What is the appropriate method for selecting a stress test, such as an Exercise (Electrocardiogram) ECG stress test or a Pharmacologic (Pharmacological) stress test, for a patient?

From the Guidelines

To pick an appropriate stress test, first determine the patient's clinical presentation, exercise capacity, and baseline ECG, considering that for patients who can exercise and have a normal baseline ECG, a standard exercise stress test using a treadmill or stationary bike is often the best choice, as supported by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. When selecting a stress test, several factors must be considered, including the patient's ability to exercise, baseline ECG findings, and specific clinical conditions.

• For patients with a normal baseline ECG who can exercise, a standard exercise stress test is typically preferred due to its ability to provide both an estimate of functional capacity and detection of myocardial ischemia, as outlined in the 2014 ACC/AHA guideline 1.
• If the patient has an abnormal baseline ECG, such as left bundle branch block, or is on digoxin, an imaging-based stress test like exercise or pharmacologic nuclear perfusion imaging or stress echocardiography should be considered, as these conditions can impair the diagnostic interpretation of a standard exercise ECG, as noted in the 2012 guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association 1.
• For patients unable to exercise due to orthopedic issues, deconditioning, or neurological problems, pharmacologic stress testing with agents such as adenosine, regadenoson, dipyridamole, or dobutamine is appropriate, with the choice of agent depending on specific patient conditions and contraindications, as discussed in the 2014 ACC/AHA guideline 1.
• The choice between nuclear imaging and echocardiography often depends on local expertise and availability, with nuclear imaging offering higher sensitivity and echocardiography providing information about valvular and structural heart disease, as highlighted in the evidence 1.
• Consideration of the patient's body habitus, such as obesity, which may limit echocardiographic image quality, and radiation exposure concerns, particularly in younger patients or those needing serial testing, is also crucial, as mentioned in the guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Choosing an Appropriate Stress Test

To pick an appropriate stress test, several factors should be considered, including the patient's ability to exercise, their resting ECG, and prior revascularization history.

• The standard exercise treadmill test (ETT) is a suitable initial test for patients with normal resting ECG and no prior revascularization who can exercise adequately 2.
• Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients and is used in the evaluation of patients with known cardiac disease 3.
• Testing of asymptomatic patients is generally not indicated, but may be performed in select deconditioned adults before starting a vigorous exercise program 3.
• Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery 3.

Considerations for Specific Patient Groups

• For women, exercise stress testing without imaging is the preferred initial choice for risk stratification 3.
• For patients with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting, exercise stress testing is rarely an appropriate option 3.
• Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing 3.
• Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms 3.

Comparison of Stress Testing Modalities

• Exercise stress CMR including wall motion and perfusion is feasible in patients with suspected ischemic heart disease and has shown promising results in comparison to SPECT 4.
• Exercise stress cardiac MR has been compared to stress echocardiography in healthy volunteers, with cardiac MR showing higher adequacy of endocardial visualization and confidence in interpretation of the stress study 5.