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Juan Sanchisa, Vicent Bodia, Angel Llacera, Julio Nuneza, Jose Antonio Ferreroa, Francisco J Chorroaa Servei de Cardiologia. Please, complete the form with your suscription data.If you are a member of the Spanish Society of Cardiology, you can use the same login and password that you use to access the Society's website. John, a previously healthy 55-year-old man, was brought to the emergency department after a motor vehicle accident. He had suddenly passed out behind the wheel of his private vehicle without any premonitory symptoms and subsequently crashed his car into a fence. Initial investigations included ECG, basic blood tests including thyroid function and troponin, CT brain and EEG.
An exercise stress test was undertaken, during which John developed typical angina-type chest pain and stress-limiting dyspnea, both responding to sublingual GTN spray. John was subsequently transferred to the coronary care unit and invasive coronary angiography was performed. Prior to angiography, coronary care unit staff noticed short runs of broad complex tachycardia on John's ECG trace, which left him momentarily lightheaded.
John's post-stress ECG demonstrates the classical pattern of critical left main coronary artery stenosis. Although this ECG pattern is not entirely specific for a left main lesion (it is also seen in severe triple-vessel disease) it nonetheless spells bad news by indicating severe diffuse subendocardial ischaemia. When deciding whether to perform a stress test to rule out significant coronary artery disease (CAD), the patient's pretest probability of CAD is important to consider.
For patients with a low pretest probability of CAD, attention should be focused on identifying non-cardiac causes of chest pain. In order to achieve a goal of 85-100% of the maximum age-predicted heart rate (which can be estimated by subtracting the patient's age from 220), patients referred for stress testing must be able to walk briskly for a short distance. In cases where exercise is not feasible, pharmacological agents can be used to stress the heart, remembering the relative sensitivity and specificity inherent in different stress modalities as summarised in the box, above right.
Choosing stress echocardiography and nuclear imaging depends on the patient's risk for CAD (preferred are patients with intermediate or high pretest probability of CAD), comorbidities as well as local expertise in these modalities.
Johns' coronary angiogram confirmed a 70% distal left main stenosis in a left-dominant coronary artery circulation. Associate Professor Stefan Buchholz is a consultant cardiologist at Mackay Base Hospital, Mackay, Qld, and associate professor at James Cook University's school of medicine. Dr Kimberly Haladyn is a resident of cardiac services at Mackay Base Hospital, Mackay, Qld. The content on this site is only available to health practitioners registered to practice in Australia.
Australian Doctor believes general practice is the cornerstone of the Australian health system, and recognises that quality primary care is a major determinant of the health of a society.
Advanced stress cardiac imaging now allows us to detect heart disease with greater accuracy than ever before.
Exercise or pharmacologic stress tests combined with echocardiography or nuclear imaging provide higher sensitivity and specificity, but they’re considerably more expensive. Don’t perform stress imaging in patients without cardiac symptoms unless high-risk markers are present. Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
Don’t perform stress imaging as a preoperative assessment in patients scheduled for low- to intermediate-risk noncardiac surgery. Use methods to reduce radiation exposure in stress imaging, including not performing such tests when limited benefits are likely. One parting thought: Stress imaging may be overused in patients who for whatever reason are not good candidates for angiography.
Providence Health & Services in Oregon is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and affiliated services guided by a Mission of caring that the Sisters of Providence began in the West nearly 160 years ago. As people of Providence, we reveal God’s love for all, especially the poor and vulnerable, through our compassionate service.
Cardiac stress testing - stress testing for the heartThe Cardiac Stress Test Exercise testing for the heart.

Documentation of the patient's symptoms, medications, past and current significant illnesses, and usual level of physical activity helps the physician determine if an exercise stress test is appropriate. The Joint Commission on Accreditation of Healthcare Organizations requires that institutions assess competence on the basis of criteria established in the medical staff bylaws. Consideration may be given to obtaining this test when patients present with symptoms of coronary artery disease, including the classic anginal symptoms of chest pressure or pain that occurs with or without exertion. Exercise stress testing may worsen the patient's condition or place the patient at increased risk of cardiac instability or injury in the setting of acute myocardial infarction, unstable angina, acute cardiac inflammation, severe congestive heart failure, uncontrolled sustained ventricular arrhythmias, symptomatic supraventricular arrhythmia, high-grade block, hemodynamically significant aortic stenosis or severe hypertension.
There is widespread downsloping ST depression, most prominent in leads, II, III, aVF and V4-6 and ST elevation in aVR >1mm. Exercise stress testing is recommended as the initial test of choice in intermediate risk patients.
He was transferred to a tertiary cardio-thoracic center for urgent coronary artery bypass surgery. We acknowledge the challenges faced by general practitioners within the complex Australian healthcare system, and use our voice to enhance the work and lives of GPs and their patients.
But these sophisticated and expensive tests also bring a challenge: When are they necessary and when will simple exercise testing suffice?
In addition, the radiation exposure from radionuclide imaging carries more risk to the patient.
This can be assessed by a variety of risk calculations, such as ATP III or Reynolds Risk Score. Treadmill tests are between 60 and 80 percent accurate, while stress echo and nuclear tests are 80 to 90 percent accurate. Treadmill tests cost about $300; echo stress tests run about $1,500 and nuclear tests can go as high as $3,500. It created algorithms for patient categories, such as symptomatic patients, asymptomatic patients, prior test results, preoperative risk assessment, etc.
Performing this test routinely every one to two years after heart procedures rarely results in meaningful management changes, and may lead to unnecessary invasive procedures and excess radiation exposure. Such testing will not change the patient’s management or outcomes, but will result in increased costs.
Stress echo is similar in sensitivity and specificity to nuclear testing, but is cheaper and without radiation risk. The patient exercises on a treadmill according to a standardized protocol, with progressive increases in the speed and elevation of the treadmill (typically changing at three-minute intervals). The physical examination must include consideration of the patient's ability to walk and exercise, along with any signs of acute or serious disease that may affect the test results or the patient's ability to perform the test.
A combined specialty task force, composed of members from the American College of Cardiology (ACC), the American College of Physicians and the American Heart Association (AHA), in 1996 issued a statement on clinical competence in exercise testing.10Equipment requirements for exercise stress testing include a bicycle ergometer or treadmill, a monitor system, a medical crash cart and a defibrillator. Patients should be told to wear loose-fitting, comfortable clothing and comfortable walking shoes. Patients with such conditions usually require immediate medical or surgical intervention as clinically indicated but may be reassessed as candidates for exercise stress testing when the acute problems are resolved. We inform, educate and engage Australian GPs about all aspects of their professional lives, foster the GP community, lead discussion and work for a strong general practice. Another way to assess pretest risk, based only on age, sex and nature of symptoms, is outlined in the table below. Testing should be performed only if the patient has peripheral artery disease, is older than 40 and diabetic, or is at more than 2 percent yearly risk for a heart disease event.
An exception to this rule would be for patients who had coronary artery bypass graft surgery more than five years earlier. A standard treadmill test is appropriate for patients without symptoms or clinical risk factors, or who have moderate to good functional capacity. It represents a preferred stress modality as long as the echo images are interpretable (about 80 percent of the time).
The test report contains comments about the maximal heart rate and level of exercise achieved, and symptoms, arrhythmias, electrocardiographic changes and vital signs during exercise. For the missing item, see the original print version of this publication.Patients with coronary artery disease who have undergone surgical intervention or are receiving medical therapy can perform an exercise stress test when they are medically stable and symptom-free.

In addition, instructions about modifying the doses of any medications should be given.HISTORYIn addition to the presence and character of chest pain, concurrent medical conditions such as claudication, severe physical disabilities and pulmonary disease should be considered in view of their effects on the patient's ability to exercise. In a patient at high risk for CAD (for example, because of advanced age or multiple coronary risk factors), an abnormal ECST is quite accurate (over 90% accurate) in predicting the presence of CAD.
However, a relatively normal ECST may not mean there is an absence of significant coronary artery disease in a patient with the same high risk factors (so-called "false negative ECST"). In a patient at low risk for CAD, a normal ECST is quite accurate (over 90%) in predicting the absence of significant CAD. Exercise usually worsens uncontrolled hypertension, and the pretest evaluation may be terminated because of this finding.15The patient's general activity level and pulmonary reserve and the presence of arthritic disease may influence the type of exercise test protocol selected and the duration and level of activity achieved. Depending on how stable the patient's diabetic condition is, all of the dose of insulin or the hypoglycemic agent or one half of the dose should be withheld before the test.Digoxin may depress the ST-segments. And an abnormal ECST test may not reflect the true presence of CAD (so-called "false-positive ECST"). The ECST may miss the presence of significant CAD and so give a false negative result. Stress scintigraphy can be performed with pharmacologic agents instead of exercise if the patient's condition does not allow sufficient physical activity for performing the study.
The ACSM does not recommend exercise stress testing for asymptomatic healthy persons who are not planning vigorous exercise, regardless of the person's age.18An exercise stress test may also be considered in asymptomatic patients who have two or more risk factors for coronary artery disease or a concurrent chronic disease, such as diabetes, that carries a high risk of coronary disease. Many exercise protocols exist to accommodate patients who need to walk at a slower pace or advance through exercise stages at a slower rate.The patient's current medications are important. If ST-segment depression of 1 mm or more is present on the baseline ECG, use of ECG criteria for exercise-induced ischemia during exercise will be difficult. Hypotension, defined as a drop of more than 10 mm Hg in the systolic blood pressure during exercise, may signify severe cardiac ischemia.15 Opinions vary as to the definition of a hypertensive response to exercise, but most authorities accept as a maximal limit a systolic pressure of 230 mm Hg.
Or the ECST may indicate the presence of significant CAD when, in fact, there is none and so yield a false-positive test result. Cardiac examination should include an assessment for the presence of murmurs and valvular disease.
For example, if at baseline a patient receiving any one of these medications has significant ectopy, the patient is at increased risk of hemodynamically significant arrhythmias with exercise and should not undergo exercise stress testing.7The antihypertensive effect of beta blockers, alpha blockers and nitroglycerin may cause significant hypotension during exercise.
Severe valvular dysfunction, especially aortic stenosis, is an absolute contraindication to exercise stress testing.4,7 Gallop rhythms are noteworthy because the presence of an S3 may indicate significant congestive heart failure, a contraindication if it is clinically severe. In general, orthostatic blood pressure assessment and a careful history will identify most patients susceptible to such a response. Findings usually include the presence and location of ST-segment changes, P-wave, T-wave and U-wave changes, and the appearance of conduction abnormalities during the exercise and recovery periods.15,23TEST CONCLUSIONSPositive Results.
These further options include radionucleide isotope injection and ultrasound of the heart (stress echocardiography) during the stress test.
While the development of an S4 during exercise may indicate significant cardiac ischemia, detection of it during a physical examination does not signify ischemia and is not grounds for not performing an exercise stress test.7A thorough pulmonary examination is helpful in detecting signs of severe pulmonary disease or congestive heart failure disorders that may not be obvious from the patient's history.
Pulmonary pathology may render the patient unable to walk on a treadmill or use the exercise equipment.An assessment of the vascular system should include palpation of the carotid and peripheral pulses, as well as evaluation for the presence of bruits over the abdominal aorta and other larger vessels. The pretest evaluation should alert the clinician to the presence of this tendency, and exercise stress testing should not be performed if such a response to exercise seems significant.4Patients who have a history of tachyarrhythmias may be considered candidates for exercise stress testing, but those with easily reproduced tachycardia during exercise or other heavy physical activity are not candidates for exercise stress testing. The hips, shoulders, arms and legs should allow relatively full mobility and support during exercise.LABORATORY STUDIESScreening laboratory studies are obtained to diagnose subclinical disease that may be present.
Such a problem may be found in patients with mitral valve prolapse syndrome, Wolff-Parkinson-White syndrome and episodic or periodic supraventricular tachycardia. Exercise stress testing should not be performed in patients with symptoms of anemia or severe hepatic, renal or metabolic disorders.A resting ECG is an essential part of the pretest evaluation.
While the presence of any of these ECG changes is not an absolute contraindication to exercise stress testing, they may interfere with the validity of the test by altering the ECG changes that are consistent with ischemia during exercise.
These ECG changes are not diagnostic of ischemia.21 Alterations in the P-wave and T-wave morphology and changes in atrioventricular conduction with exercise are considered nondiagnostic if the changes revert to baseline in the rest period.
The appearance of unifocal, premature atrial contractions or premature ventricular contractions (fewer than five per minute) is not a specific indicator for coronary artery disease.23 The development of intraventricular blocks, such as right bundle branch block, left bundle branch block and hemiblocks, is a nondiagnostic finding. An intraventricular block may also obscure ischemic changes and hinder further interpretation of the ECG.

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