Review
Cardiac Stress Testing for the Diagnosis and Management of Coronary Artery Disease: A Reference for the Primary Care Physician
Abstract
Choosing the appropriate stress test is important in the workup of patients with possible myocardial ischemia. This choice often is challenging and sometimes confusing because of the plethora of tests and guidelines available. We present a broad overview of commonly available stress tests and indications to help physicians select the most appropriate stress test for their patients.This content is limited to qualifying members.
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References
1. Lucas FL, DeLorenzo MA, Siewers AE, et al. Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993–2001. Circulation 2006; 113: 374–379.
2. Hayes KJ, Pettengill J, Stensland J. Getting the price right: Medicare payment rates for cardiovascular services. Health Aff 2007; 26: 124–136.
3. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002; 346: 793–801.
4. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997; 30: 260–311.
5. Kim C, Kwok YS, Heagerty P, et al. Pharmacologic stress testing for coronary disease diagnosis: a meta-analysis. Am Heart J 2001; 142: 934–944.
6. Fleischmann KE, Hunink MG, Kuntz KM, et al. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA 1998; 280: 913–920.
7. Coma-Canella I. Dobutamine instead of exercise stress test to detect coronary artery disease. Is electrocardiographic information enough? Rev Esp Cardiol 2002; 55: 568–570.
8. Gibbons RJ, Balady GJ, Bricker JT, et al., American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106: 1883–1892.
9. Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981; 64: 360–367.
10. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300: 1350–1358.
11. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143–3421. (Online calculator available at http://hp2010.nhlbihin.net/atpiii/calculator.asp).
12. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2010; 56: e50–e103.
13. Anderson JL, Adams CD, Antman EM, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123: e426–e579.
14. Detrano R, Gianrossi R, Mulvihill D, et al. Exercise-induced ST segment depression in the diagnosis of multivessel coronary disease: a meta analysis. J Am Coll Cardiol. 1989; 14: 1501–1508.
15. Froelicher VF, Perdue S, Pewen W, et al. Application of meta-analysis using an electronic spread sheet to exercise testing in patients after myocardial infarction. Am J Med. 1987; 83: 1045–1054.
16. Vivekananthan DP, Blackstone EH, Pothier CE, et al. Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease. J Am Coll Cardiol 2003; 42: 831–838.
17. Weiner DA, Ryan TJ, McCabe CH, et al. Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984; 3: 772–779.
18. Lauer MS, Pothier CE, Magid DJ, et al. An externally validated model for predicting long-term survival after exercise treadmill testing in Patients with suspected coronary artery disease and a normal electrocardiogram. Ann Intern Med 2007; 147: 821–828.
19. American Society of Nuclear Cardiology. Updated imaging guidelines for nuclear cardiology procedures, part 1. J Nucl Cardiol 2001; 8: G5–G58.
20. US Food and Drug administration, Drug approvals 2008. Available at: http://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/DrugandBiologicApprovalReports/UCM081805.pdf. Accessed on August 11, 2011.
21. Al Jaroudi W, Iskandrian AE. Regadenoson: a new myocardial stress agent [review] [published correction appears in J Am Coll Cardiol 2009;54(17):1635]. J Am Coll Cardiol 2009; 54: 1123–1130.
22. Port SC, Oshima M, Ray G, et al. Assessment of single vessel coronary artery disease: results of exercise electrocardiography, thallium-201 myocardial perfusion imaging and radionuclide angiography. J Am Coll Cardiol 1985; 6: 75–83.
23. Mahajan N, Polavaram L, Vankayala H, et al. Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis. Heart 2010; 96: 956–966.
24. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation 2009; 119: e561–e587.
25. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110: e82–e292.
26. Bansal S, Wackers FJDIAD Study Investigators. Five-year outcomes in high-risk participants in the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study: a post hoc analysis. Diabetes Care 2011; 34: 204–209.
27. Klocke FJ, Baird MG, Lorell BH, et al. American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American Society for Nuclear Cardiology. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003; 108: 1404–1418.
28. Lieberman AN, Weiss JL, Jugdutt BI, et al. Two-dimensional echocardiography and infarct size: relationship of regional wall motion and thickening to the extent of myocardial infarction in the dog. Circulation 1981; 63: 739–746.
29. Armstrong WF, Zoghbi WA. Stress echocardiography: current methodology and clinical applications. J Am Coll Cardiol 2005; 45: 1739–1747.
30. Pellikka PA, Nagueh SF, Elhendy AA, et al.; American Society of Echocardiography. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007; 20: 1021–1041.
31. Elhendy A, Bax JJ, Poldermans D. Dobutamine stress myocardial perfusion imaging in coronary artery disease. J Nucl Med 2002; 43: 1634–1646.
32. Geleijnse ML, Krenning BJ, Nemes A, et al. Incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography. Circulation 2010; 121: 1756–1767.
33. Sicari R, Nihoyannopoulos P, Evangelista A, et al.; European Association of Echocardiography. Stress Echocardiography Expert Consensus Statement—executive summary: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur Heart J 2009; 30: 278–289.
34. Schinkel AF, Bax JJ, Geleijnse ML, et al. Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? Eur Heart J 2003; 24: 789–800.
35. Usher BW Jr, O’Brien TX. Recent advances in dobutamine stress echocardiography. Clin Cardiol 2000; 23: 560–570.
36. Chaowalit N, McCully R, Callahan M, et al. Outcomes after normal dobutamine stress echocardiography and predictors of adverse events: long term follow-up of 3014 patients. Eur Heart J 2006; 27: 3039–3044.
37. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007; 116: e418–e499.
38. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. J Am Coll Cardiol 2008; 51: 1127–1147.
39. Bonow RO, Maurer G, Lee KL, et al.; STICH Trial Investigators. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 2011; 364: 1617–1625.
40. Shaw LJ, Olson MB, Kip K, et al. The value of estimated functional capacity in estimating outcome: results from the NHBLI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study. J Am Coll Cardiol 2006; 47 (3 suppl): S36–S43.
41. Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation 2005; 111: 682–696.
42. Amanullah AM, Berman DS, Hachamovitch R, et al. Identification of severe or extensive coronary artery disease in women by adenosine technetium-99m sestamibi SPECT. Am J Cardiol 1997; 80: 132–137.
