Contents

Search

cardiac stress testing

Indications: - suspected coronary artery disease (CAD) - most useful in patients with an intermediate pre-test probability (10-90%) - not recommended for patients with low or high pre-test probability [1] - preoperative risk assessment for non-cardiac surgery* [4] - high-risk surgery - vascular surgery - intrathoracic surgery - intraperitoneal surgery - ischemic heart disease - history of myocardial infarction - Q waves on ECG - prior positive cardiac stress test - unstable angina or active angina pectoris - use of nitrates for angina - heart failure - pulmonary edema - rales - paroxysmal nocturnal dypnea - S3 gallop - insulin-dependent diabetes mellitus - chronic renal failure with serum creatinine >= 2 mg/dL - prior cerebrovascular disease - estimated risk for major adverse cardiac event > 1% [1] * higher use of preoperative stress testing not associated with improved outcomes [7] Contraindications: - routine cardiac stress testing in asymptomatic patients after successful PCI - routine cardiac stress testing in asymptomatic patients with diabetes mellitus type 2 [1] Procedure: - use exercise stress testing if patient is able to exercise* - provides information on functional capacity & hemodynamic response - exercise time on the treadmill predicts 1-year cardiovascular death [4] - use exercise stress echocardiography if - in conjunction with valvular heart disease - qualifying baseline ECG abnormalities - left bundle-branch block - reserve pharmacologic stress testing for a) patients unable to or ill-advised* to exercise b) risk of false positive with ECG exercise stress testing is increased, such as with left bundle-branch block - GRS11 says exercise stress echocardiography procedure of choice for patients with left bundle branch block able to exercise [4] - GRS11 asserts that chest pain walking up 2 flights of stairs does not impair ability to exercise [4] c) dobutamine stress echocardiography d) myocardial perfusion scintigraphy e) dobutamine stress cardiac MRI (not ready for preoperative testing) [6] - coronary angiography for valvular heart disease with worsening symptoms [4] - severe aortic stenosis * positive exercise stress test, * "limited exercise ability" due to COPD [1] * exercise myocardial perfusion may be preferable to dobutamine echcardiography when baseline ECG abnormalities preclude exercise ECG * Notes: - 14-30% of testing inappropriate [2] - positive exercise stress ECG but normal stress echocardiography associated with increased risk for adverse cardiovascular events (15% vs 9% for both tests negative) [5] - pharmacologic vasodilators including dipyridamole, adenosine, & regadenoson can cause bronchospasm - use in caution in patients with COPD - avoid in patients actively wheezing - may be used in patients with stable COPD without active bronchospasm [6] - dobutamine stress echocardiography may be difficult to interpret with LBBB [6] - cardiac CT angiography associated with lower risk for myocardial infarction or mortality than function testing in patients with diabetes mellitus but not those without [3]

Related

cardiac computed tomography angiography; coronary computed tomography angiography; CT angiography (CCTA) cardiac magnetic resonance imaging (CMR imaging) coronary angiography coronary artery calcium (CAC testing)

Specific

exercise stress testing pharmacologic stress testing stress echocardiography

General

clinical procedure

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  2. Ladapo JA et al. Physician decision making and trends in the use of cardiac stress testing in the United States: An analysis of repeated cross-sectional data. Ann Intern Med 2014 Oct 7; 161:482 PMID: 25285541
  3. Sharma A et al. Stress testing versus CT angiography in patients with diabetes and suspected coronary artery disease. J Am Coll Cardiol 2019 Mar 5; 73:893. PMID: 30819356 https://www.sciencedirect.com/science/article/pii/S0735109719300968 - Blaha MJ, Cainzos-Achirica M. Coronary CT angiography in new-onset stable chest pain: Time for U.S. guidelines to be NICEr. J Am Coll Cardiol 2019 Mar 5; 73:903 PMID: 30819357 https://www.sciencedirect.com/science/article/pii/S073510971930097X
  4. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  5. Daubert MA, Sivak J, Dunning A Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography. JAMA Intern Med. Published online January 27, 2020. PMID: 31985749 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2759744
  6. NEJM Knowledge+ Complex Medical Care
  7. Columbo JA et al. Increased preoperative stress test utilization is not associated with reduced adverse cardiac events in current US surgical practice. Ann Surg 2023 Oct 1; 278:621. PMID: 37317868 https://journals.lww.com/annalsofsurgery/abstract/2023/10000/increased_preoperative_stress_test_utilization_is.16.aspx