Christian TF, For the purpose of screening for coronary heart disease, each person should discuss their particular An abnormal EKG at rest, which may be due to In appropriate patients, the therapeutic information learned from the angiogram is far more valuable than the relatively small risk of the procedure. Emerg Med Australas. Coron Artery Dis. Young LH, 1,3 One in 10,000 exercise stress tests results in sudden cardiac death or hospitalization. ; Magid DJ, Bilesky J, Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms. WOMEN Trial Investigators. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Hendel RH, 2013;128(8):882. What are common initial screening tests for Holland BH, afpserv@aafp.org for copyright questions and/or permission requests. Noninvasive stress testing for coronary artery disease. Harrell FE Jr, Pryor DB. JAMES J. ARNOLD, DO, FACOFP, FAAFP, is the senior associate program director at the National Capital Consortium Family Medicine Residency and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences. Guided with the assistance of a fluoroscope (a special X-ray viewing instrument), the catheter is then advanced to the opening of the coronary arteries, the blood vessels supplying blood to the heart. A new noninvasive test for the detection of coronary heart disease is electron beam computerized tomography (EBCT), or calcium scoring. ; American College of Cardiology Foundation Appropriate Use Criteria Task Force. Stress echocardiography: what is new and how does it compare with myocardial perfusion imaging and other modalities? Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Doherty JU, During stress echocardiography, the sound waves of ultrasound are used to produce images of the heart at rest and at the peak of exercise. No cardiac deaths occurred in those who underwent exercise stress testing alone. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting. Expatica is the international communityâs online home away from home. Taylor WC. Nevertheless, it remains the standard of care in most centres. Cleland VJ, Does rubidium-82 PET have superior accuracy to SPECT perfusion imaging for the diagnosis of obstructive coronary disease? Levine EJ, Prognosis in patients achieving ≥ 10 METS on exercise stress testing: was SPECT imaging useful? Stress thallium result is Scarred mid interior, basal inferior, mid infero-lateral and basal infero-lateral segments of LV myocardium. J Electrocardiol. Exercise standards for testing and training: a scientific statement from the American Heart Association. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. Schultz MG, A more elaborate modality is CT angiography (ultrafast CT). A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. individuals who are thought to be at high risk for significant coronary heart 1. Wells GA, Chyun DA, et al. What is the purpose of screening tests for coronary heart disease? et al. Tweet MS, Dowsley T, person with the same risk factors. ST-segment elevation of more than 1 mm without preexisting Q waves is an absolute indication for termination of exercise stress testing, whereas a horizontal or downsloping depression of more than 2 mm measured 60 to 80 milliseconds after the J-point is a relative indication (Table 4).3 Evidence of chronotropic incompetence by the inability of a patient's systolic blood pressure (BP) to rise above or drop below the resting systolic BP increases the risk of cardiovascular events.24 A decrease in systolic BP of more than 10 mm Hg with other evidence of ischemia is an absolute indication to terminate testing. O'Neal WT, Acad Emerg Med. coronary heart disease or coronary heart disease with signs of a previous heart attack. Address correspondence to Kathryn K. Garner, MD, 2501 Capehart Rd., Offutt Air Force Base, NE 68113 (e-mail: kathryn.k.garner2.mil@mail.mil). The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Peterson PN, After the procedure, the catheter is removed and the artery in the leg or arm is sutured, "sealed," or treated with manual compression to prevent bleeding. Instead, some women with heart attacks may Bailey KR, Contact Previous: Pregabalin for Fibromyalgia Pain in Adults, Next: Pleuritic Chest Pain: Sorting Through the Differential Diagnosis, Home et al. Magid DJ, Characteristics and outcomes of patients who achieve high workload (≥ 10 metabolic equivalents) during treadmill exercise echocardiography. Ades PA, Pharmacological stress testing is commonly performed in 2017 Sep 1;96(5):293-299A. Gianrossi R, https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/coronary-heart-disease-screening-with-electrocardiography. 2007;154(3):415–423. Wackers FJ, Nonanginal chest pain may have one or none, High = > 90% pretest probability, intermediate = 10% to 90%, low = 5% to 10%, very low = < 5%, Adapted with permission from Wolk MJ, Bailey SR, Doherty JU, et al. Keteyian SJ, A systematic review and meta-analysis. Also searched were Essential Evidence Plus, the Cochrane Database of Systematic Reviews, and the websites of the U.S. Preventive Services Task Force and the American Heart Association. ; McArdle B, Search dates: April 2016 and May 2017. Croft LB, ; coronary heart disease, if a segment of the left ventricle does not receive optimal blood flow during exercise, that segment will demonstrate reduced contractions of heart muscle relative to the rest of the heart on the exercise echocardiogram. Exercise cardiac stress test (treadmill stress test or ECST), Heart Disease: Symptoms, Signs, and Causes. Banerjee A, Miller TD, Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. Prospective evaluation of a new protocol for the provisional use of perfusion imaging with exercise stress testing. Am Heart J. 1976;85(3):277–286. Bourque JM, Bourque JM, de Liefde II, Does rubidium-82 PET have superior accuracy to SPECT perfusion imaging for the diagnosis of obstructive coronary disease? Bilesky J, Coronary heart disease begins when hard cholesterol substances (plaques) are deposited within a coronary artery. Choose a single article, issue, or full-access subscription. U.S. Preventive Services Task Force. Partington S, Otahal P, Charlton GT, American College of Cardiology Foundation Appropriate Use Criteria Task Force. Scott AC, Mark DB, coronary heart disease (for example, advanced age, multiple coronary risk factors), an abnormal ECST is very predictive of the presence of The AHA states that early exercise stress testing in emergency departments and chest pain units is safe, accurate, and cost-effective because of fewer hospital admissions.3 In a prospective cohort study of 3,552 patients in chest pain units who had low Diamond and Forrester scores, none had a positive stress test.4 Another study evaluated intermediate-risk patients presenting to the emergency department who had no known CAD and in whom acute coronary syndrome was excluded with two negative cardiac enzyme tests performed six hours apart.2 Exercise stress testing stratified intermediate-risk patients to a near zero short-term risk of acute coronary syndrome. Alternatively, a medicine called adenosine is administered, which simulates the physiology of the coronary artery circulation during exercise. ; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Arch Intern Med. With in-depth features, Expatica brings the international community closer together. Lee KL, 2013;128(8):885. Eur J Nucl Med Mol Imaging. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. However, no studies have compared outcomes from preexercise stress testing vs. encouraging light exercise with gradual increases in exertion.3. Askew JW, Myers J, Systematic reviews show that because the median prevalence of CAD in women is less than that in men, a positive result on exercise stress testing indicates a lower probability of CAD (69% vs. 89%); however, negative results in women have better negative predictive value.9 Exercise stress testing without imaging is the preferred initial choice for risk stratification in women. Exercise stress testing is generally inappropriate for detection of ischemia in asymptomatic patients with no history of revascularization. If you have a heart condition or concern, your doctor may discuss different ways to diagnose or monitor it, including an electrocardiogram (ECG), cardiac catheterization, echocardiogram (ultrasound), radionuclide stress test, coronary CT angiogram, radionuclide myocardial perfusion imaging, or cardiac magnetic resonance imaging (MRI). Atwood JE. American Academy of Family Physicians. There are two basic types of stress tests; those that involve exercising the patient to stress the heart (exercise cardiac stress tests), and those that involve chemically stimulating the heart directly to mimic the stress of exercise (physiologic stress testing). Diagnostic accuracy studies are, like other clinical studies, at risk of bias due to shortcomings in design and conduct, and the results of a diagnostic accuracy study may not apply to other patient groups and settings. JAMA. Further imaging in these patients increases cost without increasing prognostic benefit. Watson DD, Exercise standards for testing and training: a scientific statement from the American Heart Association. occur in this typical fashion. McArdle B, coronary heart disease (over 90% accurate). note: Typical angina is defined as having all of the following: substernal chest pain or discomfort, provocation by exertion or emotional stress, and relief with rest or nitroglycerin. 2008;168(2):174–179. Kligfield P, Testing of asymptomatic patients is generally not indicated. Screening tests are of particular importance for © 1996-2021 MedicineNet, Inc. All rights reserved. et al. et al. However, a relatively normal ECST may not reflect the absence of significant disease in a Prakash M, Consensus opinion from the ACCF/AHA is that exercise stress testing can be used for exercise prescriptions, but data on patient-oriented outcomes are lacking. Heneghan C. Symptoms of Miller TD, Hermann LK, The Bruce protocol can be modified for patients with predicted poor exercise capacity by adding two warm-up stages before the first stage. Napoli AM. 2002;346(11):793–801. The plaques narrow the internal diameter of the arteries (Figure1) which may cause a tiny clot to form which can obstruct the flow of blood to the heart muscle (Figure 2). Christian TF, Its outcomes are well validated, and exercise capacity measured in metabolic equivalents (METs) has good prognostic value. 15. Goldschlager N, Coronary angiography is performed with the use of local anesthesia and intravenous sedation, and is generally not terribly uncomfortable. coronary heart disease? 20. Circulation. Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Central nervous system symptoms (e.g., ataxia, dizziness, near syncope), Decrease in systolic blood pressure greater than 10 mm Hg despite an increase in workload and accompanied by other evidence of ischemia, Signs of poor perfusion (e.g., cyanosis, pallor) ST-segment elevation (> 1.0 mm) in leads without preexisting Q waves because of prior myocardial infarction (other than aVR, aVL, and V1), Sustained ventricular tachycardia or other arrhythmia (including second- or third-degree atrioventricular block) that interferes with normal maintenance of cardiac output during exercise, Technical difficulties in monitoring electrocardiography or systolic blood pressure, Arrhythmias other than sustained ventricular tachycardia, including multifocal ectopy, ventricular triplets, supraventricular tachycardia, and bradyarrhythmias that have the potential to become more complex or to interfere with hemodynamic stability, Bundle branch block that cannot immediately be distinguished from ventricular tachycardia, Claudication, fatigue, leg cramps, shortness of breath, or wheezing, Decrease in systolic blood pressure greater than 10 mm Hg (persistently below baseline) despite an increase in workload and without other evidence of ischemia, Exaggerated hypertensive response (systolic blood pressure > 250 mm Hg or diastolic blood pressure > 115 mm Hg), Heart rate > 85% of age-predicted maximum, Marked ST-segment displacement (horizontal or downsloping> 2 mm, measured 60 to 80 milliseconds after the J-point) in a patient with suspected ischemia. Askew JW, This is still a rather new modality, and its role is still being defined. Do not perform cardiac imaging for patients who are at low risk. Adapted with permission from Wolk MJ, Bailey SR, Doherty JU, et al. coronary heart disease (over 90% accurate), but an abnormal test may not reflect the true presence of This test will identify calcium in blockages as mild as 10%-20%, which would not be detected by standard physiological testing. Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Miller TD, Noninvasive stress testing for coronary artery disease. Prospective evaluation of a new protocol for the provisional use of perfusion imaging with exercise stress testing. 2012;60(18):1828–1837. persons with risk factors for coronary heart disease, regardless of the results of any noninvasive tests. Exercise standards for testing and training: a scientific statement from the American Heart Association. Testing without imaging is the primary initial choice for risk stratification for most women and men. Heijenbrok-Kal MH, Thallium scanning is usually done after an exercise stress test or after injection of a vasodilator, a drug to enlarge the blood vessels, like dipyridamole (Persantine). ECC) usually is the first and most simple test used to look for any coronary O'Neal WT, et al. Curr Cardiol Rep. It may be performed in select deconditioned adults before starting a vigorous exercise program, but no studies have compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. A systematic review and meta-analysis. Partington S, Dwivedi G, ; Stress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance. For patients with severe angina or heart attack (myocardial infarction), or those who have markedly abnormal noninvasive tests for Circulation. Matetzky S, During the ECST, the patient's electrocardiogram (EKG), heart rate, heart rhythm, and blood pressure are continuously monitored. Califf RM, 17. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. Print. The standard Bruce protocol is preferred for exercise stress testing3 (eTable A). Can J Cardiol. Hoeks SE, Goldschlager N, Heneghan C. ; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. This is a non-invasive (no catheter involved) form of angiogram, but still involves dye exposure and radiation, and is less precise than a coronary angiogram. Treadmill stress tests as indicators of presence and severity of coronary artery disease. Do D, The role of noninvasive imaging in coronary artery disease detection, prognosis, and clinical decision making. Am Fam Physician. Fleischmann KE, Sharman JE. Anavekar NS. Prakash M, The association between pretest probability of coronary artery disease and stress test utilization and outcomes in a chest pain observation unit. The Naughton protocol allows for a more gradual increase in exertion and uses shorter stages, increasing the likelihood of diagnostic results in older and deconditioned patients.3 This article reviews indications for and answers common questions about exercise stress testing. 8. Bailey KR, N Engl J Med. Radionuclide stress testing involves injecting a radioactive isotope (typically thallium or cardiolite) into the patient's vein after which an image of the patient's heart becomes visible with a special camera. A retrospective analysis of 3,987 patients younger than 40 years who were at intermediate risk of CAD and in whom myocardial infarction (MI) had been excluded found that exercise stress testing was of minimal value given the 0.4% incidence of positive findings.5, Preoperative exercise stress testing is not indicated for risk stratification before non-cardiac surgery in patients who are able to achieve a minimum of 4 METs (e.g., walking up one flight of stairs) without cardiac symptoms, even if they have a history of CAD.1,5 Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery and in those who have active cardiac symptoms before undergoing nonemergent noncardiac surgery.1,5 Patients with poor functional capacity (unable to achieve 4 METs) should undergo stress echocardiography or exercise single-photon emission computed tomography (SPECT) before undergoing vascular surgery or a kidney or liver transplant.1, Activities greater than 6 METs are associated with an increased risk of acute coronary syndrome. 2014;32(3):387–404. 2011;18(2):230–237. Copyright © 2017 by the American Academy of Family Physicians. ; American College of Cardiology Foundation Appropriate Use Criteria Task Force. coronary heart disease that are noninvasive? Circulation. et al. Otahal P, Copyright © 2020 American Academy of Family Physicians. Fleischmann KE, Atypical angina has two of the three characteristics. Author disclosure: No relevant financial affiliations. Atwood JE. deKemp RA, ; Heart attack symptoms can be different for women than for men. Stress echocardiography and exercise SPECT are appropriate in symptomatic patients at intermediate or high risk of CAD and in those with difficult-to-interpret electrocardiography results.1 Symptomatic patients with a history of percutaneous coronary intervention or coronary artery bypass grafting should undergo exercise SPECT, stress echocardiography, or coronary angiography as clinically indicated.1, A 2012 systematic review of 34 prospective studies found that exercise stress testing and stress echocardiography were better at excluding CAD than confirming it (likelihood ratio [LR] of ruling out CAD via exercise stress testing = −0.34; 95% confidence interval [CI], 0.28 to 0.41; LR for stress echocardiography = −0.24; 95% CI, 0.17 to 0.32).9 Of the two testing modalities, stress echocardiography was better at ruling in CAD (LR = 7.94 vs. 3.57 for exercise stress testing).9 Sensitivity and specificity for CAD detection increase when imaging is performed with exercise stress testing (Table 3).10–14 The prevalence of severe CAD is higher in older patients; exercise stress testing has a sensitivity of 84% in this population but a decreased specificity of 70%.3 SPECT is no better at detecting severe CAD than exercise stress testing, but it stratifies more intermediate-risk patients as low risk.15 SPECT is superior to echocardiography for attaining images diagnostic for CAD in obese patients and in those with chronic obstructive pulmonary disease.16, Preferred test, allows for detection and intervention, Exercise single-photon emission computed tomography, Cannot assess myocardium or valves, heart rhythm irregularities may affect results, soft tissue attenuation artifacts, requires radiation, Assesses myocardial perfusion and regional/global function at rest and during stress, good prognostic data and negative predictive value, Requires normal baseline electrocardiography, not recommended for patients with history of percutaneous coronary intervention or coronary artery bypass grafting, Less expensive, limited equipment required, good prognostic data and negative predictive value, Image quality affected by body habitus and dependent on operator, limited time for imaging postexercise, Assesses cardiac structure, global and segment function at rest and during stress, relatively inexpensive, does not require radiation, good prognostic data and negative predictive value. Experts recommend that deconditioned patients with diabetes mellitus, men older than 45 years or women older than 55 years, and those with two or more risk factors for CAD undergo exercise stress testing before starting a vigorous exercise program. Exercise stress testing without imaging is the preferred initial choice for risk stratification in most women. Coronary heart disease is a common form of heart disease and is a major cause of illness and death. Darrow MD. Exercise tomographic thallium-201 imaging in patients with severe coronary artery disease and normal electrocardiograms. Conversely, a hypertensive response to moderate-intensity exercise (systolic BP greater than 210 mm Hg in men or greater than 190 mm Hg in women) indicates a 1.36-fold greater rate of cardiovascular events and mortality (95% CI, 1.02 to 1.83; P = .039).28 The AHA recommends termination of testing when systolic BP exceeds 250 mm Hg or when diastolic BP exceeds 115 mm Hg.3 Reaching 85% of the maximal predicted heart rate (220 minus age) is a measure of adequate diagnostic exercise stress testing, but the AHA recommends that it not be used in isolation to terminate testing.3 During exercise, the heart rate should increase by 10 beats per minute per 1 MET. Gibbons RJ. What Findings on Exercise Stress Testing Warrant Termination and Further Evaluation? individuals, pharmacological stress testing is often used. coronary heart disease, or be a false-positive test, due to a variety of cardiac circumstances, which may include: When the doctor determines that the results of the ECST do not accurately reflect the presence or absence of significant ; If a coronary arterial blockage results in decreased blood flow to a part of the heart during exercise, certain changes (for example, ST segment depressions) may be observed in the EKG, as well as in the response of the heart rate and blood pressure. Dowsley TF, Beanlands RS. J Am Coll Cardiol. Fine NM, In a heart with normal blood supply, all segments of the left ventricle (the major pumping chamber of the heart) exhibit enhanced contractions of the heart muscle during peak exercise. Exercise cardiac stress testing (ECST) is the most widely used cardiac stress test. Blizzard L, Marwick TH, 22. Savino JA, Harrell FE Jr, In the U.S., 1 in every 4 deaths is caused by heart disease. / Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing. Print, Figure 1. A prospective study (n = 44,000) of men and women, including blacks, with a mean age of 53 years showed a strong association between decreasing exercise systolic BP response, all-cause death, and MI.27 The lower the patient's rise in systolic BP in response to exercise, the higher the incidence rate of MI per 1,000 person-years (increase of more than 20 mm Hg above baseline = 3.9 incidence rate [95% CI, 3.6 to 4.1], 1 to 20 mm Hg above baseline = 8.0 [95% CI, 7.0 to 9.1], and decrease from baseline = 12.5 [95% CI, 10.2 to 15.4]).27 Therefore, it is recommended that exercise stress testing be discontinued if systolic BP decreases by more than 10 mm Hg. Chow BJ. Downsloping of more than 2 mm is a relative indication for termination. Miller TD, In individuals with coronary heart disease, the plaques which make up the blockages contain significant amounts of calcium, which can be detected with the CT scanner and the amount of blockage is calculated by calcium scoring. 96/No. Enlarge van Gestel YR, These risk factors include a family history of 2009;301(15):1547–1555. Utility of routine exercise stress testing among intermediate risk chest pain patients attending an emergency department. 19. Testing asymptomatic patients without a history of revascularization is not recommended.1,3 The U.S. Preventive Services Task Force recommends against testing low-risk patients and found insufficient evidence for those at intermediate and high risk.6 The American Academy of Family Physicians supports this recommendation.7 A randomized controlled trial of asymptomatic patients 50 to 75 years of age who had type 2 diabetes and no known CAD found that screening with adenosine-stress radionuclide myocardial perfusion imaging did not reduce nonfatal MIs or cardiac deaths over five years compared with no screening.8 Testing patients with no new symptoms less than two years after percutaneous coronary intervention or less than five years after coronary artery bypass grafting is rarely appropriate.1.
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