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 ModalitiesModalityCommentExercise treadmill testingPreferred in patients who areable to exercise with limited symptoms andinterpretable ECGonly in low or moderate risk patients (by HEART score) without ongoing chest painindicated in patients with a moderate (4-6) or high risk (7 or higher) HEARTscore:historyslightly suspicious - 0moderately suspicious - 1highly suspicious - 2ECGnormal - 0non-specific reploarization findings - 1significant ST segment deviation - 2ageless than 45 - 045 to 64 - 165 and older - 2risk factorsnone - 01-2 - 13 or more - 2initial troponinnormal - 01-3x normal limit - 1x3 or more normal limit - 2Contraindications includeacute myocardial infarctionunstable anginasymptomatic severe aortic stenosisacute pulmonary embolism, endocarditis, myocarditis, pericarditis, and dissectionPharmacologic stress testingTypically performed in patientswho cannot exercise or in patients withuninterpretable baseline ECG(e.g.,bundle branch block)pacemakerPharmacologic agentsvasodilators are preferred inradionuclide myocardial perfusion imaging and includeadenosinedipyridamoleregadenosonshould not be performed in patients with bronchospastic airway diseaseinotropes and/or chronotrope drugs includedobutamine (preferred for stress echo)atropine