For chest pain, should an echocardiogram (echo) or stress test be done first?

Choosing Between Echocardiography and Stress Testing for Chest Pain Evaluation

For patients with chest pain, a stress test should be performed first rather than a resting echocardiogram, as stress testing provides more definitive evaluation of myocardial ischemia and has higher diagnostic value for coronary artery disease. 1

Initial Assessment Approach

• For patients with acute chest pain, risk stratification should determine the appropriate testing pathway, with patients categorized as low, intermediate, or high risk for coronary artery disease (CAD) 1
• Resting echocardiography alone cannot definitively rule out transient episodes of ischemia, especially in patients with chest pain of short duration 1
• Stress testing (either exercise or pharmacological) provides more valuable diagnostic information by revealing inducible ischemia that may not be apparent at rest 1

Testing Selection Based on Risk Category

Low to Intermediate Risk Patients:

• Stress echocardiography is preferred over resting echocardiography for evaluating chest pain in patients with low to intermediate probability of CAD 1
• Stress echocardiography has demonstrated high sensitivity (85%) and specificity (77%) for detecting significant CAD 1
• Stress echocardiography has excellent prognostic value - a negative stress echocardiogram carries a 99% 3-year event-free survival rate 2

Intermediate Risk Patients:

• For intermediate-risk patients with acute chest pain and no known CAD, exercise ECG, stress echocardiography, stress PET/SPECT MPI, or stress CMR are all useful for diagnosing myocardial ischemia 1
• Stress testing can effectively identify which patients need invasive coronary angiography 1

High Risk Patients:

• For high-risk patients with acute chest pain (new ischemic ECG changes, positive troponin, new LV dysfunction, etc.), direct referral to invasive coronary angiography is recommended rather than non-invasive testing 1

Benefits of Stress Echocardiography Over Resting Echo

• Stress echocardiography can detect wall motion abnormalities that only appear during stress, which resting echocardiography cannot identify 1, 3
• Stress echocardiography has been shown to be safe, efficient, and cost-effective for evaluating chest pain patients in the emergency department setting 3
• Stress echocardiography can significantly reduce unnecessary hospitalizations by identifying low-risk patients who can be safely discharged 2, 3

Role of Resting Echocardiography

• Resting echocardiography is most useful for evaluating non-ischemic causes of chest pain such as valvular heart disease, pericardial disease, or cardiomyopathies 1
• Resting echocardiography can provide information about cardiac function and wall motion abnormalities but has limited sensitivity for detecting ischemia without stress 4
• Point-of-care resting echocardiography may be useful for rapid assessment of patients while they are symptomatic 1

Important Considerations and Pitfalls

• Wall motion abnormalities are not synonymous with ischemia and can occur in other conditions such as myocarditis, right ventricular pressure/volume overload, Takotsubo cardiomyopathy, and bundle branch blocks 1
• The choice between different stress modalities (exercise vs. pharmacological) should be based on the patient's ability to exercise and local expertise 1
• For patients with prior inconclusive stress tests, coronary CT angiography (CCTA) may be a better next step than repeating the same type of stress test 1

By prioritizing stress testing over resting echocardiography in the evaluation of chest pain, clinicians can more effectively diagnose or exclude coronary artery disease, leading to better patient outcomes and more efficient resource utilization.