(wow) Words Of Wonders Level 1309 Answers – Ph.D. Evan Harmon, Ph.D. Martin Fried, Ph.D. Daniel Sartori, Ph.D. Greg Katz et al. Shreya P. Trivedi
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(wow) Words Of Wonders Level 1309 Answers
S: I think I will use myself as a case. I vividly remember a younger Shreya (maybe this was an intern a year or a few months ago! leave it to your imagination) in the clinic struggling to order a stress test for a patient. So many options and things to click. I remembered that I had previously been embarrassed about what a cardiologist might think about the things I clicked on just to be instructed to pass.
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M: I am with you Shreia. Physical stress, farm stress, ECG stress, stress response, nuclear stress. . . At one point you could have convinced me that stress colonoscopies were a thing and I would have believed you… As for the stress PFT, it seems more real. So how do you choose the right one?
GREG KATZ: Actually, the main question of when to do stress tests of any kind is as important, if not more important, than deciding how you want to stress the patient.
S: Okay, well, I was excited to dive right in, but we have to go back to the 30,000-foot view when a stress test is actually indicated. And there are two big buckets: the causes of coronary artery disease and the bucket I was least familiar with, NOT the causes of coronary artery disease.
E: Yes, so those non-CHD reasons to do a stress test could be an exercise-induced arrhythmia or, in the case of VPV, an assessment of additional risk in the patient’s pathway. A fun fact to know about VPV rounds is that a fast fading delta wave offers a lower risk option. One of the final non-coronary reasons for stress testing that Greg will explain is to distinguish aortic stenosis from pseudo-severe aortic stenosis or a low-flow, low-gradient condition in patients with low EF.
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GREG KATZ: If someone’s ejection fraction is low, you can have a falsely low ejection fraction through the LVOT and that can make non-severe aortic stenosis look serious when you use the continuity equation to calculate aortic valve area. And so if you’re trying to differentiate between pseudo-vocal AS and severe AS, the dobutamine stress response can be helpful because by increasing someone’s contractility and improving flow through their LVOT, you can say that the aortic valve precalculated area of 0.8 is actually 1.2 cm, so it’s not strict.
M: How amazing is that? It’s so hard for me to talk about aortic stenosis the next time I’m on my rounds so I can drop the “severe false aortic stenosis” bombshell on the residents.
S: Hey, take it easy, take it easy Marty! Before you get too carried away, we’re going to focus most of the podcast on the coronary causes of stress testing.
E. Oh, they’re coming in March, just wait. At the same time, Gregg gives a rather nice description of a relatively common clinical situation in which a patient’s chest pain sounds partly like angina and partly like something else;
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GREG KATZ: Whenever you see a patient who has symptoms or risk factors, one of the things that goes through your mind is: and how severe is this patient’s coronary disease? Very often the story that you are left with is this very unsatisfactory situation where there are some characteristics of chest pain that are very distressing and some characteristics that are very soothing. So a stress test can be helpful when trying to figure out if the symptoms or lack of perfection you can articulate in someone’s history are due to obstructive coronary disease.
E. So stress testing is probably more useful in patients with stable angina or in those cases with, as Gregg says, an “inconclusive history” when you’re not sure whether or not their symptoms might be equivalent to angina.
M: And what we are actually talking about are patients who are part of the intermediate risk population. Remember, when we talk about risk, we’re talking about factors like age, gender, and the nature of your chest pain that will help you assess the possibility of coronary heart disease. We could spend an entire podcast discussing Bayesian probability and clinical epidemiology, but the bottom line is that stress testing probably won’t do you much good in very low or very high risk patients.
S: #ThingsVeDoForNoReason Stress testing for low risk chest pain – shout out to Tony Brave on Twitter! We’ll get to why later when we think about false positives, but one more point to set up this framework for stress tests: also the goal.
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GREG KATZ: The other big group is if you have a patient who you know has coronary artery disease and you want to find out what the risk is; You must do an anatomical examination. Do they have to go to the catalog before going to surgery? Should they be more carefully considered for revascularization because there are a number of other risk factors in their presentation? Stress testing, if you look at population-based data, you’ll see that people with greater ischemia in stress testing have a much higher rate of major adverse cardiovascular events (MACE), and it’s even semi-quantitative of how old we are. , does anyone have : a stress test can be useful when you’re talking to that patient in the clinic and trying to figure out how intensively you have to get them on the statin or how aggressive you have to be with their diet and lifestyle changes.
M: More on that, but to summarize this gem, which was really a framework. there are non-coronary causes of stress testing and coronary causes of stress testing. Some examples from the previous group are arrhythmias and valvular evaluations. Thinking about coronary disease also has two purposes: diagnosis and prognosis. We want to highlight people with a medium probability who have a problematic history to see if we are causing their symptoms. We may also highlight people with known coronary artery disease in whom we may be interested in better determining the clinical significance of their disease, such as ischaemia.
S: Okay, back to the wide-eyed young Shreya at the clinic, pulling my hair out trying to figure out which stress test to order. Mr. Corey Nari is a 60-year-old man with glucose intolerance, LDL in the mid-150s, family history of heart disease, who presented with new-onset dyspepsia while climbing stairs. I remember thinking that just the reflux notes were a little strange, and with all of his risk factors, I felt pretty confident that a stress test was needed, so let’s do it Monday morning and be done with it. I would choose the following test. .
M: Yes, I’m still advocating PFT for stress here… But seriously, the way to choose a stress test is to separate the two components of the test.
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GREG KATZ: Making sure we share the same mental model. Whenever you send someone for a stress test, you make two decisions, how do I emphasize them and how do I imagine them?
M: Ok, I love a good frame! First, select a method of stressing the patient, usually exercise, vasodilators, or inotropes. Second, we choose a diagnostic method, usually an EKG or one of the many imaging modalities we’ll talk about in the next gem.
S: Yes, let’s focus on the stress factor. ok if my options are exercise, vasodilators and inotropes how do i choose?
GREG KATZ: So anyone who’s trainable should be trained, and when you decide what kind of stress test you want to do, you want to stress somebody and you want to replicate the experiences that they’re having in their lives as best you can. You can. So if you have someone who is really active, you want to encourage them to push themselves. . . so you can replicate and cause the symptoms you may have in your normal life. If you have a patient who is very sedentary, you still want to exercise them because you get a lot of predictive information based on how far someone can go on a stress test. So anyone who can train should train.
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S: Okay, Mr. Nari says his exercise tolerance is limited by severe knee pain. So I don’t think they will get HR to 80-85% of max heart rate, so how do I choose between pharmacologic stressors, vasodilators, and inotropes? Greg makes me feel a little better because there isn’t necessarily a right or wrong answer here.
GREG AKSH:
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