Is a stress test accurate in diagnosing coronary artery disease in men 50 and older with typical angina (chest pain) pectoris?

From the Guidelines

Stress testing is a moderately accurate diagnostic tool for coronary artery disease in men 50 and older with typical angina pectoris, with a sensitivity of around 70-80% and specificity of 70-75%. For these patients, exercise stress testing is often recommended as an initial diagnostic tool, especially when the pre-test probability of coronary artery disease is intermediate to high based on age, gender, and symptom characteristics 1. The test works by increasing cardiac workload through exercise (typically on a treadmill or stationary bicycle) while monitoring ECG changes, blood pressure response, and symptoms. In patients with typical angina (chest pain precipitated by exertion, relieved by rest, and with characteristic quality and location), the diagnostic yield is higher compared to those with atypical symptoms. However, stress testing has limitations including false positives in patients with left ventricular hypertrophy, electrolyte abnormalities, or certain medications, and false negatives in patients with single-vessel disease.

Some key points to consider when interpreting stress test results include:

• The inability to perform an exercise test is itself a negative prognostic factor 1
• Stress testing with imaging (such as nuclear perfusion imaging or stress echocardiography) may be preferred for higher diagnostic accuracy, particularly in patients with baseline ECG abnormalities or those unable to exercise adequately 1
• The Duke treadmill score remains a widely used method to assess risk and prognosis, with a low-risk score indicating a highly favorable prognosis 1
• In patients who cannot exercise, pharmacologic stress testing with echocardiography or myocardial perfusion imaging is recommended 1

If the stress test is positive or inconclusive, coronary angiography may be necessary for definitive diagnosis. It is essential to weigh the benefits and limitations of stress testing in the context of individual patient characteristics and clinical presentation, and to consider the potential need for additional diagnostic testing or referral to a specialist. Overall, stress testing remains a valuable tool in the diagnosis and management of coronary artery disease, but its results should be interpreted in the context of a comprehensive clinical evaluation.

From the Research

Accuracy of Stress Test in Diagnosing Coronary Artery Disease

• The accuracy of a stress test in diagnosing coronary artery disease in men 50 and older with typical angina pectoris is supported by several studies 2, 3, 4, 5, 6.
• A study published in 2006 found that stress testing can be performed with exercise or pharmacologic agents to increase cardiac work, and patients with high-risk features should be referred for coronary angiography and possible revascularization 2.
• Another study from 1978 found that angina during exercise testing identified 85% of true positive tests for coronary artery disease, whereas S-T depression alone identified only 64% of such tests 3.
• A more recent study from 2022 found that global myocardial work combined with treadmill exercise stress can detect significant coronary artery disease in patients with angina pectoris, with a high area under the receiver operating characteristic curve (AUC) of 0.836 4.
• Other studies have also found that exercise testing can be useful in diagnosing coronary artery disease, particularly in patients with an intermediate pretest probability of CAD 5, 6.
• However, it is noted that the interpretation and selection of exercise tests depend on the pretest probability of CAD, and abnormal exercise test results provide probability estimates, not definite statements 6.

Factors Affecting Accuracy

• The accuracy of stress tests can be affected by various factors, including age, sex, and work load at onset of angina 3.
• A study from 1985 found that older men with stable typical angina are particularly likely to have left main coronary artery stenosis or three-vessel disease with poor ventricular function 6.
• Another study from 2012 found that handgrip exercise test can be useful in diagnosing coronary artery disease, particularly in patients with typical chest pain but negative maximal bicycle exercise-electrocardiogram test 5.

Diagnostic Value

• Stress tests have diagnostic value in detecting coronary artery disease, particularly in patients with an intermediate pretest probability of CAD 6.
• A study from 2022 found that global myocardial work parameters combined with exercise stress can provide additional value for estimating the probability of significant CAD 4.
• However, it is noted that exercise tests are not useful for trying to rule out CAD in patients with anginal pain, and clinical evidence of poor ventricular function may alone suffice to select patients with angina pectoris for coronary arteriography 6.