Is a stress test accurate in men with typical angina pectoris (chest pain) receiving digitalis (digoxin)?

From the Guidelines

Stress tests may be less accurate in men with typical angina pectoris who are taking digitalis, and alternative stress testing methods such as stress echocardiography or exercise perfusion imaging are recommended as the initial test for risk stratification 1.

Key Points to Consider

• Digitalis (digoxin) can cause ST-segment depression on an electrocardiogram (ECG), which can mimic the changes seen during exercise-induced ischemia, potentially leading to false-positive results.
• For patients with chronic stable angina who are able to exercise, do not have left bundle-branch block or an electronically paced ventricular rhythm, and have abnormal results on resting ECG or are using digoxin, exercise perfusion imaging or exercise echocardiography is recommended as the initial test for risk stratification 1.
• The American College of Physicians (ACP) agrees with the consensus of the writing committee of the American College of Cardiology/American Heart Association (ACC/AHA) to recommend the use of stress imaging (not exercise ECG) for risk stratification in patients with chronic stable angina who are taking digoxin 1.

Recommendations for Stress Testing

• Exercise perfusion imaging or exercise echocardiography is recommended as the initial test for risk stratification in patients with chronic stable angina who are able to exercise, do not have left bundle-branch block or an electronically paced ventricular rhythm, and have abnormal results on resting ECG or are using digoxin 1.
• For patients who are unable to exercise, pharmacologic stress tests using dobutamine or adenosine may provide more reliable results 1.

Importance of Accurate Stress Testing

• Accurate stress testing is crucial for risk stratification and guiding treatment decisions in patients with chronic stable angina.
• The choice of stress test should be individualized based on the patient's clinical characteristics and ability to exercise.
• The interpreting physician should be informed about the patient's digitalis use to account for baseline ECG changes and potential false-positive results.

From the Research

Accuracy of Stress Test in Men with Typical Angina Pectoris Receiving Digitalis (Digoxin)

• The accuracy of a stress test in men with typical angina pectoris receiving digitalis (digoxin) is a topic of interest in cardiology.
• According to 2, standard treadmill exercise testing is most accurate in patients with normal findings on a resting electrocardiogram who are not taking digoxin.
• This suggests that the accuracy of a stress test may be affected by the use of digitalis (digoxin) in men with typical angina pectoris.
• However, the study does not provide direct evidence on the accuracy of stress tests in men with typical angina pectoris receiving digitalis (digoxin).

Factors Affecting Stress Test Accuracy

• Several factors can affect the accuracy of a stress test, including the type of stress test used, the patient's resting electrocardiogram, and the presence of coronary artery disease.
• 3 found that troponin-T positivity after a stress test was higher in patients with three-vessel disease, suggesting that stress tests can be useful in detecting severe coronary artery disease.
• 4 found that mental stress tests can be effective in inducing vasospastic angina pectoris, highlighting the importance of considering different types of stress tests.
• 5 found that recovery-limited ST segment depression during exercise ECG stress testing confers the same prognosis as that occurring during exercise, emphasizing the need to monitor patients during the recovery period.
• 6 found that angina during exercise testing increases the sensitivity of the test and identifies cohorts of subjects at high risk for subsequent coronary events.

Limitations of Current Evidence

• While the available evidence provides some insights into the accuracy of stress tests in men with typical angina pectoris, there is limited direct evidence on the specific topic of interest.
• Further research is needed to fully understand the accuracy of stress tests in men with typical angina pectoris receiving digitalis (digoxin).