Does a patient with chest pain require both an echocardiogram (echo) and a stress test as part of their diagnostic workup?

Risk-Stratified Approach to Echo and Stress Testing in Chest Pain

Not all patients with chest pain require both an echocardiogram and a stress test—the decision depends entirely on risk stratification, with low-risk patients (<1% 30-day MACE risk) requiring neither test, while intermediate-risk patients benefit from a resting echo followed by selective stress testing based on findings. 1

Low-Risk Patients: No Testing Required

Low-risk patients with acute chest pain (<1% 30-day risk of death or MACE) can be safely discharged home without admission or urgent cardiac testing, including both echo and stress tests. 1

• This represents a significant proportion of chest pain presentations and avoids unnecessary testing in patients who will not benefit 1
• Risk stratification should incorporate clinical information including age, ECG findings, symptoms, CAD risk factors, and cardiac troponin levels 1

Intermediate-Risk Patients: Sequential Testing Strategy

Step 1: Resting Echocardiogram First

For intermediate-risk patients with acute chest pain, transthoracic echocardiography is recommended as the initial rapid bedside test (Class I recommendation). 1

The resting echo serves multiple critical purposes:

• Establishes baseline ventricular and valvular function 1
• Evaluates for wall motion abnormalities suggesting acute ischemia 1
• Assesses for pericardial effusion and other non-ischemic causes 1
• However, a normal resting echo does NOT exclude ischemia or significant coronary disease 2

Step 2: Stress Testing—When and Which Type

After resting echo, stress testing is indicated for intermediate-risk patients with no known CAD who are eligible for diagnostic testing after negative or inconclusive ACS evaluation. 1

Stress Test Selection Algorithm:

For patients capable of exercise with interpretable baseline ECG:

• Exercise ECG is appropriate as first-line stress testing 1
• Provides both diagnostic and prognostic information 1

For patients with baseline ECG abnormalities (LBBB, digoxin use, Wolff-Parkinson-White, ventricular pacing):

• Stress imaging is required instead of exercise ECG alone 1
• Options include stress echocardiography, SPECT MPI, PET MPI, or stress CMR 1

Stress echocardiography is equivalent to stress nuclear MPI and superior to exercise ECG alone for risk stratification in intermediate-risk patients. 1, 3

• Identifies significantly more patients with low post-test probability of CAD (80% vs 31% for exercise ECG) 3
• Has higher specificity for significant CAD (84% positive predictive value vs 56% for exercise ECG) 3
• Reduces need for further testing compared to exercise ECG (16% vs 52%) 3

When Both Tests Are NOT Needed

The following scenarios require alternative approaches rather than routine echo plus stress testing:

Patients Under 40 Years, Low-to-Intermediate Risk:

• Diagnostic yield of routine stress testing is extremely low (0.24-0.32%) 4
• Consider discharge with outpatient follow-up if truly low risk 4

Patients with Prior Recent Negative Testing:

• Normal CCTA within 2 years (no plaque/no stenosis) 1
• Negative stress test within 1 year with adequate stress achieved 1
• These patients do not require repeat testing 1

Patients with Inconclusive or Nondiagnostic Stress Echo:

Do not repeat stress echocardiography—proceed to alternative testing: 2

• Coronary CT angiography (CCTA) is preferred for low-to-intermediate risk patients 2
• Stress cardiac MRI provides superior image quality when echo is nondiagnostic 2
• Consider invasive coronary angiography if clinical suspicion remains high 2

Critical Pitfalls to Avoid

Resting echo alone cannot exclude ischemia—wall motion abnormalities at rest may indicate prior infarction but do not assess for inducible ischemia. 2

Wall motion abnormalities are not synonymous with ischemia—myocarditis, cardiomyopathy, bundle branch blocks, and RV pressure overload can all produce regional wall motion abnormalities. 2

Stress testing adds minimal value when cardiac troponin is negative—in one study, stress testing identified only an additional 4.5% of patients for revascularization beyond troponin testing alone. 5

Submaximal stress tests are nondiagnostic—failure to achieve at least 85% of maximum predicted heart rate renders exercise testing uninterpretable. 2

The Bottom Line Algorithm

1. Risk stratify first using clinical data, ECG, and troponin 1
2. Low risk (<1% 30-day MACE): Discharge without testing 1
3. Intermediate risk: Start with resting echo 1
4. If resting echo shows acute findings: Proceed to angiography 1
5. If resting echo normal/nondiagnostic: Proceed to stress testing (imaging preferred over ECG alone) 1, 3
6. If stress test positive: Consider angiography 1
7. If stress test negative: Discharge with medical management 1
8. If stress test nondiagnostic: CCTA or stress MRI, not repeat stress echo 2