What are the next steps after an abnormal exercise stress test (Exercise Tolerance Test, ETT)?

From the Guidelines

After an abnormal exercise stress test, the next step typically involves further cardiac evaluation with either a coronary angiogram or a non-invasive imaging test such as a nuclear stress test, stress echocardiogram, or coronary CT angiography, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. The choice of test depends on the patient's specific abnormality, risk factors, and symptoms.

• The patient should take prescribed medications like aspirin (81-325mg daily), a statin if indicated, and possibly a beta-blocker such as metoprolol (25-100mg twice daily) to reduce cardiac workload, as suggested by the guideline 1.
• It is crucial to report any worsening symptoms like chest pain, shortness of breath, dizziness, or palpitations immediately to the doctor or go to the emergency room.
• The abnormal stress test suggests possible coronary artery blockage or other cardiac issues that require clarification, as false positives can occur.
• Lifestyle modifications including a heart-healthy diet, regular moderate exercise as tolerated, smoking cessation, and stress management are also important during this evaluation period. According to the guideline, if the stress test is abnormal, consideration of coronary angiography and revascularization depending on the extent of the abnormal test is necessary, and the patient can then proceed to surgery with guideline-directed medical therapy (GDMT) or consider alternative strategies, such as noninvasive treatment of the indication for surgery or palliation 1.

From the Research

Next Steps After an Abnormal Exercise Stress Test

If an exercise stress test is abnormal, the next steps may include:

• Further testing, such as cardiac imaging or cardiac catheterization, to confirm the diagnosis of coronary artery disease (CAD) 2, 3
• Risk stratification to determine the level of risk for adverse cardiac events 3, 4
• Consideration of medical management, such as lifestyle modifications or medication, to reduce the risk of cardiac events 5
• Possible referral to a cardiologist for further evaluation and treatment 2, 3

Factors to Consider

When interpreting the results of an abnormal exercise stress test, several factors should be considered, including:

• The patient's symptoms and medical history 3, 4
• The results of other diagnostic tests, such as echocardiography or myocardial perfusion imaging 2, 3
• The patient's ability to achieve adequate exercise during the stress test 4
• The presence of other risk factors for CAD, such as high blood pressure or high cholesterol 2, 3

Prognostic Value

The prognostic value of an abnormal exercise stress test is an important consideration in determining the next steps in management. Studies have shown that patients with abnormal exercise stress test results are at increased risk for adverse cardiac events, including death, myocardial infarction, and coronary revascularization 5. However, the presence of normal stress echocardiography results may modify this risk, and further study is needed to determine the optimal management strategy for these patients 5.