What are the contraindications to stress tests?

Contraindications to Stress Testing

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

Universal Contraindications (All Stress Test Modalities)

These contraindications apply regardless of whether you're performing exercise, pharmacologic, or imaging-based stress testing:

Acute Cardiac Conditions

• Active acute coronary syndrome (ACS) or high-risk unstable angina 1, 2, 3
• Acute myocardial infarction within 2 days 1, 2
• Decompensated heart failure or uncontrolled heart failure 1, 2, 3
• Acute aortic dissection 1
• Acute myocarditis or pericarditis 1

Valvular Disease

• Severe symptomatic aortic stenosis 1
• Critical aortic stenosis (particularly for dobutamine stress) 1, 3
• Hemodynamically significant left ventricular outflow tract obstruction 1, 3

Arrhythmias and Conduction Abnormalities

• Significant ventricular arrhythmias (e.g., ventricular tachycardia) 1, 2
• Complete atrioventricular block 1
• Uncontrolled atrial fibrillation 1
• High risk for arrhythmias due to QT prolongation 1

Blood Pressure Extremes

• Severe systemic arterial hypertension (≥200/110 mm Hg) 1, 2, 3
• Significant hypotension (systolic blood pressure <90 mm Hg) 1, 2

Pulmonary Conditions

• Acute pulmonary embolism 1, 2
• Severe pulmonary hypertension 1, 2

Exercise Stress Testing-Specific Contraindications

Inability to Exercise

• Unable to achieve ≥5 METs or unsafe to exercise 1
• Physical inability to exercise adequately 1

ECG Interpretation Limitations

• Abnormal ST changes on resting ECG (left bundle branch block, Wolff-Parkinson-White pattern, ventricular paced rhythm, digoxin use) unless the test is performed solely to establish exercise capacity and not for ischemia diagnosis 1

Pharmacologic Stress Testing-Specific Contraindications

Vasodilator Stress (Adenosine, Dipyridamole, Regadenoson)

• Known or suspected bronchoconstrictive or bronchospastic disease 1, 2, 3
• Second- or third-degree atrioventricular block (without permanent pacemaker) 1, 2, 3
• Sinus bradycardia <45 bpm 1, 2
• Recent use of dipyridamole or dipyridamole-containing medications 1, 2, 3
• Use of methylxanthines (aminophylline, caffeine) within 12 hours 1, 2, 3
• Known hypersensitivity to adenosine or regadenoson 1
• Severe COPD 1, 2

Dobutamine Stress

• Critical aortic stenosis 1, 3
• Hemodynamically significant LVOT obstruction 1, 3
• Hypokalemia 3
• Uncontrolled congestive heart failure 3
• Uncontrolled dysrhythmias 3

Atropine (if used as adjunct)

• Myasthenia gravis 1
• Obstructive gastrointestinal disorders 1
• Narrow-angle glaucoma 1
• Obstructive uropathy 1

Stress Echocardiography-Specific Contraindications

• Limited acoustic windows (e.g., in COPD patients, obesity) 1, 3
• Inability to reach target heart rate (for exercise stress echo) 1, 3
• Respiratory failure 1, 2

Stress CMR-Specific Contraindications

• Reduced GFR (<30 mL/min/1.73 m²) 1
• Implanted devices not safe for CMR or producing artifact 1
• Significant claustrophobia 1
• Caffeine use within past 12 hours (for vasodilator stress) 1

Critical Pitfalls to Avoid

Medication Screening Failures

• Failing to screen for caffeine intake before vasodilator stress tests leads to false-negative results due to competitive adenosine receptor antagonism 2
• Overlooking dipyridamole-containing medications (e.g., Aggrenox) can precipitate severe adverse reactions when combined with vasodilator stress agents 2

Respiratory Complications

• Performing vasodilator stress in patients with active bronchospastic disease can precipitate severe, life-threatening bronchospasm 2
• This is particularly dangerous with adenosine and dipyridamole, which can cause significant bronchoconstriction 2

Radiation Considerations

• Pregnancy is a relative contraindication to nuclear stress testing due to fetal radiation exposure 2
• Younger patients have elevated projected cancer risk from radiation exposure; consider alternative non-radiation modalities when appropriate 2
• Follow ALARA (As Low as Reasonably Achievable) principles for all nuclear imaging 2

Weight Limitations

• Very obese patients exceeding weight-bearing limits of SPECT imaging tables (often 300 lb/135 kg) may require planar scintigraphy instead 2

Clinical Stability Assessment

• Do not perform stress testing in clinically unstable patients even if they don't meet specific contraindication criteria 1
• Acute illness of any kind (acute respiratory distress, severe infections) warrants postponement 1

Timing After Acute Events

• Wait at least 2 days after acute MI before considering stress testing 1, 2
• Submaximal testing can be performed before discharge, but symptom-limited testing should wait 2-3 weeks post-MI 4