Lựa chọn nghiệm pháp gắng sức nào cho bệnh nhân bloc nhánh trái hoặc bệnh nhân được tạo nhịp tim

Hội nghị Nhịp học Toàn quốc - Hà nội - 11/2016
Vietnam National Rhythm Conference

Lựa chọn nghiệm pháp gắng sức nào
cho bệnh nhân bloc nhánh trái hoặc
bệnh nhân được tạo nhịp tim?
Selection of stress test for patients with
paced ventricular rhythm or
left bundle branch block
TS. NGUYỄN THỊ THU HOÀI
VIỆN TIM MẠCH QUỐC GIA VIỆT NAM



Indications for Stress Testing
• AHA/ACC endorse many indications for
stress testing
• 11 Class I indications
• 8 Class IIa indications
• 14 Class IIb indications
Gibbons et al. Circulation. 2002;106:1883


Categories of Patients
• Symptomatic patients without known CAD
• Patients with known CAD ± symptoms
• Patients with recent myocardial infarction


Categories of Patients
• Asymptomatic patients

–
–
–
–

Type 2 diabetes
Multiple risk factors
Starting exercise program
Hypertension

• Valvular heart disease
• Heart failure
• Heart rhythm disturbances


Choice of Stress Testing Modality in Different Clinical Settings
Localize ischemia or assess viability?

No
Marked baseline
ECG abnormalities, digitalis,
previous revascularization?
No

Able to exercise?
No
Yes

Standard Stress ECG

Yes
Able to exercise?
No

Yes

Yes

Able to exercise?
No
Yes

Pharmacologic
imaging study

Exercise
imaging study


Information from Stress Test
• Diagnostic testing
– Establish presence of coronary artery disease
– ST segment changes (ischemia)

• Prognostic testing
– Estimate long-term survival
– Estimate short-term or long-term risk of CV
event
• FAC or peak VO2
• Duke Treadmill Score

• Heart rate responses


Stress testing in LBBB
 LBBB prevalence increases with age (17% at age 80
in Northern Europe)
 Prevalence of CAD in patients with LBBB: 30% 50%
 Confers an adverse prognosis


Stress testing in LBBB


Stress testing in LBBB
ACC/AHA 2002 guidelines on exercise testing:
There is NO level of ST segment depression that
confers diagnostic significance during exercise ECG
testing in patients with LBBB


Exercise and pharmacologic stress radionuclide
myocardial perfusion imaging (rMPI)

False possitive rate in LBBB: 10-20%


383 bn bloc nhánh trái:
206 gắng sức thể lực
127 adenosin
50 dobutamine

Do mất đồng bộ và khử cực muộn
ở phần trái của VLT: VLT co bóp
vào cuối TK tâm thu, khi đó thất
vẫn đang giãn, hạn chế tưới máu
TK đầu tâm trương, đây là giai
đoạn bắt xạ tưới máu.
Periyanan Vaduganathan, JACC 1996


O’Keefe JACC 1993


Exercise and pharmacologic stress radionuclide
myocardial perfusion imaging (rMPI)
For prognosis: Vasodilator rMPI also provides

important prognostic information in patients with
CHD, which is incremental to clinical assessment

Mairsse 1995, Marwick 2013, Haft 2015


Dobutamine stress echocardiography vs
dobutamine rMPI in LBBB
Dobutamine stress echo had a better accuracy and

specificity than dobutamine rMPI because of false
positive septal and anteroseptal perfusion defects

associated with LBBB with rMPI

Mairsse 1995, Marwick 2013, Haft 2015


Dobutamine stress echocardiography vs
dobutamine rMPI in LBBB
Dobutamine stress echo had a better accuracy and

specificity than dobutamine rMPI because of false
positive septal and anteroseptal perfusion defects

associated with LBBB with rMPI

Mairsse 1995, Marwick 2013, Haft 2015


Usefulness and limitations of dobutamine-atropine
stress echo for the diagnosis of CAD in patients with
LBBB - a multicenter study


Usefulness and limitations of dobutamine-atropine
stress echo for the diagnosis of CAD in patients with
LBBB - a multicenter study
The potential diagnostic value of DSE:
 Stress-induced

new

or

worsening

wall

motion

abnormalities had a sensitivity of 68% and a specificity of
91%.
 However, sensitivity for the anterior circulation was lower
(44%) in patients with abnormal septal thickening at rest.
Geleijnse, Eur Heart J 2000


Usefulness and limitations of dobutamine-atropine
stress echo for the diagnosis of CAD in patients with
LBBB - a multicenter study
 Echocardiography provide pertinent information on the
distribution and extent of CAD, chamber size, global and
regional function, and valvular function.
 Image interpretation can be more difficult when resting
regional wall motion abnormalities exist, and interobserver
variability remains a limitation.
 Image quality can be reduced in certain patients because of
body habitus or pulmonary disease.
Thomas Allison, Mayo Clinic


Accuracy of dobutamine–atropine stress

echocardiography for the detection of
coronary artery disease in the anterior and
posterior circulation

Accuracy of dobutamine–atropine stress
echocardiography for the detection of
coronary artery disease in the anterior
circulation in patients with normal and
abnormal rest septal thickening


For prognosis:
- 387 patients who underwent either dobutamine or
dipyridamole stress echo
- Follow-up 29 months: patients with evidence of ischemia
on stress echo had significant reductions in 5 year survival
(77% vs 92%) and 5 year survival free of a MI (60% vs
87%).
- Pharmacologic stress echo significantly improved risk
stratification in those without previous MI, but not in those
with prior MI.
Cortigiani, Am J Med 2001


Exercise
echocardiography
LBBB
Siêu âm gắng
sức bằng
xe đạp lựcSiêu

kế âm gắngin
sức bằng thảm chạy

Exercise-induced wall motion abnormalities had an overall sensitivity of
76% and a specificity of 83%. The sensitivity was 100% for LAD but only
46% and 40% percent for LCx and RCA.
Heller, 2011


Dobutamine stress CMR vs
Echocardiography in patients with LBBB
Mordi 2014: 82 patients with LBBB, suspected CAD
Dobutamine stress CMR (DSCMR) had higher
specificity (87.5% vs 72.9%), negative predictive value
(80.8% vs 67.3%), accuracy (80.4% vs 72.0%) than
DSE.
Mordi I, JACC 2014


Paced Ventricular Rhythm
 A paced right ventricular rhythm produces
LBBB on the ECG.
 Like LBBB, a paced ventricular rhythm
produces false positive defects on exercise rMPI
if pacing continues during exercise


Paced Ventricular Rhythm
 The effect of pacing on septal radionuclide uptake: thallium
rMPI and regional myocardial blood flow measurements

were obtained during RV pacing and during RA pacing.

 Thallium uptake and blood flow were homogeneous
throughout the LV during RA pacing.
 Septal abnormalities during RV pacing, as septal thallium

uptake was reduced by 31% with a comparable reduction in
blood flow

Hirzel HO, Am J Cardiol 1984