[] Q [Clinical Knowledge] Cardiac stress test with cMRI

Practical approach to cardiac stress test 

Ref.
Uptodate: https://www.uptodate.com/contents/selecting-the-optimal-cardiac-stress-test?search=cardia%20stress%20test&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Dr. Ellenbogen's recommendation
[ ] Can I obtain Dr. Hundley's presentation?


Modality
 Stress: Ex vs. Chemical
 Detector: EKG vs. ECHO vs. Nuclear vs. cMRI

Ex and normal EKG = Ex EKG -> good for limited candidate with some benefit(Px)
(Not for : LBBB, V-Pacing, LVH = masking.
                >1 ST depression, WPW, Prior PCI.
               for viability test)
Ex and ECHO = not appropriate
Ex and Nuclear = possible
Ex and cMRI = not applicable

Chemical and EKG = no
Chemical and ECHO = Good for someone with ICD/PM patient.(Preferred than nuclear test)
 => is it true???

Chemical and Nuclear = TRY TO AVOID THIS(prolonged process, not for ICD/PM)
(basically interchangable to Chemical and ECHO except LBBB, V-pacing)
                                        Just go ahead to cMRI
Chemical and MRI = Best sensitivity and One shot (no need to wait for stress vs resting in nuclear test)

[Processs]
1.Ex and EKG(normal) without angina eval(for viablity) => can! less likely in the real world.
2.Rest of them = cMRI stress test for almost everyone
  (CTx. ICD/PM)
3.LBBB or V-pacing = Nuclear stress test
4. Otherwise(ICD/PM but no V-pacing, LBBB) = Chemical and ECHO. (dobutamine stress test)

CTx.
EKG - abnormality(5 and prior PCI/viability test = ischemic workup)
Dobutamine - recent MI, VT, Ao. dissection, HTN (extreme active disease = should not)
Adenosine - active wheezing, SSS/2nd degree AV block, active wheezing, HYPOTENSION
Old like 80s.(relatively not meaningful) 

SO ONLY 2 question

ICD/PM ? - no cMRT = dob echo vs lexi
LBBB/V pacing? = lexi 
no LBBB/V pacing with ICD/PM = dob echo