Cardiac+Ischemia

Cardiac ischemia (angina)
Within our system, there are three commonly available tests for evaluating possible cardiac ischemia, i.e. angina: Here are some pointers to consider when trying to decide which of these tests to order. This is by no means a very comprehensive discussion of this subject. When in doubt, please contact the medicine attending on call for "clinics" to discuss.
 * **Exercise treadmill** (fax the requisition to 370-5379)
 * **Myocardial Perfusion Scan** (e.g. Persantine thallium stress test) (complete the radiology requisition. Per email from C. Farnitano June 2009, these should be ordered as "Myocardial Perfusion Scans" to give the actual test center discretion over what isotope to use)
 * **Dobutamine stress echocardiogram** (fax the requisition to 370-5379)
 * 1) The patient needs to be able to exercise for an exercise treadmill or exercise stress ECHO. A good screening question is if they can walk up two flights of stairs without stopping. If not, consider a Persantine thallium test.
 * 2) If the patient can exercise, a treadmill should always be the first-line test.
 * 3) However, a **resting EKG** must be ordered in clinic before the treadmill, in order to determine if a standard treadmill can be performed.
 * 4) If the patient can exercise but the EKG is not suitable for a treadmill, consider either a dobutamine ECHO or a Persantine thallium test
 * A left bundle branch block or paced rhythm is a contraindication to a treadmill test.
 * Severe repolarization abnormalities from LVH are a relative contraindication
 * If you are unsure on the appropriateness of the EKG for treadmill, please contact the medicine attending.
 * 1) Stress ECHOs are in very limited supply, so you should discuss with a medicine attending before ordering. They should usually be ordered only when a patient can do neither an exercise treadmill nor a Persantine thallium test.

(Last reviewed by Denis Mahar September 2008)