Updated: 1/8/2020

Stress Test

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Snapshot
  • A 62-year-old man presents to his primary care physician a few days after developing chest pain. This is the first time he has ever had chest pain and it occurred while he was shoveling snow. Past medical history is unremarkable. He denies to ever drinking alcohol but has smoked half a pack of cigarettes per day for 30 years. He went to the emergency department and was found to have a normal electrocardiogram and CK-MB. The patient denies having another episode of chest pain since. Arrangements are made for cardiac stress testing.
Introduction
  • Cardiac stress testing can allow for the diagnosis of cardiac disease and is a prognostic tool
    • the type of cardiac stress testing depends on
      • the type of stress such as
        • exercise
        • pharmacologic
      • the type of assessment
        • electrocardiogram (ECG)
        • echocardiography (echo)
        • radionuclide imaging (nuclear stress test)
  • Factors to take into consideration when performing cardiac stress testing are many and include
    • the patient's ability to exercise
    • their resting ECG
    • a history of prior revascularization
  • Medications including beta-blockers, calcium channel blockers (e.g., amlodipine), and nitrates should be stopped 48 hours before undergoing a cardiac stress test
    • except if patient has known CAD
      • in this case patient should remain on antianginal medications such as the test is used to assess the efficacy of the medication with exertion
Cardiac Stress Testing
 
Cardiac Stress Testing Modalities
Modality
Comment
Exercise treadmill testing 
  • Preferred in patients who are able to exercise with limited symptoms and interpretable ECG
    • only in low or moderate risk patients (by HEART score) without ongoing chest pain 
      • indicated in patients with a moderate (4-6) or high risk (7 or higher) HEART score:
        • history
          • slightly suspicious - 0
          • moderately suspicious - 1
          • highly suspicious - 2
        • ECG
          • normal - 0
          • non-specific reploarization findings - 1
          • significant ST segment deviation - 2
        • age
          • less than 45 - 0
          • 45 to 64 - 1
          • 65 and older - 2
        • risk factors
          • none - 0
          • 1-2 - 1
          • 3 or more - 2
        • initial troponin
          • normal - 0
          • 1-3x normal limit - 1
          • x3 or more normal limit - 2
  • Contraindications include
    • acute myocardial infarction
    • unstable angina
    • symptomatic severe aortic stenosis
    • acute pulmonary embolism, endocarditis, myocarditis, pericarditis, and dissection
Pharmacologic stress testing
  • Typically performed in patients who cannot exercise or in patients with
    • uninterpretable baseline ECG (e.g., bundle branch block)
    • pacemaker
  • Pharmacologic agents
    • vasodilators are preferred in radionuclide myocardial perfusion imaging and include
      • adenosine
      • dipyridamole
      • regadenoson
      • should not be performed in patients with bronchospastic airway disease
    • inotropes and/or chronotrope drugs include
      • dobutamine (preferred for stress echo)
      • atropine

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