Understanding Question Marks in Nuclear Stress Test Reports
The question marks in your report are likely formatting artifacts or bullet points from the reporting software, not indicators of diagnostic uncertainty. These symbols commonly appear in automated reporting systems as placeholders for bullet points or section markers and do not signify that your interpreting physician is unsure about the findings 1.
What Your Report Actually Shows
Your nuclear stress test demonstrates borderline findings for ischemia based on specific ECG changes during recovery:
The ST Depression Pattern
- 1.0 mm of upsloping ST depression occurred in the inferolateral leads (II, III, aVF, V5, V6) during the recovery phase 1
- Upsloping ST depression is considered a less specific finding for ischemia compared to horizontal or downsloping ST depression 1
- The fact that it resolved by minute 5 of recovery is actually a favorable prognostic sign, as prolonged ST depression correlates with more severe coronary disease 1
Why "Borderline" Matters
The term "borderline for ischemia" reflects that:
- Upsloping ST depression ≥1.0 mm falls into a gray zone—it can occur with true ischemia but also in normal individuals, especially during recovery when catecholamine levels remain elevated 1
- The inferolateral distribution suggests possible involvement of the right coronary or circumflex arteries, but the pattern alone doesn't definitively confirm obstructive disease 2
- Your ECG changes were not accompanied by the most specific markers of severe ischemia, such as ST elevation, horizontal/downsloping depression ≥2 mm, or changes in multiple lead zones 1, 2
The Arrhythmias Noted
Rare PACs (premature atrial contractions) and occasional PVCs (premature ventricular contractions) during recovery are extremely common and generally benign findings 1:
- These occur in the recovery phase due to high catecholamine levels combined with changing hemodynamics as your heart rate slows 1
- The frequency described ("rare" and "occasional") indicates these are not clinically significant 1
- Exercise-induced arrhythmias with ST depression are less concerning than those with ST elevation 1
What This Means Clinically
Your nuclear perfusion images (the actual pictures of blood flow to your heart) are the most important part of this test 3:
- If your nuclear images showed no perfusion defects, the borderline ECG changes have minimal prognostic significance and your cardiac event risk remains low 3
- If perfusion defects were present, their size and reversibility determine your risk far more than the ECG changes alone 4, 2, 3
- Studies show that when nuclear imaging is normal, even positive ECG changes do not predict cardiac events (hazard ratio 1.214, not statistically significant) 3
Next Steps
Request clarification from your ordering physician specifically about the nuclear perfusion images:
- Ask whether any perfusion defects were identified and their extent (measured as percentage of myocardium involved) 4
- If perfusion defects were present, ask if they were reversible (indicating ischemia) or fixed (indicating prior infarction) 4, 5
- The combination of perfusion findings with your ECG changes determines whether further testing (such as coronary angiography) is warranted 1, 6
Common Pitfall to Avoid
Do not focus excessively on the ECG component alone—the nuclear perfusion images provide far superior prognostic information 5, 3. The ECG changes you describe are nonspecific and their clinical significance depends entirely on whether they correlate with actual perfusion abnormalities on the nuclear images 3.