Exercise Stress Echocardiography
Transoesophageal Echcardiography (TOE)
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Which test to assess coronary arteries in age 40+?
Heart disease remains the most common cause of death in Australia despite an improved standardised death rate and age of death due to heart disease. Approximately 50% of first heart attacks are fatal: waiting for the first event to decide on treatment strategies is not recommended! Diet and lifestyle continue to be central recommendations, and use of cholesterol lowering medications (centred around statins) is common. Risk prediction models (e.g. Australian Cardiovascular Risk Calculator http://www.cvdcheck.org.au/) should be used in every patient, but these probability- and population-based tools may not reflect an individual’s actual disease burden. Further imaging is often performed to help guide management, summarised below.
Coronary Artery Calcium Score (CACS): Inexpensive, fast, low radiation, providing an absolute score (approximately $150, no Medicare rebate). Normal CACS = zero. Any non-zero score is abnormal indicating the presence of atherosclerosis. CACS 0-10 = minimal, CACS 10-100 = mild, CACS 100-400 = moderate and CACS >400 = large plaque burden. Decisions to treat are often made based on CACS, which makes intuitive sense but is not strictly evidence based. A large randomised trial testing this approach is currently underway in Australia (the CAUGHT-CAD study, https://www.baker.edu.au/research/clinical-trials/CAD/CAD-more).
CT coronary angiography (CTCA): This involves a contrast injection during coronary CT. The coronary arteries are reconstructed using 3D imaging, and an accurate assessment of plaque burden is reported along with CACS. CTCA is approx $500, but provides more information than CACS alone. Best suited to asymptomatic moderate risk individuals, to evaluate atypical chest pain, or for assessment of prior coronary bypass grafts.
Conventional coronary angiography: Invasive, requiring arterial puncture and catheters inserted into the coronary arteries, well suited for acute coronary syndromes or evaluation of a haemodynamically significant stenosis. Because of its invasive nature, it should not be performed in asymptomatic individuals at low to moderate risk, particularly because mild coronary disease (without a stenosis) may be completely missed by conventional coronary angiography.
Stress ECG: Continuous 12 lead ECG monitoring during exercise. Well suited for patients with angina symptoms, and to assess exercise tolerance. This test is not recommended for asymptomatic moderate to low risk individuals, since it is neither sensitive nor specific. The most likely abnormal result in this group is a false positive test, which inevitably leads to further testing, expense and un-necessary concern.
Stress Echo or Stress Nuclear Imaging: Both of these have superior sensitivity and specificity compared with stress ECG, but are still most suited to patients with classic symptoms. Stress echo has some advantages over stress nuclear in that it is free of radiation, cheaper, and can assess functional changes (e.g. valve gradients and diastolic filling) with exercise. Stress imaging does not exclude subclinical coronary disease so is not recommended in asymptomatic low to moderate risk individuals.
Resting Echo: To assess structure and function of the heart, including systolic and diastolic function, pulmonary pressures and valve disease. It does not assess coronary disease unless there is severe disease or prior infarction, resulting in abnormal left ventricular function at rest.