cardiac stress testing
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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
- prior positive cardiac stress test
- unstable angina or active angina pectoris
- heart failure
- 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]
- high-risk surgery
* 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
- use exercise stress echocardiography if
- in conjunction with valvular heart disease
- qualifying baseline ECG abnormalities
- reserve pharmacologic stress testing for
- patients unable to or ill-advised* to exercise
- risk of false positive with exercise is increased, such as with left bundle-branch block
- dobutamine stress echocardiography
- myocardial perfusion scintigraphy
- 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 preferable 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]
More general terms
More specific terms
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)
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
- ↑ 2.0 2.1 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: https://www.ncbi.nlm.nih.gov/pubmed/25285541
- ↑ 3.0 3.1 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/30819357 https://www.sciencedirect.com/science/article/pii/S073510971930097X - ↑ 4.0 4.1 4.2 Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
- ↑ 5.0 5.1 Daubert MA, Sivak J, Dunning A Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography. JAMA Intern Med. Published online January 27, 2020. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31985749 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2759744
- ↑ 6.0 6.1 6.2 6.3 NEJM Knowledge+ Complex Medical Care
- ↑ 7.0 7.1 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: https://www.ncbi.nlm.nih.gov/pubmed/37317868 https://journals.lww.com/annalsofsurgery/abstract/2023/10000/increased_preoperative_stress_test_utilization_is.16.aspx