Can a patient with a history of seizures undergo a stress test if there's a high suspicion for myocardial infarction (MI)?

Stress Testing in Patients with Seizures and Suspected Myocardial Infarction

Patients with a history of seizures can safely undergo stress testing when there is high suspicion for myocardial infarction, but pharmacological stress testing is strongly preferred over exercise stress testing to avoid triggering seizures. 1

Assessment of Patients with Seizures and Suspected MI

When evaluating a patient with seizures and suspected MI, consider:

• Seizures can occasionally be associated with myocardial infarction, occurring either before or after the cardiac event 2
• The diagnostic need must be balanced against safety concerns

Recommended Approach

Initial Evaluation

1. Obtain serial cardiac troponin measurements (at presentation and 1-3 hours later)
2. Perform 12-lead ECG immediately upon presentation
3. Assess renal function and complete blood count

Stress Testing Selection

Preferred Option:

• Pharmacological stress testing with imaging (nuclear MPI or echocardiography)
  • This is the safest approach for patients with seizure disorders 1
  • Avoids physical exertion that could potentially trigger seizures
  • Provides high diagnostic accuracy for coronary artery disease

Contraindicated Option:

• Exercise ECG testing
  • Not recommended for patients with seizure disorders due to risk of triggering seizures
  • Exercise testing could potentially lower seizure threshold in susceptible individuals

Specific Pharmacological Agents

• Vasodilator stress agents (dipyridamole, adenosine, regadenoson):

  • Generally preferred over dobutamine in seizure patients
  • Lower risk of triggering arrhythmias or seizures

• Dobutamine:

  • Use with caution in seizure patients
  • May increase heart rate and blood pressure more dramatically

Timing Considerations

• For patients with unstable angina/NSTEMI:

  • Perform stress testing after patient has been free of ischemia at rest or with low-level activity for 12-24 hours 1

• For patients with STEMI:

  • Defer stress testing until at least 3 weeks after the event in clinically low-risk patients 1

Special Considerations

• Imaging modality selection:

  • Nuclear myocardial perfusion imaging or echocardiography are both appropriate options 1
  • Selection should be based on local expertise and availability

• Risk stratification:

  • Use GRACE or TIMI risk scores to guide management decisions 3
  • High-risk patients may benefit from direct coronary angiography rather than stress testing

• Contraindications to stress testing:

  • Active seizures
  • Uncontrolled epilepsy
  • Recent stroke or TIA
  • Severe comorbidity likely to limit life expectancy 1

Common Pitfalls to Avoid

• Do not perform exercise stress testing in patients with seizure disorders when pharmacological alternatives are available
• Do not withhold necessary cardiac testing solely due to seizure history
• Do not use dobutamine as first choice for pharmacological stress in seizure patients when vasodilator options are available
• Do not perform stress testing during the postictal period when autonomic instability may be present

By following these guidelines, clinicians can safely and effectively evaluate patients with seizure disorders who have suspected myocardial infarction, ensuring appropriate diagnosis while minimizing risks.