Diagnostic Criteria for Cardiovascular Disease

Indications for Exercise Stress Test and Echocardiogram

The American College of Cardiology recommends an exercise stress test as the initial examination for patients with symptoms suggestive of cardiac disease and known risk factors, if the patient can exercise adequately and has an interpretable ECG; the echocardiogram is reserved for specific situations where there is clinical evidence of valvular, pericardial, or coronary artery disease 1
The European Heart Journal suggests that an exercise stress test is the first-line examination when the patient has an intermediate probability of coronary artery disease, an interpretable resting ECG, and can perform at least 5 METs of physical exercise 1, 2, 3
The American College of Cardiology indicates that an echocardiogram is recommended when there is clinical evidence of valvular or pericardial disease, or when the exercise stress test is inadequate or non-diagnostic 4, 5, 6, 7

The sensitivity and specificity of the exercise stress test are approximately 61% and 70-77%, respectively 1
The echocardiogram stress test has a sensitivity of 79% and specificity of 83% for detecting obstructive coronary artery disease in women, superior to the exercise ECG alone 3
The use of dobutamine stress echocardiography has a sensitivity of 75-93% and specificity of 79-92% for detecting coronary artery disease 3, 8

For patients with acute chest pain, an echocardiogram is strongly recommended when there is evidence of valvular or pericardial disease, and reasonably recommended for known or suspected coronary artery disease 4, 5
For patients with dyspnea, an echocardiogram is recommended when there are clinical findings suggestive of significant cardiac disease 4
The American College of Cardiology does not recommend routine screening with exercise stress test or echocardiogram in asymptomatic patients without significant coronary risk factors 5, 7

The use of contrast ultrasonography can improve diagnostic accuracy when two or more contiguous myocardial segments are not visualized adequately, increasing diagnostic quality to >97% of cases 2, 3
The European Heart Journal recommends the use of stress echocardiography for diagnosing myocardial ischemia and estimating the risk of major adverse cardiovascular events in patients with an intermediate to high pre-test probability (>15-85%) of obstructive coronary artery disease 2