Cardiac Stress Testing
This infographic highlights key aspects of cardiac stress testing, comparing multiple modalities and outlining indications for their use.
Indications
- Evaluation of stable chest pain in patients with intermediate to high CAD risk
- Risk stratification for new-onset symptoms in patients with known CAD
- Assessment of valvular heart disease and HCM
- Evaluation of microvascular disease and coronary vasculopathy in transplant patients
- Identification of hibernating myocardium in known CAD cases
Types of Stress Testing
- Exercise Stress Test (Treadmill):
- Recommended for patients who can exercise adequately to achieve 5 METS and 85% of maximum predicted HR
- Report analysis includes:
- Duration of exercise, METS achieved, % max HR, HR/BP response
- Pharmacologic Stress Testing:
- Inotropes (e.g., dobutamine) for patients unable to exercise; avoid in ventricular arrhythmias or severe HTN
- Vasodilators (e.g., adenosine, regadenoson) suitable for most patients but avoided in COPD/asthma or hypotension
- Note: Avoid caffeine for at least 12–24 hours before testing
Compare & Contrast Stress Modalities
| Modality | Who? | Pros | Cons | Positive Test |
|---|---|---|---|---|
| EKG | Patients without baseline EKG abnormalities | Easy, no radiation | Cannot localize ischemia | 1-mm horizontal or downsloping ST depression |
| Echo | Abnormal baseline EKG; HCM, AS evaluation | Evaluates wall motion, pulmonary HTN | Patient-dependent image quality | New wall motion abnormalities |
| SPECT | Known CAD | Functional assessment of ischemia | Limited in high BMI, radiation exposure | Perfusion defects during stress |
| PET | Known CAD, microvascular disease | Quantifies blood flow, assesses viability | Expensive, limited availability | Abnormal MBFR |
| MRI | High clinical suspicion of CAD | Allows tissue characterization | Patient limitations (e.g., metallic implants) | Late gadolinium enhancement |
Key Recommendations
- Exercise testing is preferred if the patient can reach the required workload.
- Use pharmacologic testing for those with physical limitations.
- Review the duration of exercise, METS, and HR/BP response for meaningful insights.
Created by Dr. Gurleen Kaur
Reviewed by Dr. Simrat Kaur, Dr. Amit Goyal, and Dr. Jessie Holtzman
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