Cardiac Stress Testing: Who,

when, why, and how

Objectives
• Understand basic indications and contraindications to stress
testing

• Understand the differences between types of stress tests and

know which one to order

• Learn about some of the newer data on stress testing,

especially in regards to “screening” stress tests
Background
• ETT has been around for a long time; Dr. Bruce originally
published his protocol in 1963
• Nuclear SPECT imaging was developed in the 1980’s
• Stress echocardiography developed concurrently but
became more popular in the 1990’s and the specificity
got even better with widespread use of LV contrast
media.
Background
• Indications and implications have changed
dramatically with improvements in medical therapy
• ASA was novel in the 1980’s; first statin was marketed in
1987
• Key Point:
• Stress testing is not designed to detect any CAD, but to
detect obstructive CAD
• >50% LM; >70% epicardial artery
Bayes’ Theorm
• Bayes work in the 1700’s is what drives our stress
testing model today
• His theory basically says that the post-test probability
of an event is driven dramatically by the pre-test
probability
• The usefulness of a test is in the intermediate pre-test
probability
Who needs a stress test?
• 55 y/o male with DM, HTN, HL, 50 pack-year smoking
hx, and typical angina?

• 62 y/o female with right-sided chest pain q 2-3 days

that is brought on by exertion?

• 25 y/o male with a single episode of chest pain after

eating a spicy meal?
Interpretation of results
• 1st pt: Pre-test is 95%; with a positive test, it is 99%. With a
negative test, it is 90%

• 3rd pt: Pre-test is 3%; with a positive test, it is 10%; with a

negative test, it is 1%

• 2nd pt: Pre-test is 45%; with a positive test, it is 87%; with a

negative test, it is 10%
So…
• Key Point:
• The determination of your pre-test probability is the key
to deciding who needs a stress test.
Determining Risk
• Exercise stress test guidelines* tell us to quantify angina using 3
characteristics
• Substernal location of chest pain
• Provoked by exertion or emotional stress
• Relieved by rest or NTG
• Typical/Definite angina: 3/3
• Atypical/Probable: 2/3
• Nonanginal Chest Pain: 1/3
• Asymptomatic: 0/3

* Gibbons, et al. Journal American Collge of Cardiology, 2002

Determining Risk
Determining Risk

-Note that testing is appropriate for intermediate risk

-Also note that asymptomtatic folks are all LOW risk

To put it in simple words
• You all are obviously very capable of determining general
cardiac risk, but if you need help, check Framingham risk
score
• <10% is low risk
• 10-20% is intermediate
• >20% is high-risk
• Very low risk, reassure;
• Very high risk, call any on of the Docs!
• Stress those in between.
Once you’ve decided to stress
• Each stress test can be broken down into a “stress”
component and an “imaging” component
• “Stress” component include exercise (preferred),
dobutamine, Lexiscan (regadenoson), Persantine
(dipyridamole), adenosine, and pacing.
• “Imaging” components include EKG (first line), echo, and
nuclear
Stress Component
• Exercise is preferred method of stress
• Get physiologic data including BP, heart rate recovery, arrhythmia
evaluation, etc
• Don’t exercise pt’s who can’t exercise
• Those with significant leg or back issues
• Those who are unsteady
• Those who can’t reach 85% of MPHR
• There are protocols other than Bruce that can be considered
Stress Component
• Regadenoson, Adenosine and Dypi are all vasodilator stress agents

• Vasodilate coronaries creating a steal phenomenon in stenosed vessels

• Most important contraindications are severe reactive airway disease

and serious bradyarrhythmias/AV conduction defects

• Caffeine interferes with effects; pt must have at least 12 hours (24

preferred) without caffeine
Stress Component
• Dobutamine is a beta-agonist, causing elevated heart rate
and contractility

• Most important contraindication is the presence of serious

ventricular arrhythmias

• B-blockers will interfere with effect, so should be held

ECG Component
• EKG is first-line, for those who have an interpretable EKG
• Exceptions include
• LBBB
• WPW
• Dig Effect
• Left ventricular hypertrophy with secondary ST T changes
• Paced rhythm
• >1 mm ST depression on resting ECG
ECG Component
• Exercise if you have
• RBBB
• Minor ST-T wave changes
• Occasional PVC’s
• Stress ECG is also very useful for determining functional
capacity and efficacy of therapy
• We can evaluate more than just the ECG
• Caveat: Location of ST depression does not correlate with
area of ischemia
Imaging Component
• Echocardiography looks at several views of all walls of the LV and
compares them at rest and stress, looking for hypokinesis of affected wall.
Always use LV enhancing agent.
• Requires good echo windows
• Not obese
• No bad COPD
• Pt must be able to transfer quickly after exercise (time-dependent study)
• Important caveat: ordering a stress echo does not mean that valves or
other structures will be evaluated; we only look at 4 basic views of LV
cavity, so if you need other evaluation, please order a standard echo
(preferably prior to the stress echo and on a separate day)
Imaging Component
• Nuclear perfusion imaging evaluates blood flow to various walls,
comparing rest and stress
• Probably the most versatile test, though obesity and bowel
interference can be a problem.
• Should order a 2 day nuclear imaging protocol in obese (and very stout
patient)
• We prefer a Nuclear perfusion imaging with CT attenuation protocol if
obese and females with large breasts to improve sensitivity and
specificity
• Caveat: long test (pt’s should plan for 2-4 hours and occasionally 2
days)
Putting it together
• Need to pick both a stress and an imaging component that
fits your patient
• Vasodilators OK for either nucs or echo, but most often used
with nucs
• Dobutamine can be used with either echo or nucs
• Again, exercise is preferred modality
Putting it together
• For most patients, a standard exercise treadmill test is first
line and preferred

• Pt’s who can exercise and have interpretable ECG’s

• Use imaging for those who cannot exercise, have

uninterpretable ECG, or have non-diagnostic or suspicious
ETT
What about accuracy?
• ETT: Sens=68%; Spec=77%
• Accuracy=73%

• Exercise Echo: Sens=88%; Spec=79%

• Dobs Echo: Sens=81%; Spec=80%

• Exercise Nuc: Sens=87%; Spec=73%

• Vasodilator Nuc: Sens=89%; Spec=75%

Heart January; 89(1): 113–1182:

Circulation. 2003; 108:

My personal bias (No evidence)
• ETT is first line; if it correlates with my suspicion, I’m done; if not, I
pursue imaging

• If I want the test to be positive, I will pursue a nuc (probably overcalls)

• If I want the test to be negative, I will pursue a stress echo (probably

undercalls)
What about cost?
• Obviously, hospitals charge much more than this, but here are the
cost comparisons for each test:
• ETT: $
• Echo: $$
• Nuc: $$$
• Most cost effective to start with ETT
Special Considerations
• Yes, women have a higher false positive ETT rate; guidelines still say it
is first line.
• B-blockers, CCB’s: Generally, if trying to diagnose CAD, I recommend
holding. If trying to evaluate success of therapy, I recommend
continuing
• In pt’s with a LBBB, preferred test is a vasodilator nuclear scan
• In pt’s with previous CAD, some sort of imaging test is preferred (ie,
not just a standard treadmill).
Contraindications
• Almost nothing is absolute, but two key areas to pay
attention to

• Severe outflow tract obstruction: HCM, Aortic Stenosis

(can be done, but must be done very carefully)

• Key Point: Unstable Coronary Symptoms. These people

can die on the treadmill
Contraindications to exercise testing
Contraindications to exercise testing
Screening Stress Tests
• A stress test is there to detect hemodynamically significant
CAD, not just any CAD

• As a general rule, you should approach asymptomatic

patients with standard risk stratification using Framingham
Risk Score and family history;
• most of the time, a stress test is not needed
Asymptomatic Adults
• Guidelines Synopsis
• An exercise ECG may be considered for cardiovascular risk assessment in
intermediate-risk asymptomatic adults (including sedentary adults considering
starting a vigorous exercise program), particularly when attention is paid to non-
ECG markers such as exercise capacity. (Class IIb, LOE B)

• Stress echocardiography is not indicated for cardiovascular risk assessment in

low- or intermediate-risk asymptomatic adults. (Exercise or pharmacologic
stress echocardiography is primarily used for its role in advanced cardiac
evaluation of symptoms suspected of representing CHD and/or estimation of
prognosis in patients with known coronary artery disease or the assessment of
patients with known or suspected valvular heart disease). Class III, LOE C
 Asymptomatic Adults
• Stress MPI may be considered for advanced cardiovascular risk
assessment in asymptomatic adults with diabetes or asymptomatic
adults with a strong family history of CHD or when previous risk
assessment testing suggests high risk of CHD, such as a CAC score of 400
or greater (Class IIb, LOE C)

• Stress MPI is not indicated for cardiovascular risk assessment in low- or

intermediate-risk asymptomatic adults (Exercise or pharmacologic stress
MPI is primarily used and studied for its role in advanced cardiac
evaluation of symptoms suspected of representing CHD and/or
estimation of prognosis in patients with known CAD). Class III, LOE C
What about diabetics? (DIAD Trial)
• In 2009, we got the DIAD trial* (Detection of Ischemia in
Asymptomatic Diabetics)

• Enrolled pt’s with DM dx’d after age 30 and no h/o DKA or

CAD

• Important exclusion criteria: h/o angina, stress test or heart

cath in last 3 years, abnormal EKG, or other indication for
stress testing
What about diabetics? (DIAD Trial)
• Conclusion of authors was that asymptomatic diabetic
patients do not benefit from screening stress tests

• A few notable caveats

• Very low event rate (0.6%)
• Probably low-risk patients
• Significant amount of long-term crossover
• Excellent medical control of risk factors
DIAD trial
• The key points here for me are twofold:

• Risk factor modification is the key, not stress testing

• Risk factor modification works! (ie, not everyone needs a

stent…but that’s a separate talk)
What about Pre-Op Patients?
• Pre-operative evaluation for non-cardiac surgery is a whole
separate talk in itself

• An evolving field, but recent guidelines are pretty clear on

this point: most patients do not always need a stress test
prior to surgery

• *J Am Coll Cardiol 2009;54

Pre-op evaluation
• No recent trial has shown any benefit of pre-operative stress
testing or revascularization

• There are no class I recommendations for pre-operative

stress testing; the best the guidelines will give you is a IIa
recommendation for pt’s with 3 risk factors who cannot do 4
METs and are undergoing vascular surgery
It’s positive…now what?
• First rule is, don’t panic
• Second, treat those patients like you would any CAD patient
• Start Anti-platelets
• Check Lipids and treat to LDL <100 (<70)
• Control BP
• Separate out stable from unstable symptoms to the best of your ability

• Most patients probably deserve a cath, but not all need it

and some aren’t candidates
Key Points
• Stress tests aim to detect obstructive CAD
• Determining pre-test probability is fundamental to
deciding who to stress
• A standard exercise treadmill test is first line for most
patients
• “Screening” stress tests should be rare events (?
Pilots, very high risk DM, very high risk surgery)
QUESTIONS????

Thank you