Do we do a stress test for patients with fatigue?

Fatigue Evaluation: Stress Test Not Indicated as First-Line Assessment

Stress testing is not indicated as a first-line diagnostic approach for patients presenting with fatigue unless there are specific cardiac symptoms or risk factors present.

Appropriate Fatigue Assessment Algorithm

Initial Screening

• Use a 0-10 numeric rating scale to quantify fatigue severity 1:
  • Mild: 1-3
  • Moderate: 4-6
  • Severe: 7-10

For Moderate to Severe Fatigue (Score ≥4)

1. Focused History and Physical Examination

   • Assess onset, pattern, duration, and alleviating/worsening factors 2, 1
   • Review current disease status and treatments 2
   • Evaluate impact on daily functioning and quality of life 2

2. Evaluate Treatable Contributing Factors

   • Pain assessment
   • Emotional distress (depression, anxiety)
   • Sleep disturbance and sleep hygiene
   • Anemia
   • Nutritional status
   • Activity level
   • Medication side effects
   • Alcohol/substance abuse
   • Comorbidities 2, 1

3. Laboratory Testing

   • Complete Blood Count (CBC)
   • Comprehensive Metabolic Panel (CMP)
   • Thyroid Function Tests (TSH, free T4)
   • Inflammatory markers (ESR, CRP)
   • Iron studies
   • Vitamin D level
   • Fasting glucose/HbA1c 1

When to Consider Cardiac Evaluation

Cardiac stress testing should only be considered when:

• Patient has concurrent cardiac symptoms (chest pain, dyspnea, palpitations)
• Patient has significant cardiovascular risk factors
• Initial evaluation suggests cardiac etiology 3

Evidence-Based Approach to Fatigue Management

Non-Pharmacological Interventions

• Structured physical activity plan including stretching and aerobic exercise 4
• Cognitive behavioral therapy for chronic fatigue 4
• Sleep hygiene optimization 1
• Short naps as performance enhancers 4

Pharmacological Considerations

• Address underlying causes first
• Consider SSRIs if depression is present 4
• Caffeine for episodic situations requiring alertness 4

Common Pitfalls to Avoid

1. Premature or Unnecessary Testing

   • Laboratory studies affect management in only 5% of fatigue cases 4
   • Repeating normal tests is generally not indicated
   • Stress testing without cardiac symptoms is low-yield and costly 3

2. Missing Serious Underlying Conditions

   • Cancer-related fatigue requires thorough evaluation 2
   • Neurological causes of fatigue may require specialized assessment 5
   • Endocrine disorders can present primarily with fatigue 1

3. Inadequate Follow-up

   • Schedule regular follow-up visits rather than sporadic urgent appointments 4
   • Use validated fatigue assessment tools for monitoring (FSS has excellent internal consistency with Cronbach alpha = 0.93) 6

By following this structured approach, clinicians can effectively evaluate and manage fatigue while avoiding unnecessary testing such as stress tests when not clinically indicated.