From the Guidelines
Chest pain on exertion is typically evaluated using a combination of diagnostic tests, including electrocardiogram (ECG), stress testing, and imaging tests such as coronary computed tomography angiography (CCTA) and cardiac catheterization, with the choice of test depending on the patient's risk factors, symptoms, and initial test results, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. The initial assessment of chest pain on exertion typically includes:
- Electrocardiogram (ECG) to detect abnormal heart rhythms or signs of heart damage
- Blood tests such as cardiac enzymes (troponin, CK-MB) to check for heart muscle injury
- Stress testing, including exercise stress tests (treadmill or stationary bike), stress echocardiograms, and nuclear stress tests
- Imaging tests such as CCTA and cardiac catheterization to provide detailed images of coronary arteries The 2024 ESC guidelines recommend estimating the pre-test likelihood of obstructive epicardial CAD using the Risk Factor-weighted Clinical Likelihood model, and using additional clinical data to adjust this estimate 1. For patients with a low to moderate pre-test likelihood of obstructive CAD, CCTA is recommended to diagnose obstructive CAD and estimate the risk of major adverse cardiac events (MACE) 1. For patients with a moderate to high pre-test likelihood of obstructive CAD, stress echocardiography or SPECT/PET myocardial perfusion imaging is recommended to diagnose myocardial ischemia and estimate the risk of MACE 1. The choice of diagnostic test should be individualized based on the patient's risk factors, symptoms, and initial test results, with the goal of identifying conditions like coronary artery disease, which is a common cause of exertional chest pain due to inadequate blood flow to the heart muscle during increased demand.
From the Research
Diagnostic Tests for Chest Pain on Exertion
The following diagnostic tests are used to evaluate chest pain on exertion:
- Electrocardiogram (ECG) obtained within 10 minutes of presentation 2
- Troponin levels measurement using recommended protocols 2, 3
- Stress testing, such as exercise treadmill testing, stress echocardiography, or myocardial perfusion scintigraphy 2, 4
- Coronary computed tomography angiography (CCTA) for patients at low to intermediate risk for acute coronary syndromes 4
- Risk stratification using Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score 2, 5
Diagnostic Evaluation
The diagnostic evaluation of chest pain on exertion begins with an ECG and troponin levels measurement. If the ECG finding is normal and results of two troponin tests are negative, risk stratification should be calculated using TIMI or HEART score 2. Based on the score, further evaluation to exclude coronary artery disease (CAD) is completed during hospitalization or after discharge, using exercise treadmill testing, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography 2, 4.
Biomarkers and Risk Stratification
Cardiac troponins are highly specific for myocardial injury, which could be attributable to a myriad of underlying causes 3. The HEART score and clinical coronary artery disease (CAD) consortium (CADC) model can be used for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) 5. The CADC model was more effective at predicting obstructive CAD compared to the HEART score, while the HEART score and CADC model were equally effective to safely identify low-risk patients 5.