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
• preoperative risk assessment for non-cardiac surgery*
  • 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%

* higher use of preoperative stress testing not associated with improved outcomes

Contraindications

• routine cardiac stress testing in asymptomatic patients after successful PCI
• routine cardiac stress testing in asymptomatic patients with diabetes mellitus type 2

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
  • use exercise stress echocardiography if
    • in conjunction with valvular heart disease
    • qualifying baseline ECG abnormalities
    • left bundle-branch block
• reserve pharmacologic stress testing for
  • patients unable to or ill-advised* to exercise
  • 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
      • GRS11 asserts that chest pain walking up 2 flights of stairs does not impair ability to exercise
  • dobutamine stress echocardiography
  • myocardial perfusion scintigraphy
  • dobutamine stress cardiac MRI (not ready for preoperative testing)
• coronary angiography for valvular heart disease with worsening symptoms
  • severe aortic stenosis

* positive exercise stress test,

* "limited exercise ability" due to COPD

* exercise myocardial perfusion may be preferable to dobutamine echcardiography when baseline ECG abnormalities preclude exercise ECG

*

Notes

• 14-30% of testing inappropriate
• positive exercise stress ECG but normal stress echocardiography associated with increased risk for adverse cardiovascular events (15% vs 9% for both tests negative)
• 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
• dobutamine stress echocardiography may be difficult to interpret with LBBB
• cardiac CT angiography associated with lower risk for myocardial infarction or mortality than function testing in patients with diabetes mellitus but not those without

More general terms

• clinical procedure

More specific terms

• exercise stress testing
• pharmacologic stress testing
• stress echocardiography

Additional terms

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