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Several examples of the beneficial uses in diagnosis and treatment of cardiac patients are mentioned. However, keep in mind that the current list is only a brief summary and in real life the use of the ECG is broader. First, the ECG is an important tool in diagnosing and managing acute myocardial infarction. In patients with chest pain that is suspect for myocardial ischemia, the characteristic ST-segment changes (elevations or depressions) are one of the important corner stones of diagnosis and subsequent treatment.  In addition, rapid resolution of the ECG changes of myocardial infarction after reperfusion therapy has prognostic value and identifies patients with reperfused coronary arteries.  
Several examples of the beneficial uses in diagnosis and treatment of cardiac patients are mentioned. However, keep in mind that the current list is only a brief summary and in real life the use of the ECG is broader. First, the ECG is an important tool in diagnosing and managing acute myocardial infarction. In patients with chest pain that is suspect for myocardial ischemia, the characteristic ST-segment changes (elevations or depressions) are one of the important corner stones of diagnosis and subsequent treatment.  In addition, rapid resolution of the ECG changes of myocardial infarction after reperfusion therapy has prognostic value and identifies patients with reperfused coronary arteries.  
 
In the diagnosis of the cause for severe rhythm disturbances, cardiac shock or after cardiac arrest the ECG is also of great importance for rapidly assessing possible underlying (cardiac) causes. Metabolic disturbances or medication induced arrhythmias can induce characteristic changes of the QT time, QRS and ST morphology. The diagnosis based on the ECG observations can be life-saving in emergency situations with patients in shock or after a cardiac arrest.
In the diagnosis of the cause for severe rhythm disturbances, cardiac shock or after cardiac arrest the ECG is also of great importance for rapidly assessing possible underlying (cardiac) causes. Metabolic disturbances or medication induced arrhythmias can induce characteristic changes of the QT time, QRS and ST morphology. The diagnosis based on the ECG observations can be life-saving in emergency situations with patients in shock or after a cardiac arrest.


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The two-dimensional echocardiographic imaging technique is used to investigate the heart in multiple planes in order to asses the existence of (dys)function and structural abnormalities of cardiac chambers and valves throughout the cardiac cycle. Both the cross sectional and longitudinal views are used to look for the presence of any anatomical or functional abnormalities with most of the structures of the heart. [''Figure 4 & 5'']
The two-dimensional echocardiographic imaging technique is used to investigate the heart in multiple planes in order to asses the existence of (dys)function and structural abnormalities of cardiac chambers and valves throughout the cardiac cycle. Both the cross sectional and longitudinal views are used to look for the presence of any anatomical or functional abnormalities with most of the structures of the heart. [''Figure 4 & 5'']


[[Image:Apical_4_chamber_view.gif|300px|right|thumb|'''Figure 4.''' Apical four chamber view by two dimensional echocardiography. ]]
[[Image:Apical_4_chamber_view.gif|300px|left|thumb|'''Figure 4.''' Apical four chamber view by two dimensional echocardiography. ]]
[[Image:LeftVentricleShortAxis.gif|300px|right|thumb|'''Figure 5.''' Short axis view of left ventricle by two dimensional echocardiography. ]]
[[Image:LeftVentricleShortAxis.gif|300px|right|thumb|'''Figure 5.''' Short axis view of left ventricle by two dimensional echocardiography. ]]


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Unfortunately, it is impossible to obtain high-quality images or Doppler signals in as many a small percent of patients. Underlying conditions such as obesity, emphysema or chest wall deformities can limit the use of transthoracic echocardiography. A technique to partly cope with these limitations is transoesophageal echocardiography (TEE) [''Figure 9''].  
Unfortunately, it is impossible to obtain high-quality images or Doppler signals in as many a small percent of patients. Underlying conditions such as obesity, emphysema or chest wall deformities can limit the use of transthoracic echocardiography. A technique to partly cope with these limitations is transoesophageal echocardiography (TEE) [''Figure 9''].  
   
   
{| class="wikitable" cellpadding="0" cellspacing="0" border="0" width="300px"
[[Image:Transesophageal echocardiography diagram.svg|300px|thumb|'''Figure 9.''' Transoesophageal echocardiography ultrasound diagram.]]
|-
|align="center" bgcolor="#FFFFFF"|[[Image:Transesophageal echocardiography diagram.svg|300px]]
|-
|'''Figure 9.''' Transoesophageal echocardiography ultrasound diagram.
 
Source: Wikimedia public domain.
|}


With TEE a smaller ultrasound probe is placed on a gastroscopic device for introduction in the oesophagus behind the heart. Besides overcoming structural problems, in general TEE produces much higher resolution images of posterior cardiac structures. With TEE left atrial thrombi, small mitral valve vegetations, and thoracic aortic dissection can be diagnosed a high degree of accuracy. The downside of the techniques is the invasiveness of the procedure; the introduction of a probe into the oesophagus is very often experienced as rather uncomfortable by patients.
With TEE a smaller ultrasound probe is placed on a gastroscopic device for introduction in the oesophagus behind the heart. Besides overcoming structural problems, in general TEE produces much higher resolution images of posterior cardiac structures. With TEE left atrial thrombi, small mitral valve vegetations, and thoracic aortic dissection can be diagnosed a high degree of accuracy. The downside of the techniques is the invasiveness of the procedure; the introduction of a probe into the oesophagus is very often experienced as rather uncomfortable by patients.
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==Cardiac stress test==
==Cardiac stress test==
[[Image:Stress_test.jpg|thumb|300px|'''Figure 10.''' Cardiac stress test making use of a walking treadmill. Source: Wikimedia public domain.]]
[[Image:Stress_test.jpg|thumb|300px|thumb|'''Figure 10.''' Cardiac stress test making use of a walking treadmill. Source: Wikimedia public domain.]]


'''Cardiac stress test''' (or '''Cardiac diagnostic test''') is a test used in medicine and cardiology to measure the heart's ability to respond to external stress in a controlled clinical environment.
Cardiac stress tests compare the coronary circulation while the patient is at rest with the same patient's circulation observed during maximum physical exertion, showing any abnormal blood flow to the heart's muscle tissue (the myocardium). This test can be used to diagnose ischemic heart disease, and for patient prognosis after a heart attack (myocardial infarction).
 
The stress response is induced by exercise or drug stimulation. Cardiac stress tests compare the coronary circulation while the patient is at rest with the same patient's circulation observed during maximum physical exertion, showing any abnormal blood flow to the heart's muscle tissue (the myocardium). The results can be interpreted as a reflection on the general physical condition of the test patient. This test can be used to diagnose ischemic heart disease, and for patient prognosis after a heart attack (myocardial infarction).
 
The cardiac stress test is done with heart stimulation, either by exercise on a treadmill, pedalling a stationary exercise bicycle ergometer<cite>One</cite> or with intravenous pharmacological stimulation, with the patient connected to an electrocardiogram (or ECG). People who cannot use their legs may exercise with a bicycle-like crank that they turn with their arms.<cite>Two</cite>


The level of mechanical stress is progressively increased by adjusting the difficulty (steepness of the slope) and speed. The test administrator or attending physician examines the symptoms and blood pressure response. With use of ECG, the test is most commonly called a cardiac stress test, but is known by other names, such as exercise testing, stress testing treadmills, exercise tolerance test, stress test or stress test ECG.
The level of mechanical stress is progressively increased by adjusting the difficulty (steepness of the slope) and speed. The test administrator or attending physician examines the symptoms and blood pressure response. With use of ECG, the test is most commonly called a cardiac stress test, but is known by other names, such as exercise testing, stress testing treadmills, exercise tolerance test, stress test or stress test ECG.


==Stress echocardiography==
===Indication===
A stress test may be accompanied by echocardiography.<cite>One</cite> The echocardiography is performed both before and after the exercise so that structural differences can be compared.
 
==Nuclear stress test==
The best known example is myocardial perfusion imaging. Typically, a radiotracer (Tc-99 sestamibi, Myoview or Thallous Chloride 201) may be injected during the test. After a suitable waiting period to ensure proper distribution of the radiotracer, photos are taken with a gamma camera to capture images of the blood flow. Photos taken before and after exercise are examined to assess the state of the coronary arteries of the patient.
 
Showing the relative amounts of radioisotope within the heart muscle, the nuclear stress tests more accurately identify regional areas of reduced blood flow.
 
Stress and potential cardiac damage from exercise during the test is a problem in patients with ECG abnormalities at rest or in patients with severe motor disability. Pharmacological stimulation from vasodilators such as dipyridamole or adenosine, or positive chronotropic agents such as dobutamine can be used. Testing personnel can include a cardiac radiologist, a nuclear medicine physician,a nuclear medicine technologist, a cardiology technologist, a cardiologist, and/or a nurse.
 
==Function==
[[Image:StressECG STDepression.jpg|thumb|right|300px|Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts.]]
[[Image:StressECG STDepression.jpg|thumb|right|300px|Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts.]]


The American Heart Association recommends ECG treadmill testing as the first choice for patients with medium risk of coronary heart disease according to risk factors of smoking, family history of coronary artery stenosis, hypertension, diabetes and high cholesterol.
The American Heart Association recommends ECG treadmill testing as the first choice for patients with medium risk of coronary heart disease according to risk factors of smoking, family history of coronary artery stenosis, hypertension, diabetes and high cholesterol.


*Perfusion stress test (or sestamibi) is appropriate for select patients, especially those with an abnormal resting electrocardiogram.
===Diagnostic value===
*Intracoronary ultrasound or angiogram can provide more information at the risk of complications associated with cardiac catheterization.
 
==Diagnostic value==
The common approach for stress testing by American College of Cardiology and American Heart Association indicates the following:<cite>Two</cite>
The common approach for stress testing by American College of Cardiology and American Heart Association indicates the following:<cite>Two</cite>


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(Sensitivity is the percentage of sick people who are correctly identified as having the condition. Specificity indicates the percentage of healthy people who are correctly identified as not having the condition.)
(Sensitivity is the percentage of sick people who are correctly identified as having the condition. Specificity indicates the percentage of healthy people who are correctly identified as not having the condition.)


The value of stress tests has always been recognized as limited in assessing heart disease such as atherosclerosis, a condition which mainly produces wall thickening and enlargement of the arteries. This is because the stress test compares the patient's coronary flow status before and after exercise and is suitable to detecting specific areas of ischemia and lumen narrowing, not a generalized arterial thickening.
The value of stress tests has always been recognized as limited in assessing coronary atherosclerosis. This is because the stress test has a relatively high false-negative and false-positive rate. Other detection methods have higher sensitivity and specificity but this improved test characteristics often comes at a price, either in the form of radiation (CT), risk of complications in an invasive procedure (coronary angiography), or costs and limited availability (MRI).
 
According to American Heart Association data,[citation needed] about 65% of men and 47% of women have as their first symptom of cardiovascular disease a heart attack or sudden cardiac arrest. Stress tests, carried out shortly before these events, are not relevant to the prediction of infarction in the majority of individuals tested.[dubious – discuss] Over the past two decades, better methods[citation needed] have been developed to identify atherosclerotic disease before it becomes symptomatic.
 
These detection methods have included either ''anatomical'' or ''physiological.''
 
*'''Examples of anatomical methods include'''
**CT coronary calcium score
**Intima-media thickness (IMT)
**Intravascular ultrasound (IVUS)


*'''Examples of physiological methods include'''
===Contraindications===
**Lipoprotein analysis
**HbA1c
**Hs-CRP
**Homocysteine
 
The anatomic methods directly measure some aspects of the actual process of atherosclerosis itself and therefore offer the possibility of early diagnosis, but are often more expensive and may be invasive (in the case of IVUS, for example). The physiological methods are often less expensive and more secure, but are not able to quantify the current status of the disease or directly track progression.
 
==Contraindications==
Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care.<cite>Three</cite> Some estimates show that such screening accounts for 45% of cardiac stress imaging, and evidence does not show that this results in better outcomes for patients.<cite>Three</cite> Unless high-risk markers are present, such as diabetes in patients aged over 40, peripheral arterial disease; or a risk of coronary heart disease greater than 2 percent yearly, most health societies do not recommend the test as a routine procedure.<cite>Three</cite><cite>Four</cite><cite>Five</cite><cite>Six</cite>
Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care.<cite>Three</cite> Some estimates show that such screening accounts for 45% of cardiac stress imaging, and evidence does not show that this results in better outcomes for patients.<cite>Three</cite> Unless high-risk markers are present, such as diabetes in patients aged over 40, peripheral arterial disease; or a risk of coronary heart disease greater than 2 percent yearly, most health societies do not recommend the test as a routine procedure.<cite>Three</cite><cite>Four</cite><cite>Five</cite><cite>Six</cite>


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*Acutely ill for any reason<cite>Seven</cite>
*Acutely ill for any reason<cite>Seven</cite>


==Adverse effects==
===Adverse effects===
Side effects from cardiac stress testing may include
Side effects from cardiac stress testing may include


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*As the tracers used for this test are carcinogenic, frequent use of these tests carries a small risk of cancer.
*As the tracers used for this test are carcinogenic, frequent use of these tests carries a small risk of cancer.


==Pharmacological agents==
===Limitations===
The choice of pharmacologic stress agents used in the test depends on factors such as potential drug interactions with other treatments and concomitant diseases.
 
Pharmacologic agents such as Adenosine, Lexiscan (Regadenoson), or dipyridamole is generally used when a patient cannot achieve adequate work level with treadmill exercise, or has poorly controlled hypertension or left bundle branch block. However, an exercise stress test may provide more information about exercise tolerance than a pharmacologic stress test.<cite>Eight</cite>
 
Commonly used agents include:
*Vasodilators acting as adenosine receptor agonists, such as Adenosine itself, and Dipyridamole (brand name ''Persantine''),<cite>Nine</cite> which acts indirectly at the receptor.
*Regadenoson (brand name ''Lexiscan''), which acts specifically at the Adenosine A2A receptor, thus affecting the heart more than the lung.
*Dobutamine. The effects of beta-agonists such as dobutamine can be reversed by administering beta-blockers such as propranolol.
 
Lexiscan (Regadenoson) or Dobutamine is often used in patients with severe reactive airway disease (Asthma or COPD) as adenosine and dipyridamole can cause acute exacerbation of these conditions. If the patient's Asthma is treated with an inhaler then it should be used as a pre-treatment prior to the injection of the pharmacologic stress agent. In addition, if the patient is actively wheezing then the physician should determine the benefits versus the risk to the patient of performing a stress test especially outside of a hospital setting.
 
Aminophylline may be used to attenuate severe and/or persistent adverse reactions to Adenosine and Lexiscan.
 
==Limitations==
The stress test does not detect:
The stress test does not detect:
*Atheroma
*Atheroma
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The test has relatively high rates of false positives and false negatives compared with other clinical tests.
The test has relatively high rates of false positives and false negatives compared with other clinical tests.


==Results==
===Results===
Once the stress test is completed, the patient generally is advised to not suddenly stop activity, but to slowly decrease the intensity of the exercise over the course of several minutes.
Once the stress test is completed, the patient generally is advised to not suddenly stop activity, but to slowly decrease the intensity of the exercise over the course of several minutes.


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*Unstable atheroma produces ''vulnerable plaques'' hidden within the walls of coronary arteries which go undetected by this test.
*Unstable atheroma produces ''vulnerable plaques'' hidden within the walls of coronary arteries which go undetected by this test.
*Limitation in blood flow to the left ventricle can lead to recurrent angina pectoris.
*Limitation in blood flow to the left ventricle can lead to recurrent angina pectoris.
==Stress echocardiography==
A stress test may be accompanied by echocardiography.<cite>One</cite> The echocardiography is performed both before and after the exercise so that structural differences can be compared.
==Nuclear stress test==
The best known example is myocardial perfusion imaging. Typically, a radiotracer (Tc-99 sestamibi, Myoview or Thallous Chloride 201) may be injected during the test. After a suitable waiting period to ensure proper distribution of the radiotracer, photos are taken with a gamma camera to capture images of the blood flow. Photos taken before and after exercise are examined to assess the state of the coronary arteries of the patient.
Showing the relative amounts of radioisotope within the heart muscle, the nuclear stress tests more accurately identify regional areas of reduced blood flow.
Stress and potential cardiac damage from exercise during the test is a problem in patients with ECG abnormalities at rest or in patients with severe motor disability. Pharmacological stimulation from vasodilators such as dipyridamole or adenosine, or positive chronotropic agents such as dobutamine can be used. Testing personnel can include a cardiac radiologist, a nuclear medicine physician,a nuclear medicine technologist, a cardiology technologist, a cardiologist, and/or a nurse.


==References==
==References==
Retrieved from "https://www.textbookofcardiology.org/wiki/Special:MobileDiff/2389...2542"

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