Indications and Contraindications for Cardiac Stress Testing

Indications for Cardiac Stress Testing

• The American College of Cardiology recommends cardiac stress tests for patients with suspected coronary artery disease (CAD) who are at intermediate risk, patients with acute chest pain who have been stabilized, and for prognostic assessment in patients with established CAD 1, 2
• Stress testing should be performed in patients with chest pain who are at low to intermediate risk after initial evaluation shows no high-risk features (normal ECG, negative cardiac biomarkers) 3, 4
• Testing should be performed within 72 hours of presentation for low-risk patients evaluated on an outpatient basis 5
• For patients evaluated in chest pain units or emergency departments, stress testing can be performed after 8-12 hours of observation if the patient remains pain-free with normal ECGs and cardiac biomarkers 4, 2
• Imaging modalities (echocardiography, nuclear imaging) should be added when patients have resting ST-segment depression, left ventricular hypertrophy, bundle-branch block or intraventricular conduction defect, pre-excitation syndrome, digoxin therapy, or paced rhythm 2, 6, 7
• Pharmacological stress testing with imaging is recommended when physical limitations prevent adequate exercise 2
• Submaximal exercise testing can be performed before discharge (around 4-6 days post-event) for prognostic assessment and activity prescription in patients with acute coronary syndrome 7, 6
• Symptom-limited exercise testing can be performed 14-21 days after discharge if a predischarge test was not done in patients with acute coronary syndrome 7, 6
• Stress testing is useful for activity counseling and exercise training as part of cardiac rehabilitation in patients who have undergone coronary revascularization 7, 6
• For patients with known CAD and new symptoms, stress testing can help determine if there is progression of disease or new obstructive lesions 1
• Evaluation of asymptomatic persons with diabetes mellitus who plan to start vigorous exercise is recommended 7, 6
• Consider testing in asymptomatic men older than 45 years and women older than 55 years who plan to start vigorous exercise, work in occupations where impairment might impact public safety, or are at high risk for CAD due to other diseases 7, 6
• Patients with cocaine-associated chest pain who are at low to intermediate risk can undergo stress testing after 9-12 hours of observation if they remain stable 8

Contraindications to Stress Testing

• Severe comorbidity likely to limit life expectancy and/or candidacy for revascularization is a contraindication to stress testing 7, 6
• Acute myocardial infarction patients with uncompensated heart failure, cardiac arrhythmia, or severe noncardiac conditions that limit exercise ability should not undergo stress testing 7, 6
• Patients already selected for cardiac catheterization should not undergo stress testing, although stress imaging may still be useful to evaluate ischemia in borderline lesions 7, 6
• Routine screening of asymptomatic men or women without risk factors is not recommended 7, 6

Common Pitfalls to Avoid

• Ordering stress tests in asymptomatic low-risk patients without risk factors is not recommended 7, 6
• Failing to use imaging when indicated in patients with baseline ECG abnormalities can lead to decreased accuracy 2
• Performing stress tests too early in patients with acute myocardial infarction who are not clinically stable is not recommended 7, 6
• Failing to consider pharmacologic stress testing when patients cannot achieve adequate exercise levels can lead to inaccurate results 2