Indications for Stress Testing in Suspected Coronary Artery Disease
Stress testing is indicated primarily for symptomatic patients with intermediate pretest probability of coronary artery disease (CAD), for risk stratification in patients with known CAD, and in specific high-risk asymptomatic populations. 1
Primary Indications for Stress Testing
Symptomatic Patients
- Evaluation of patients with symptoms suggestive of CAD (chest pain, dyspnea, or other ischemic equivalents) with intermediate pretest probability of disease 1
- Assessment of patients with unstable angina who have been clinically stabilized and are in the intermediate- or low-risk category 1
- Evaluation of patients with equivocal or inconclusive prior test results when a definitive determination of CAD presence would affect therapy 1
- Assessment when initial stress testing yields ambiguous or indeterminate results in patients with high likelihood of CAD 1
Risk Stratification in Known CAD
- Prognostic assessment in patients with established CAD to guide management decisions 1, 2
- Evaluation of patients after acute myocardial infarction when clinically stable (submaximal test before discharge or symptom-limited test after 2-3 weeks) 1
- Assessment of functional capacity and response to therapy in patients with known CAD 2
Special Populations
- Evaluation of asymptomatic persons with diabetes mellitus who plan to start vigorous exercise 1
- Assessment of asymptomatic men older than 45 years and women older than 55 years who:
- Plan to start vigorous exercise (especially if sedentary)
- Are involved in occupations where impairment might impact public safety 1
- Evaluation of patients before non-cardiac surgery in specific high-risk scenarios (particularly vascular surgery) 3
Contraindications to Stress Testing
- Acute coronary syndrome that is not clinically stable 1
- Uncompensated heart failure 1
- Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise 1
- Severe aortic stenosis with symptoms 1
- Acute pulmonary embolism or infarction 4
- Acute myocarditis or pericarditis 4
- Acute aortic dissection 4
Selection of Stress Test Modality
Standard Exercise ECG Testing
- Initial test of choice for patients with:
Stress Imaging (Echo or Nuclear)
- Recommended for patients with:
- Stress echocardiography is not indicated for cardiovascular risk assessment in low- or intermediate-risk asymptomatic adults 1
Pharmacologic Stress Testing
- Indicated when patients cannot exercise adequately due to:
- Vasodilator agents (adenosine, regadenoson, dipyridamole) or dobutamine may be used based on specific patient characteristics 6, 5
Special Considerations for Asymptomatic Patients
- Routine screening with stress testing is generally not recommended for asymptomatic individuals 1
- Stress myocardial perfusion imaging may be considered in:
- Asymptomatic patients with diabetes
- Asymptomatic individuals with strong family history of CAD
- Patients with high coronary artery calcium score (≥400) 1
- In the European guidelines, stress testing or CT coronary angiography may be considered in very high-risk asymptomatic individuals with diabetes who also have peripheral arterial disease, high CAC score, proteinuria, or renal failure 1
Clinical Pitfalls to Avoid
- Performing stress tests in low-risk asymptomatic individuals without risk factors (low yield, potential for false positives) 1
- Ordering stress tests in patients with recent normal coronary evaluation and no change in symptoms 3
- Using stress testing as the initial test in patients with high pre-test probability of severe multivessel or left main disease (these patients may benefit from direct referral to coronary angiography) 1
- Failing to recognize the limitations of stress testing (sensitivity 72-83%, specificity 79-95% depending on modality) 1, 2
- Performing routine stress testing less than two years after PCI or less than five years after CABG in asymptomatic patients with no new symptoms 3