Modalities of Cardiac

Stress Test
Tiffany T. Nguyen MD
April 2014
Objectives
 To understand the indications and
contraindications for stress testing.

 To learn the different modalities of cardiac

stress test.

 To effectively select the optimal cardiac

stress test for each patient.
Indications
Who to stress?
 Symptoms suggesting angina.
 Acute chest pain
 Recent ACS after 3 months of conservative therapy
 Known CHD and change in clinical status.
 Prior coronary revascularization.
 Valvular heart disease.
 New heart failure or cardiomyopathy.
 Chronic left ventricular dysfunction and CHD who are candidates
for revascularization.
 Selected arrhythmias
 Undergoing non-urgent non-cardiac surgery.
Contraindications
Who NOT to stress?
 Unstable angina
 Acute myocardial infarction
 Arrhythmia with hemodynamic instability
 Aortic dissection
 Symptomatic aortic stenosis
 Symptomatic severe heart failure
 Pulmonary embolism
 Myocarditis, Pericarditis
Pre-Test Probability
ACC/AHA 2012 Guidelines
Low probability - <10% - no further testing, except for prognostic information.
Intermediate probability - 10-90% - non-invasive testing for diagnosis (exercise ECG as
first modality).
High probability - >90% - non invasive testing for prognosis/management prior to
cardiac cath.

Age Nonanginal pain Atypical angina Typical angina

Men Women Men Women Men Women

30-39 4% 2% 34% 12% 76% 26%

40-49 13% 3% 51% 22% 87% 55%

50-59 20% 7% 65% 31% 93% 73%

60-69 27% 14% 72% 51% 94% 86%

Two Components
 Each cardiac imaging modality has two
components:

 Stressing agent: treadmill, dobutamine, or

adenosine

 Imaging agent: EKG, echo, or radionuclide tracer

(thallium or technetium)
Stressing Agents
Stressor Pro Con
Treadmill Physiologic, simple,
less expensive, good
for patient who can
walk
Dobutamine No exercise needed Caution in patients with
arrhythmias
Adenosine or No exercise needed; Adenosine may induce
dipyridamole (used with uncomfortable bronchospasm – caution in
nuclear) sensation of “heart COPD and asthma!
stoppage”
Imaging Agents
Stressor Pro Con
EKG Simple, less Less information. May not be
expensive able to localize the lesion. Can
not use if there are baseline
EKG abnormalities i.e. LBBB
with ST changes

Echocardiogram Good if patient has Operator dependent to some

pre-existing EKG extent. May have poor windows
abnormalities. More due to body habitus. Pre-
info than EKG. Less existing wall motion
expensive than abnormalities may make
nuclear. interpretation more challenging.

Thallium or technetium Localizes ischemia Expensive

and infarcted tissue.
Finally …
 What is a “MIBI?” What is a “Lexiscan?”
 Both are adenosine nuclear stress tests

 MIBI: the technetium molecule is attached to

sestamibi molecule. The combined sestamibi-
Technitium-99 molecule is aka “cardiolite”

 Lexiscan: uses a derivative of adenosine called

regadenosine, which has 2-3 minute half-life
instead of 30sec, so is easier to work with.
Sensitivity and Specificity

Sensitivity Specificity
Exercise EKG 68% 77%

Stress Echo 76% 88%

Nuclear Imaging 79-92% 73-88%

 Selecting Modalities
Indication

Diagnosis or Prognosis Localize Ischemia

Exercise? Exercise?
no no

yes
Pharmacologic test
with Imaging yes

Normal EKG
Not on Digoxin
no
No prior revascularization
Exercise Imaging
yes

Exercise EKG
Case Question
A 60yo man is evaluated for chest pain of 4 months’ duration. He
describes the pain as sharp, located in the left chest, with no
radiation or associated symptoms, that occurred with walking one to
two blocks and resolves with rest. Occasionally, the pain improves
with continued walking or occurs during the evening hours. He has
hypertension. Family history does not include cardiovascular
disease in any first-degree relatives. His only medication is
amlodipine.
On physical examination, he is afebrile, blood pressure is 130/80mHg,
pulse rate is 72/min, and respiration rate is 12/min. BMI is 28. No
carotid bruits are present, and a normal S1 and S2 with no murmurs
are heard. Lung fields are clear, and distal pulses are normal. EKG
showed normal sinus rhythm.
Case Question
 Which of the following is the most
appropriate diagnostic test to perform next?

a. Adenosine nuclear perfusion stress test.

b. Coronary angiography
c. Echocardiography
d. Exercise treadmill
Take Home Points
 Stress testing is indicated for patients with
intermediate pre-test probability

 Each stress test has two components: an

imaging modality and stress modality

 When determining which stress test to order,

keep in mind their ability to exercise and
whether any contraindications are present