What is the most appropriate cardiac stress test to order?

From the Guidelines

The best cardiac stress test to order is an exercise electrocardiogram (ECG) stress test for most patients with intermediate pretest probability of coronary artery disease. This test involves having the patient exercise on a treadmill or stationary bicycle while monitoring their ECG, blood pressure, and symptoms. For patients unable to exercise adequately, a pharmacological stress test using either dobutamine or vasodilators (adenosine, dipyridamole, or regadenoson) combined with imaging modalities is recommended 1.

Key Considerations

• Stress echocardiography or nuclear myocardial perfusion imaging provides additional diagnostic information by visualizing wall motion abnormalities or perfusion defects.
• For higher-risk patients or when greater accuracy is needed, stress cardiac MRI or PET imaging offers superior diagnostic performance.
• The choice should be individualized based on the patient's ability to exercise, body habitus, baseline ECG abnormalities, and local expertise.
• Contraindications include acute coronary syndrome, uncontrolled arrhythmias, severe aortic stenosis, and acute heart failure.

Special Situations

• In patients with left bundle-branch block, exercise MPI has an unacceptably low specificity because of septal perfusion defects that are not related to CAD, and pharmacological stress MPI is suggested instead 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significant heart block, bronchospasm, critical carotid occlusive disease, or a condition that prevents their being withdrawn from theophylline preparations or other adenosine antagonists.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.

Imaging Modalities

• Stress echocardiography is favored if an assessment of valvular function or pulmonary hypertension is clinically important.
• MPI may be appropriate in patients with inadequate echocardiographic image quality, such as those with morbid obesity or severe chronic obstructive lung disease.
• Local expertise may help dictate the choice of test, and either exercise stress echocardiography/DSE or MPI may be appropriate in many instances 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Cardiac Stress Test Options

The choice of cardiac stress test depends on various factors, including the patient's medical history, symptoms, and physical abilities. Some of the most common cardiac stress tests include:

• Standard treadmill exercise testing
• Myocardial perfusion imaging
• Radionuclide angiography
• Stress echocardiography
• Cardiopulmonary exercise testing
• Pharmacologic stress testing

Selection Criteria

The selection of a specific stress test should depend on several factors, including:

• Local expertise with the various techniques
• The strengths and limitations of the techniques as they relate to the individual patient
• The presence of abnormal findings on a resting electrocardiogram
• The patient's ability to exercise adequately
• The presence of certain medical conditions, such as coronary artery disease or valvular heart disease 2, 3, 4

Patient-Specific Considerations

Certain patient populations may require special consideration when selecting a cardiac stress test, including:

• Patients with abnormal findings on a resting electrocardiogram, who may require one of the stress imaging techniques 2
• Patients who are unable to exercise adequately, who may require pharmacologic stress testing 2, 5
• Patients with known coronary artery disease, who may require stress perfusion imaging for diagnostic and prognostic purposes 2, 6
• Asymptomatic patients, who may not require cardiac stress testing unless they have certain risk factors or are undergoing preoperative evaluation for noncardiac surgery 3, 4

Test Characteristics

Each cardiac stress test has its own advantages and limitations, including:

• Standard treadmill exercise testing: widely available, less expensive, but may not be as accurate in patients with abnormal findings on a resting electrocardiogram 2
• Myocardial perfusion imaging: well validated for detecting left main and three-vessel coronary artery disease, but may be more expensive and require specialized equipment 2, 6
• Stress echocardiography: less expensive and provides more ancillary information, but may not be as well validated for assessment of severe coronary artery disease or prognosis 2