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Noninvasive Cardiac Testing

William E. Cayley, Jr, MD, MDiv

American Family Physician. 2024;110(6):577-584.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

For patients with chest discomfort, noninvasive cardiac testing can be used for the diagnosis of acute coronary syndrome and for the evaluation of the risk of future cardiovascular events and disease severity in patients with known coronary artery disease. Clinical prediction rules can guide risk assessment for patients with acute or stable chest discomfort. For acute chest discomfort, patients with low risk do not need urgent testing, and those at high risk should have invasive coronary angiography. For acute chest discomfort in patients at intermediate risk, exercise stress testing can provide useful prognostic information on the likelihood of future mortality and survival despite modest sensitivity and specificity for coronary artery disease. Exercise or pharmacologic stress testing with imaging allows dynamic assessment of ventricular function and perfusion. For stable chest discomfort in patients with low risk, coronary artery calcium scoring can be used to exclude calcified plaque or exercise stress testing can be used for the evaluation of future cardiac risk and prognosis. For stable chest discomfort in patients with intermediate or high risk, exercise stress testing or stress testing with imaging (ie, echocardiography, myocardial perfusion imaging, or cardiac magnetic resonance imaging) may be used for the evaluation for myocardial ischemia.

Heart disease is the leading cause of death in the United States, and approximately 1 in 200 outpatient office visits is for the evaluation of chest discomfort.1,2 Noninvasive cardiac testing can be used for the diagnosis of acute coronary syndrome (ACS) in patients with acute chest discomfort and for evaluating the risk of future cardiovascular events in patients with stable chest discomfort and disease severity in patients with stable coronary artery disease (CAD).3 Stress tests use progressive aerobic exercise or medication to elicit cardiovascular abnormalities that are absent at rest and to assess adequacy of cardiac function.3

WHAT'S NEW ON THIS TOPIC

Noninvasive Cardiac Testing
For patients with low-risk stable chest discomfort without known CAD, it is reasonable to obtain coronary artery calcium scores to exclude calcified plaque. Alternatively, it may be reasonable to perform exercise stress testing without imaging to exclude ischemia and determine functional capacity.
For patients with stable chest pain associated with consistent precipitants, such as exertion or emotional stress, the CAD Consortium 2 calculator provides the best discrimination between patients with a low (< 10%) vs intermediate or high (> 10%) risk of CAD.

CAD = coronary artery disease.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Do not screen for CAD with exercise stress testing with ECG for asymptomatic people at low risk of cardiovascular events.6 A Systematic review by the USPSTF that found the harms of screening low-risk patients with exercise stress testing outweigh benefits
Use an appropriate clinical prediction tool for risk stratification in patients with acute chest discomfort (eg, HEART pathway) or stable chest discomfort (eg, CAD Consortium 2 calculator) to determine the need for further testing.8 C Expert opinion from 2021 ACC/AHA guideline
For patients with an intermediate risk of CAD and stable chest discomfort, stress testing with echocardiography, myocardial perfusion imaging, or cardiac magnetic resonance imaging, or exercise stress testing with ECG are appropriate.8 B Cost-effectiveness analyses of patient-oriented outcomes synthesized in the 2021 ACC/AHA guideline
For low-risk patients with stable chest discomfort, tiered testing that starts with exercise stress testing with ECG followed by stress testing with echocardiography in select patients is a cost-effective approach.8,29 B Cost-effectiveness analyses of patient-oriented outcomes synthesized in the 2021 ACC/AHA guideline

ACC/AHA = American College of Cardiology/American Heart Association; CAD = coronary artery disease; ECG = electrocardiography; USPSTF = US Preventive Services Task Force.

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 https://www.aafp.org/afpsort.

WILLIAM E. CAYLEY JR, MD, MDiv, is an adjunct clinical professor at the University of Wisconsin School of Medicine and Public Health in Eau Claire, and practices at Eau Claire Medical Clinic in Wisconsin.

Address correspondence to William E. Cayley Jr, MD, MDiv, at bcayley@yahoo.com.

Author disclosure: No relevant financial relationships.

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