Σύγκρουση Συμφερόντων

Σύγκρουση Συμφερόντων A. Πιτταράς Καμία σύγκρουση συμφερόντων που να αφορά το περιεχόμενο της ομιλίας

Δοκιμασία κόπωσης Είναι μια από τις συχνότερες μη επεμβατικές μεθόδους εκτίμησης ασθενών με υποψία ή τεκμηριωμένη καρδιαγγειακή νόσο Χρησιμοποιείται για: την επιβεβαίωση και / ή τον αποκλεισμό ύπαρξης και έκτασης στεφανιαίας νόσου την εκτίμηση της πρόγνωσης τον προσδιορισμό της λειτουργικής ικανότητας την εκτίμηση της αποτελεσματικότητας της θεραπείας Gibbons et al. ACC/AHA guideline update for exercise testing

Δοκιμασία κόπωσης σε υπερτασικούς ασθενείς Σε ασθενείς με ΑΥ, κατά τη δοκιμασία κόπωσης παρατηρείται: Δυσανάλογη του όγκου παλμού, ενώ η ΚΣ στη μεγίστη άσκηση είναι χαμηλή, όπως δυσανάλογα χαμηλή και η ΚΠ Ο χρόνος άσκησης είναι μειωμένος Η αεροβική ουδός επιτυγχάνεται νωρίτερα και η μέγιστη πρόσληψη Ο2 Η αντοχή στην άσκηση έως 30% σε σύγκριση με ταυτόσημης ηλικίας νορμοτασικά άτομα. Ann Intern Med 1996;124:41-55

Contraindications to ETT Relative Left main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities Severe Arterial Hypertension Tachyarrhythmias or bradyarrhythmias Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Mental or physical impairment leading to inability to exercise adequately High-degree atrioventricular block

ETT in HTN: Recommendations Individuals with Stage 2 HTN (SBP/DBP 160/100 mm Hg) or with TOD (e.g., LVH, retinopathy) must not engage in any exercise, including exercise testing prior to a medical evaluation and adequate BP management. A symptom-limited ETT is recommended prior to engaging in an exercise program testing. Additional evaluations may ensue and vary depending on findings of the ETT and the clinical status of the individual. Resting SBP/DBP >200/115 mm Hg are relative contraindications to exercise testing

Exercise ECG Montalescot G, Sechtem U, et al. EHJ 2013;34(38):2949 3003.

ETT IN ALL HTNsives? ETT is indicated in HTNsives with Average and High risk for assessment of asymptomatic CAD - Greenland et. al. JACC 2010 ACC/AHA Guidelines - Agapiti Rosei et. al. High BP Cardiov. Prev. 2008

CV risk determination in 2013

Changes in the total risk assessment recommendations

Montalescot G, Sechtem U, et al. EHJ 2013;34(38):2949 3003.

ETT in HTNsives Diagnostic aproach Prognostic information

ETT: Reliable Diagnostic Tool? Sensitivity Specificity Predictive Value

ETT: Sensitivity Sensitivity = True Positive: False Positive: Pts with ΕΤΤ(+) & Angio(+) All the Pts with Angio (+) ΕΤΤ(+) & Angio(+) ΕΤΤ(+) & Angio(-)

ETT: SPECIFICITY = SPECIFICITY Pts with ΕΤΤ(-) & Angio(-) True Negative: False Negative: All the Pts with Angio (-) ΕΤΤ(-) & Angio (-) ΕΤΤ(-) & Angio (+)

ETT : Predictive Value = Predictive Value True Positive True Positive + False Positive

Sensitivity - Specificity, % Diagnostic accuracy of Stress Tests in HTNsives 100 90 80 70 70 60 50 40 30 91 93 73 Sensitivity Specificity 100 91 91 90 64 47 38 28 20 10 0 201Tl Dobutamin 201Tl e ECHO scintigraph scintigraph y y exercise Jelica Milosavljevic1. Dipyridamole-Dobutamine Stress Echocardiography for the Detection of dipyridamol Myocardial Ischemia in Patients with Hypertension Herz 2005;30:215 22 e Exercise ECG Exercise Dipyridamol ECHO e ECHO

ETT PARAMETERS Duration Heart Rate BP Double Product (HR * SBP) ECG Symptoms

HR MAX AGE PREDICTED HR: (220 - AGE) 85%

Blood Pressure SBP & DBP Rest-End of every stage-max-recovery) High Resting BP (>180/110) Exaggerated Exercise BP Response

Double Product Double Product : (HR * SBP) 25000 bpm*mmhg

ETT IN HTNsives Diagnosis CAD

Diagnosis of Myocardial Ischaemia in HTN The Diagnosis of CAD in HTNsives is a Major Clinical Problem of Cardiology 60% of Angina Pts are HTNsives, and 30-40% of them have abnormal resting ECG and ETT. The Specificity of ECG ETT in HTNsives is extremely low (non acceptable) independently of the presence or not of LVH. J of Hypertension 2001;19:1177-1183

Multiple Pathways guide the HTNsives to Ischaemia Due to Coronary Flow Reserve, HTNsives with normal coronary arteries and LVH usually present: - Exercise ST-T or - Th-201 SPECT filling defects or - Stress Echo wall motion abnormalities 50% of HTNsives with normal coronary arteries & ETT(+) don t have LVH. J of Hypertension 2001;19:1177-1183

Clinical Findings That Suggest an ETT Positive for Ischemia ECG changes during Exercise & Recovery The occurrence of frequent PVCs Multifocal PVCs or VT at mild exercise (less than 70 percent of maximal heart rate) is suggestive of an exercise stress test positive for myocardial ischemia. Exercise-induced hypotension Exercise-induced angina or anginal equivalents Appearance of an S3, S4 or heart murmur during exercise

ECG Changes That Suggest an ETT Positive for Ischemia

Nonsignificant Findings During ETT Fatigue, dyspnea, diaphoresis, flushing Incremental increase in BP and HR ECG changes - Shortening of QT interval - Functional J point depression 0.2 mv for < 0.06 secs - Peaking of T waves and P waves - Shortening of P-R interval

Inconclusive, or Nondiagnostic Findings on ETT Development of clinically insignificant arrhythmias - Unifocal premature PVCs - Atrial or junctional tachyarrhythmias Development of blocks - Primary or secondary type I AV block - Bundle branch blocks - Hemiblocks - Changing atrioventricular conduction Morphology changes - T-wave flattening - P-wave changes < 0.01 mv - ST depression < 0.10 mv

Gender Difference in Sensitivity & Specificity False Positive (Men) Sketch 8% False Positive (Women) 67% Linhard 22% (5% Rest ECG) Koppes 24-35% Amsterdam 11% 15% CASS (3153) 3% False Negative: 38% 14% False Negative: 22% CASS (Adj)

How can we distinguish between True & False Positive ETT Pain History Drugs Physical Findings ST-T changes with Hyperventilation Rapidly upsloping ST-T depression Increase of septal q waves Fast ST-T recovery Fasting ETT vs Postprandial b-blockers

Conclusions: In patients with normal resting ECGs, we conclude the following: (1) a history of hypertension is not a cause of a false-positive exercise test, and (2) higher exercise systolic BP is a significant but weak predictor of ST-segment depression. Standard exercise testing should remain a useful diagnostic modality when evaluating these patients for myocardial ischemia. Patients with a positive exercise ECG and a high exercise systolic BP should not be assumed to have a falsepositive study.

Am Fam Physician. 1998 Oct 1;58(5):1126-30. Postexercise SBP response: Clinical application to the assessment of ischemic heart disease. 0 Stress test parameters indicating the presence and extent of coronary.artery disease 9 0 > the blood have traditionally included such variables as exercise duration,pand B S pressure and ST-segment responses to exercise. The k three-minute SBP ratio, y a c ra is a useful and another important indicator of significant coronary Pe arterycdisease, u / c who are undergoing P readily obtainable measure that can beb applied in alla patients S c i t y stress testing for the evaluation of known or suspected ischemic heart disease. The r s e o n ov the g c ratio is calculated byedividing SBP three minutes into the recovery a i D R n % test by the SBP at peak exercise. A threei phase of am treadmill 7 exercise 5 3 than 0.90 is considered abnormal and has a minute SBP ratio greater diagnostic accuracy of approximately 75 percent for the detection of coronary artery disease (i.e., an accuracy comparable to that of ST-segment depression). Higher values for the ratio are associated with more extensive coronary artery disease, as well as an adverse prognosis after myocardial infarction. Thus, the three-minute SBP ratio provides information that is complementary to the traditional exercise test parameters for identifying high-risk ischemic heart disease.

ETT Diagnosis CAD LVH

2007 ESH/ESC Guidelines Novelties on BP Measurements / Values SBP vs DBP / Role of PP Isolated office (white coat) hypertension Masked hypertension Central BP Exercise / Stress BP Out-of-office BP thresholds / targets for treatment

Pt A Pt B Age 67 58 Rest BP 120/80 120/78 BP @ 5 METs 160/80 210/92 Peak BP 190/80 230/100

ETT in HTN: Recommendations The ETT should be terminated if exercise SBP/DBP When ETT is performed for the specific purpose of >250/115 mm Hg. designing the Ex Rx, it is preferred individuals take their usual antihypertensive medications as recommended. Individuals on β-blockers have an attenuated HR response to exercise and reduced maximal exercise capacity. Individuals on diuretics may experience hypokalemia and other electrolyte imbalances, cardiac dysrhythmias, or potentially a false-positive exercise test.

Exaggerated BP Response to Exercise and Risk for Developing HTN Relative Risk 4 3 2 1 0 Miyai, et al. Hypertension 2002;39:761-6

PHYSICAL FITNESS AND NEW ONSET OF HTN IN PRE-HTNSIVES A.Pittaras, M. Doumas, P. Kokkinos et. al. Top Scoring Abstract AHA & ACC Meeting

LVMI & Exercise SBP in Pre-hypertensive Men and Women g/m2 Kokkinos P., Pittaras A et al. Circulation 2004 EX-HTN * p<0.01 135 Normal 125 115 105 95 85 75 * *

Albumin/Creat PWV Am J Med 2008; 121: 894-902 Am J Med 2008; 121: 894-902

Exercise BP Threshold for LVH We identified a SBP 150 mm Hg at the exercise workload of about 5 METs as the threshold for LVH. P. Kokkinos, A. Pittaras Hypertension 2007:49:55-61

Predictive Value of Exercise BP at 5 METs and Daytime APB Sensitivity Specificity Exercise BP 150 mm Hg 88% 74% Daytime ABP 140 mm Hg 85% 73% P. Kokkinos, A. Pittaras Hypertension 2007:49:55-61 EKG Sensitivity: 6-53% Devereux, RB. Circulation 1990; 81:1144-6. Levy D, eat al. Circulation 1990; 81:815-20

BP @ 2 min Recovery

ETT PARAMETERS Duration Heart Rate BP Double Product (HR * SBP) ECG Symptoms

Duke Treadmill Score (DTS) for risk stratification in stable coronary artery disease patients

Exercise Capacity: The stronger predictor of mortality in HTNsives ± risk factors 14% Increase in exercise capacity for 1 ΜΕΤ Mortality Risk hazard ratio=0.86 CI: 0.84-0.88; p <0.001 P.Kokkinos, M. Doumas, A.Pittaras, A. Manolis et. Al. Hypertension 2009

Exercise Capacity: The stronger predictor of mortality in Obese HTNsives 18% Increase in exercise capacity for 1 ΜΕΤ Mortality Risk hazard ratio=0.82 CI: 0.84-0.88; p <0.001

ΣΥΜΠΕΡΑΣΜΑΤΑ Η Δοκιμασία Κόπωσης ενδείκνυται σε Υπερτασικά άτομα Μέσου και Υψηλού Κινδύνου για τη διάγνωση ασυμπτωματικής Στεφανιαίας Νόσου.

ΣΥΜΠΕΡΑΣΜΑΤΑ Η ΔΚ είναι χρήσιμη στα άτομα υψηλού κινδύνου για HTN (προυπερτασικά - high normal) λόγω της υψηλής προγνωστικής της ικανότητας. Συσχέτιση της ΑΠ κοπώσεως, με την μάζα της LV, LVH & TOD. (νορμοτασικούς- υπερτασικούς -προυπερτασικούς) Η διαγνωστική αξία της δ. κοπώσεως για τη διάγνωση της Σ.Ν στους υπερτασικούς είναι μειωμένη, αλλά η αρνητική προγνωστική αξία υψηλή.

ΣΥΜΠΕΡΑΣΜΑΤΑ Η ανταπόκριση της ΑΠ στην άσκηση κατέχει σημαντικό ρόλο στην ανίχνευση μυοκαρδιακής ισχαιμίας ( πολλαπλής αιτιολογίας ) και την ανάδειξη ΥΑΚ (σημαντικό και ανεξάρτητο προγνωστικό δείκτη) Προσφέρει προγνωστικές πληροφορίες για νοσηρότητα και θνητότητα από καρδιαγγειακά συμβάντα Βοηθά στις θεραπευτικές μας επιλογές