What are the indications for an Exercise Stress Test (EST) beyond Coronary Artery Disease (CAD)?

Indications for Exercise Stress Testing Beyond Coronary Artery Disease

Exercise stress testing (EST) has several important indications beyond the diagnosis and risk stratification of coronary artery disease, including evaluation of valvular heart disease, arrhythmias, hypertrophic cardiomyopathy, and assessment of functional capacity for various clinical scenarios. 1, 2

Valvular Heart Disease

• Aortic Regurgitation: EST is the only valvular condition with significant evidence supporting its use in management decisions 3
• Aortic Stenosis:
  • Recommended when mean Doppler gradient >30 mmHg or peak Doppler gradient >50 mmHg if patient is interested in athletic participation 2
  • Useful for asymptomatic young adults <30 years to determine exercise capability and blood pressure response 2
  • Contraindicated in symptomatic severe aortic stenosis 2

Hypertrophic Cardiomyopathy (HCM)

• Recommended for:
  • Symptomatic HCM patients without resting or provocable outflow tract gradient ≥50 mmHg (Class I) 2
  • Asymptomatic HCM patients to detect dynamic left ventricular outflow tract obstruction (Class IIa) 2
  • All pediatric patients with HCM regardless of symptom status (Class I) 2
  • Patients with nonobstructive HCM and advanced heart failure (NYHA class III-IV) to quantify functional limitation 2
  • Consider every 2-3 years in patients with HCM where functional capacity is uncertain 2

Arrhythmia Evaluation

• Helpful in evaluating patients with syncope to identify exercise-induced arrhythmias 3
• Useful in determining the cause of palpitations that occur during physical activity 4
• Can help evaluate the effectiveness of antiarrhythmic therapy 1

Hypertension Assessment

• Identifies patients at risk of developing hypertension if they show an abnormal hypertensive response to exercise 3
• Evaluates blood pressure response in patients with borderline or labile hypertension 4

Functional Capacity Assessment

• Recommended when functional capacity is uncertain or ambiguous to guide therapy 2
• Provides prognostic information as part of initial evaluation in patients with cardiovascular disease 2
• Exercise capacity is one of the strongest prognostic indicators for long-term risk 2
• Useful for developing appropriate exercise prescriptions in both healthy and diseased populations 5

Special Populations

• Post-Revascularization: Useful in symptomatic patients with prior revascularization (PCI or CABG) 1
• Older Adults: Can be used to identify coronary artery disease, though pharmacologic stress testing may be necessary due to comorbidities 2, 3
• Diabetes: Consider in adults with diabetes ≥40 years of age, though pharmacologic stress may be preferred with resting ECG abnormalities 2

Preoperative Risk Assessment

• Helpful for risk stratification in patients undergoing vascular surgery 4
• Useful for patients with active cardiac symptoms before undergoing nonemergent noncardiac surgery 4
• Not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms 4

Important Considerations and Contraindications

• EST is contraindicated in:

  • Acute myocardial infarction within 2 days
  • Unstable angina not previously stabilized
  • Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
  • Symptomatic severe aortic stenosis
  • Uncontrolled symptomatic heart failure
  • Acute pulmonary embolism, myocarditis, or pericarditis 2

• EST is not diagnostic in patients with:

  • Left bundle branch block
  • Paced ventricular rhythm
  • Wolff-Parkinson-White syndrome
  • Significant resting ECG abnormalities 1

When exercise testing is not feasible or when ECG abnormalities limit interpretation, alternative stress testing modalities such as stress echocardiography, nuclear perfusion imaging, or pharmacologic stress testing should be considered 1.