Stress tests 

Stress modality - exercise, dobutamine, vasodilator (i.e. regadenason, dipyridamole) 

Detection modality - EKG, Echo, Nuclear, MRI, symptoms 

EKG exercise 
- brief, upsloping ST depressions are OK, broad/flat/downsloping ST depressions are not
- in order to be diagnostic, you have to reach 85% of max predicted HR 

- Sens & spec: ~70%  

- stop when HR is at 85% of predicted or if pt stops for reason of symptoms 

- good for "rule out" test in low-risk patients 

Nuclear test 

- Tells you exactly where the lesion is - much more accurately than EKG

- Very sensitive - you will find something. If you want to find something, you will find it here. 

- Don't do this if you want to minimize your false-positive (i.e. someone will get thrown off a transplant list because of a false positive test -  in this case do a dobutamine echo instead) 

Cath everyone before sternotomy - if they could benefit from a CABG you might as well do it while you're in there. 

NO dobutamine or vasodilators in AS 

ST elevation in AVR
- proximal LAD or Left Main disease. 

Preop clearance -- when to get a stress test