What is the most appropriate stress test to order?

From the Guidelines

The exercise electrocardiogram (ECG) stress test is the most appropriate initial stress test to order for patients with suspected coronary artery disease who can exercise adequately. This recommendation is based on the strongest and most recent evidence from the American College of Cardiology and American Heart Association guidelines 1. The exercise ECG stress test involves walking on a treadmill or pedaling a stationary bicycle while ECG, blood pressure, and symptoms are monitored.

Key Considerations for Stress Test Selection

• For patients unable to exercise, pharmacological stress tests using medications like dobutamine or vasodilators (adenosine, regadenoson, or dipyridamole) are appropriate alternatives 1.
• If more detailed imaging is needed, stress echocardiography, nuclear perfusion imaging (SPECT or PET), or cardiac MRI with stress can provide additional diagnostic information about myocardial perfusion and wall motion.
• Coronary CT angiography might be preferred for patients with low to intermediate risk.
• The choice of stress test should consider the patient's exercise capacity, baseline ECG abnormalities, body habitus, and specific diagnostic questions.

Special Situations

• In patients with left bundle-branch block, exercise MPI has an unacceptably low specificity, and pharmacological stress MPI is suggested over exercise stress imaging 1.
• In patients with indications for stress testing who are unable to perform adequate exercise, pharmacological stress testing with either DSE or MPI may be appropriate 1.
• Intravenous dipyridamole and adenosine should be avoided in patients with significant heart block, bronchospasm, critical carotid occlusive disease, or a condition that prevents their being withdrawn from theophylline preparations or other adenosine antagonists; regadenoson has a more favorable side-effect profile and appears safe for use in patients with bronchospasm 1.

Guideline Recommendations

• The American College of Physicians, American College of Cardiology Foundation, American Heart Association, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, and Society of Thoracic Surgeons recommend standard exercise ECG testing for risk assessment in patients who are able to exercise to an adequate workload and have an ECG that can be interpreted during exercise (Grade: strong recommendation; moderate-quality evidence) 1.
• The organizations also recommend the addition of either radionuclide myocardial perfusion imaging or echocardiography to standard exercise ECG testing for risk assessment, in patients with stable IHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Grade: strong recommendation; moderate-quality evidence) 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Types of Stress Tests

• Myocardial perfusion imaging, radionuclide angiography, stress echocardiography, and cardiopulmonary exercise testing are various types of stress tests available 2
• Standard treadmill exercise testing is widely available and less expensive than imaging techniques, but its accuracy is limited in patients with abnormal findings on a resting electrocardiogram or those taking digoxin 2
• Stress imaging modalities, such as myocardial perfusion imaging and stress echocardiography, offer greater accuracy and sensitivity, especially in patients with abnormal resting electrocardiograms 2, 3

Selection of Stress Test

• The choice of stress test depends on local expertise, patient characteristics, and the specific clinical question being addressed 2, 4
• Exercise-based stress tests are preferred over pharmacological stress tests, as they provide additional diagnostic and prognostic information, such as functional capacity and blood pressure response 3, 5
• Pharmacologic stress testing is usually reserved for patients who are unable to exercise adequately 2, 4

Indications and Contraindications

• Exercise stress testing is indicated for diagnosing coronary artery disease, developing exercise prescriptions, and evaluating cardiopulmonary function 5, 6
• Contraindications for exercise stress testing include unstable angina, acute myocardial infarction, and severe valvular heart disease, among others 5, 6
• Pharmacologic stress testing is contraindicated in patients with certain medical conditions, such as asthma or severe hypertension 4

Special Considerations

• Women may benefit from nuclear imaging stress tests, which are a preferable modality in this population 3
• Older patients or those with comorbidities may require pharmacologic stress testing instead of exercise-based testing 6
• Patients with certain valvular heart disorders, such as aortic regurgitation, may benefit from exercise stress testing to guide management decisions 6