagnostic characteristics and capabilities of these
tests, physicians can better assess patients' risk of
coronary artery disease based on their previous test
results and more effectively recommend further
testing and interventions.

As with all diagnostic tests, no single cardiac test is
ideal. They are useful as part of a risk stratification
scheme, but, with the current state of diagnostic
testing, some cases of serious coronary disease will
always be missed.
utilitar de testare
Teste de stres farmacologic cu imagistica nucleara
este echivalent cu un test de efort cu imagistica
nucleara de la detectarea bolii coronariene .
Reinei, totui , c, deoarece pacientii care au
suferit de testare farmacologica de stres tind s aib
mai multe comorbiditi ,posttest probabilitatea de
a bolii este mai mare la pacienii care au fost
supuse unui test farmacologic . Un farmacologic
rezultat normal test de stres confer un 1-2 % pe an
rata eveniment cardiac , n timp ce un exerciiu de
rezultat normal de testare cu imagistica nuclear are
o vitez mai mic de 1 % pe an . [ 32 ] limitri de
testare
Teofilina poate reduce modificri ischemice pe
ECG cu testarea vasodilatatoare. Cofeina a fost
raportat de a avea un efect similar. Cu toate
acestea, un studiu a demonstrat ca o ceasca de
cafea, cu o or nainte de testele de stres nu a
atenua rezultatele imagistica nucleara adenozinei.
[33] blocante ale canalelor de calciu, beta-blocante,
i nitraii pot modifica, de asemenea, defecte de
perfuzie la testele de stres farmacologice i Prin
urmare, n mod ideal, ar trebui s fie ntrerupt timp
de 24 de ore nainte de teste de stres farmacologic.
Dipiridamol i adenozin poate duce la
bronhospasm, acestea sunt n general evitate la
pacientii cu boala severa a cailor respiratorii
reactive sau active respiratie suieratoare.
Dobutamina este sigur de utilizat la aceti pacieni.

rezumat
Testarea cardiac neinvaziv este utilizat ca parte a
unui plan mai larg de stratificare a riscului pentru
pacienii cu posibile sindroame coronariene acute.
Exist multe teste, i fiecare are avantaje unice i
dezavantaje. Caracteristicile pacienilor i resursele
locale dicta care dintre teste cardiace sunt alese.
Variabilitatea exist n ct de bine testele cardiace
noninvazive se coreleaza cu rezultatele
angiografice. In ciuda acestui variabilitate, de cele
mai multe teste sunt utile pentru determinarea
riscului pe termen scurt a infarctului miocardic i
moarte.

Testele cardiace noninvazive sunt mbuntirea ca
noile tehnologii i metode de diagnostic sunt n
curs de dezvoltate. Ca studiile viitoare dezvluie
caracteristicile de diagnosticare adevrate i
capacitile acestor teste, medicii pot evalua mai
bine pacientii cu risc de boala coronariana bazeaz
pe rezultatele testelor lor anterioare i recomand
mai eficient teste suplimentare i intervenii.

Ca cu toate testele de diagnostic, nici un test
cardiac nu este ideal. Ele sunt utile ca parte a unui
sistem de stratificare a riscului, dar, cu starea
actual de teste de diagnostic, unele cazuri de boli
coronariene grave, va fi ntotdeauna ratat.