Exercise Stress Testing: Indications and Common Questions

 

Exercise stress testing is a validated diagnostic test for coronary artery disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Testing of asymptomatic patients is generally not indicated. It may be performed in select deconditioned adults before starting a vigorous exercise program, but no studies have compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery. Exercise stress testing without imaging is the preferred initial choice for risk stratification in most women. Sensitivity and specificity increase with the use of adjunctive imaging such as echocardiography or myocardial perfusion imaging with single-photon emission computed tomography. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary artery disease who have no new symptoms less than two years after percutaneous intervention or less than five years after coronary artery bypass grafting. The Duke treadmill score has excellent prognostic value for exercise stress testing. Imaging is not necessary if patients are able to achieve more than 10 metabolic equivalents on exercise stress testing. Exercise stress testing is not indicated before noncardiac surgeries in patients who can achieve 4 metabolic equivalents without symptoms.

Exercise stress testing is used to detect inducible cardiac ischemia in symptomatic intermediate-risk patients who can exercise and who have interpretable electrocardiography results.1  Risk is determined by American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines for stable ischemic heart disease or the Diamond and Forrester score to assess pretest probability of coronary artery disease (CAD; Table 1).1,2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Preoperative exercise stress testing for risk stratification before noncardiac surgery is not indicated if the patient is able to achieve 4 or more metabolic equivalents without symptoms.

C

1, 5

Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery and in those who have active cardiac symptoms before undergoing nonemergent noncardiac surgery.

C

1, 5

Exercise stress testing is not recommended in asymptomatic patients to screen for coronary artery disease.

C

3, 6, 7

Adjunctive imaging increases cost without improving prognostic value in patients who can achieve more than 10 metabolic equivalents during exercise stress testing.

B

19, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Preoperative exercise stress testing for risk stratification before noncardiac surgery is not indicated if the patient is able to achieve 4 or more metabolic equivalents without symptoms.

C

1, 5

Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery and in those who have active cardiac symptoms before undergoing nonemergent noncardiac surgery.

C

1, 5

Exercise stress testing is not recommended in asymptomatic patients to screen for coronary artery disease.

C

3, 6, 7

Adjunctive imaging increases cost without improving prognostic value in patients who can achieve more than 10 metabolic equivalents during exercise stress testing.

B

19, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN CARDIOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

American College of Cardiology

Do not perform cardiac imaging for patients who are at low risk.

American Society of Nuclear Cardiology

Avoid using stress echocardiography on asymptomatic patients who meet low-risk scoring criteria for coronary disease.

American Society of Echocardiography

Avoid cardiovascular stress testing for patients undergoing low-risk surgery.

Society for Vascular Medicine

Patients

The Authors

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KATHRYN K. GARNER, MD, is a faculty member at the National Capital Consortium Family Medicine Residency in Fort Belvoir, Va., and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

WILLIAM POMEROY, MD, is a staff cardiologist at Keesler Medical Center, Biloxi, Miss.

JAMES J. ARNOLD, DO, FACOFP, FAAFP, is the senior associate program director at the National Capital Consortium Family Medicine Residency and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Kathryn K. Garner, MD, 2501 Capehart Rd., Offutt Air Force Base, NE 68113 (e-mail: kathryn.k.garner2.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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