How often should a stress test be performed for a patient with a history of myocardial infarction (MI)?

From the Guidelines

Patients with a history of myocardial infarction (MI) should not undergo routine periodic stress testing, but rather testing should be guided by the presence of symptoms or changes in clinical status, as recommended by the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease 1. The frequency of stress testing in patients with a history of MI should be individualized based on their risk factors, symptoms, and clinical characteristics.

• For asymptomatic patients with good exercise capacity and no complications following their MI, testing may not be necessary unless there is a change in clinical status.
• Patients with ongoing symptoms, incomplete revascularization, or multiple cardiovascular risk factors may require more frequent testing, but this should be determined on a case-by-case basis. The specific type of stress test—whether exercise ECG, nuclear imaging, stress echocardiography, or pharmacological stress testing—should be selected based on the patient's physical capabilities and clinical characteristics, as recommended by the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons guideline for the diagnosis of stable ischemic heart disease 1. If a patient develops new or worsening symptoms such as chest pain, shortness of breath, or decreased exercise tolerance between scheduled tests, they should undergo stress testing promptly regardless of when their last test was performed, as these symptoms may indicate a change in their clinical status that requires further evaluation. The evidence from the ISCHEMIA trial and the POST-PCI RCT suggests that routine stress testing in asymptomatic patients with stable coronary artery disease does not provide a significant benefit in terms of reducing major adverse cardiac events, and that a more symptom-oriented approach to testing may be more appropriate 1.

From the Research

Stress Test Frequency for Patients with a History of Myocardial Infarction (MI)

• The frequency of stress tests for patients with a history of MI is not explicitly stated in the provided studies, but the importance of stress testing in evaluating coronary artery disease and predicting the risk of recurrent cardiac events is emphasized 2, 3.
• Stress testing can be performed using exercise or pharmacological stress agents, and the choice of method depends on the patient's ability to exercise and other factors 4, 5, 3.
• For patients who have had an MI, stress testing can be used to assess left ventricular function, residual ischemia, and the tendency toward ventricular arrhythmias, and to identify patients at high risk of recurrent cardiac events 2.
• The studies suggest that stress testing can be performed as soon as 2 days after an MI, and that patients with normal perfusion images by pharmacological stress have a low annual incidence of cardiac events 3.
• The predictive value of a strongly positive stress test in patients with minimal symptoms, including those with a history of MI, is also discussed, and the results suggest that stress testing can be useful in predicting left main or other severe coronary artery disease even in asymptomatic patients 6.

Key Considerations

• The choice of stress test method (exercise or pharmacological) depends on the patient's ability to exercise and other factors 4, 5, 3.
• Stress testing can be used to assess left ventricular function, residual ischemia, and the tendency toward ventricular arrhythmias in patients with a history of MI 2.
• Patients with normal perfusion images by pharmacological stress have a low annual incidence of cardiac events 3.
• Stress testing can be useful in predicting left main or other severe coronary artery disease even in asymptomatic patients 6.