Is it okay to perform a stress test on a 65-year-old male with bigeminy (premature ventricular contractions) who has never had an echocardiogram (echo)?

From the Guidelines

It is generally acceptable to perform a stress test on a 65-year-old male with bigeminy who has never had an echocardiogram, but certain precautions should be taken, as indicated by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Before proceeding with the stress test, several factors should be considered to ensure the patient's safety and the test's validity.

• A baseline ECG and vital signs should be obtained to assess the frequency and nature of the bigeminy.
• The patient should be evaluated for symptoms such as chest pain, dizziness, or syncope that might indicate hemodynamic compromise from the arrhythmia.
• If the bigeminy is asymptomatic and the patient is hemodynamically stable, the stress test can typically proceed with careful monitoring, as stress echocardiography has been shown to be a valuable tool for detecting myocardial ischemia and assessing cardiac function 1. However, if the bigeminy increases significantly during exercise or the patient develops symptoms, the test should be terminated.
• It would be beneficial to perform a baseline echocardiogram before the stress test to evaluate cardiac structure and function, as underlying structural heart disease could influence the interpretation of the stress test results and the clinical significance of the bigeminy, and stress echocardiography can provide diagnostic accuracy and risk-stratification capabilities similar to those obtained with other contemporary functional imaging testing modalities 1. The presence of bigeminy itself is not an absolute contraindication to stress testing, but the test should be conducted under close supervision by experienced personnel with resuscitation capabilities readily available, considering the advantages of stress echocardiography, including its wide availability, low cost, and lack of ionizing radiation 1.

From the Research

Patient Assessment

• The patient is a 65-year-old male with bigeminy, scheduled for a stress test, and has never had an echocardiogram.
• The patient's condition and medical history are crucial in determining the suitability of a stress test.

Stress Test Considerations

• According to 2, exercise and pharmacological stress echocardiography are effective alternatives to myocardial scintigraphy for detecting myocardial ischemia.
• The study 2 found that exercise stress echocardiography had a higher diagnostic accuracy than dobutamine or dipyridamole stress echocardiography in patients with a predominance of one-vessel coronary artery disease.
• However, the presence of beta-blocker therapy can affect the accuracy of stress echocardiography tests, as shown in 3, which found that concurrent beta-blockade attenuates the ability of dobutamine stress echocardiography to detect significant coronary lesions.

Beta-Blocker Therapy

• The study 4 found that beta-blocker use does not affect heart rate recovery in patients with a negative exercise stress echocardiography result, but improves heart rate recovery in patients with a positive result.
• Another study 5 compared adenosine and exercise stress tests in patients on beta-blocker therapy and found that adenosine was superior in showing reversibility and had higher diagnostic sensitivity.

Decision to Stress the Patient

• Based on the available evidence, it is essential to consider the patient's medical history, including any beta-blocker therapy, before deciding to proceed with a stress test.
• The patient's bigeminy and lack of prior echocardiogram should be taken into account when determining the most suitable stress test protocol.
• Consultation with a cardiologist or a healthcare professional is necessary to determine the best course of action for this patient, considering the potential risks and benefits of stress testing in this specific case, as discussed in 6.