What are the contraindications to a stress test?

Contraindications to Stress Testing

Stress testing is contraindicated in patients with acute coronary syndrome, decompensated heart failure, severe/symptomatic aortic stenosis, uncontrolled arrhythmia, severe systemic arterial hypertension (≥200/110 mm Hg), acute aortic dissection, pericarditis/myocarditis, pulmonary embolism, and severe pulmonary hypertension. 1, 2

General Absolute Contraindications

• Acute myocardial or pericardial inflammatory disease 1
• Acute coronary syndrome or high-risk unstable angina 1, 2
• Decompensated heart failure 1, 2
• Severe or symptomatic aortic stenosis 1, 2
• Uncontrolled cardiac arrhythmias 1, 2
• Severe systemic arterial hypertension (≥200/110 mm Hg) 1, 2
• Acute aortic dissection 1
• Acute pericarditis or myocarditis 1, 2
• Acute pulmonary embolism 1, 2
• Severe pulmonary hypertension 1, 2

Modality-Specific Contraindications

Exercise Stress Testing

• Inability to exercise 1
• Abnormal ST changes on resting ECG that would interfere with interpretation 1
• Left bundle branch block, pre-excitation syndrome (Wolff-Parkinson-White), ventricular paced rhythm 1
• Digoxin therapy with significant baseline ST-segment abnormalities 1
• Greater than 1 mm of resting ST-segment depression 1
• Severe comorbidity limiting exercise capacity 1

Pharmacologic Stress Testing

Vasodilator Stress (Adenosine, Dipyridamole, Regadenoson)

• Significant arrhythmias (e.g., ventricular tachycardia, second or third-degree atrioventricular block) 1, 2
• Significant hypotension (systolic blood pressure <90 mm Hg) 1, 2
• Known or suspected bronchoconstrictive or bronchospastic disease 1, 2
• Recent use of dipyridamole or dipyridamole-containing medications 1, 2
• Use of methylxanthines (e.g., aminophylline, caffeine) within 12 hours 1, 2
• Sinus bradycardia <45 bpm 1

Dobutamine Stress

• Critical aortic stenosis 1, 2
• Hemodynamically significant left ventricular outflow tract obstruction 1, 2
• Hypokalemia 2
• Uncontrolled congestive heart failure 2
• Uncontrolled dysrhythmias 2

Special Populations with Higher Risk

• Patients with pulmonary hypertension 1
• Patients with documented long-QTc syndrome 1
• Patients with dilated/restrictive cardiomyopathy with congestive heart failure or arrhythmia 1
• Patients with a history of hemodynamically unstable arrhythmia 1
• Patients with hypertrophic cardiomyopathy who have symptoms, greater than mild left ventricular outflow tract obstruction, or documented arrhythmia 1
• Patients with greater than moderate airways obstruction on baseline pulmonary function tests 1
• Patients with Marfan syndrome and activity-related chest pain 1

Clinical Considerations

• When exercise stress testing is contraindicated, pharmacologic stress testing should be considered as an alternative 1, 3
• For patients unable to exercise adequately, pharmacologic stress testing is preferred to avoid false-negative results 3
• The presence of a defibrillator, oxygen, suction system, and emergency drugs is essential in any stress testing laboratory 1
• Exercise testing is preferred over pharmacologic stress testing whenever functional status permits, as it provides additional prognostic information about exercise capacity and hemodynamic responses 1, 3

Safety Precautions

• All stress testing facilities must be equipped with emergency equipment including a defibrillator, oxygen, suction system, and emergency medications 1
• Personnel conducting stress tests must be trained in recognizing complications and implementing emergency protocols 1
• Careful screening for contraindications should be performed immediately before the test 1
• Physician supervision is required when testing patients with recent (within 7-10 days) acute coronary syndrome, severe left ventricular dysfunction, severe valvular stenosis, or complex arrhythmias 1