Can a patient with reduced left ventricular ejection fraction (EF) of 50% and a small pericardial effusion over the left ventricle undergo a stress test?

From the Guidelines

A stress test can be performed on a patient with a low ejection fraction (EF) of 50% and a small pericardial effusion over the left ventricle, but with certain precautions. The decision should be individualized based on the patient's clinical stability, as suggested by the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease 1. For stable patients without symptoms of cardiac tamponade or hemodynamic compromise, a pharmacological stress test (using dobutamine, adenosine, or regadenoson) is generally safer than exercise testing.

The test should be performed under close monitoring with emergency equipment readily available. Prior to the test, a comprehensive echocardiogram should be done to assess the size and hemodynamic impact of the effusion, as recommended by the guidelines on the management of stable angina pectoris: executive summary: the task force on the management of stable angina pectoris of the European Society of Cardiology 1. If there are any signs of increasing effusion size, tamponade physiology (right ventricular diastolic collapse, respiratory variation in mitral inflow), or clinical deterioration, the stress test should be postponed.

The reduced EF of 50% (which is actually mild reduction, as normal is typically >55%) indicates some degree of left ventricular dysfunction that requires evaluation, making the stress test valuable for assessing ischemia as a potential cause. However, the presence of pericardial effusion suggests possible underlying pericarditis or other cardiac pathology that may need to be addressed before or alongside coronary artery disease evaluation. Key considerations in deciding whether to proceed with a stress test include:

• The patient's clinical stability and absence of symptoms of cardiac tamponade or hemodynamic compromise
• The results of a comprehensive echocardiogram to assess the size and hemodynamic impact of the effusion
• The potential benefits of assessing ischemia as a potential cause of left ventricular dysfunction
• The potential risks of the stress test, including complications such as cardiac arrhythmias, myocardial infarction, or worsening of the pericardial effusion.

Given the potential risks and benefits, a pharmacological stress test is recommended for this patient, with close monitoring and emergency equipment readily available, as it is generally safer than exercise testing for stable patients with a low ejection fraction and small pericardial effusion.

From the Research

Patient with Low EF and Small Pericardial Effusion

• The patient has a low ejection fraction (EF) of 50% and a small pericardial effusion over the left ventricle.
• The question is whether a stress test can be performed on this patient.

Stress Test Considerations

• According to the study by 2, diastolic stress test echocardiography can be useful in patients with suspected heart failure with preserved ejection fraction (HFpEF).
• The study by 3 suggests that cardiac function should be assessed during stress in patients with suspected HFPEF, but it is unclear how to define impaired diastolic reserve.
• However, there is no direct evidence in the provided studies that addresses the specific situation of a patient with low EF and small pericardial effusion.

Diastolic Stress Test

• The study by 2 found that an E/e' ratio >15 during exercise was the most accurate parameter to detect HFpEF, with an accuracy of 86%.
• Combining E/e' with tricuspid regurgitation (TR) velocity >2.8 m/s during exercise provided a significant increase in the sensitivity to detect patients with HFpEF during exercise.
• The study by 3 proposes a ramped exercise protocol on a semi-supine bicycle, starting at 15 W, with increments of 5 W/min to a submaximal target.

Safety and Efficacy of Diuretics

• The study by 4 found that diuretics reduce congestion in patients with HFpEF, but comparison of clinical effects across diuretic classes or combinations of diuretics in patients with HFpEF are not well described.
• The study by 5 found that diuretic dose increase was associated with higher resource utilization, but not with mortality, in patients with heart failure with reduced ejection fraction.
• The study by 6 compared diuresis patterns in hospitalized patients with heart failure with reduced versus preserved ejection fraction and found that cumulative diuretic efficiency did not differ between the two groups.