What tests performed by medical consultants can help further evaluate patients with known or suspected ischemic heart disease

  • Exercise electrocardiogram (ECG) is a noninvasive test that attempts to produce ischemic changes on ECG (ST depression = 1 mm from baseline) or symptoms by having the patient exercise to maximum capacity. Information obtained relates to the thresholds of heart rate and blood pressure that can be tolerated. Maximal heart rates, blood pressure response, and clinical symptoms guide interpretation of the results.
  • Exercise thallium scintigraphy increases the sensitivity and specificity of the exercise ECG. The isotope thallium is almost completely taken up from the coronary circulation by the myocardium and can then be visualized radiographically. Poorly perfused areas that later refill with contrast delineate areas of myocardium at risk for ischemia. Fixed perfusion defects indicate infarcted myocardium.
  • Dipyridamole thallium imaging is useful in patients who are unable to exercise. This testing is frequently required in patients with peripheral vascular disease who are at high risk for IHD and in whom exercise test is limited by claudication. Dipyridamole is a potent coronary vasodilator that causes differential flow between normal and diseased coronary arteries detectable by thallium imaging.
  • Echocardiography can be used to evaluate left ventricular and valvular function and measure ejection fraction.
  • Stress echocardiography (dobutamine echo) can be used to evaluate new or worsened regional wall motion abnormalities in the pharmacologically stressed heart. Areas of wall motion abnormality are considered at risk for ischemia.
  • Coronary angiography is the gold standard for defining the coronary anatomy. Valvular and ventricular function can be evaluated, and hemodynamic indices can be measured. Because angiography is invasive, it is reserved for patients who require further evaluation based on previous tests or who have a high probability of severe coronary disease.

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