Cardiac stress test

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Cardiac stress test
Stress test.jpg
A male patient walks on a stress test treadmill to have his heart's function checked.
Other namesCardiopulmonary exercise test
ICD-9-CM 89.4
MeSH D025401
MedlinePlus 003878

A cardiac stress test is a cardiological examination that evaluates the cardiovascular system's response to external stress within a controlled clinical setting. This stress response can be induced through physical exercise (usually a treadmill) or intravenous pharmacological stimulation of heart rate. [1]

Contents

As the heart works progressively harder (stressed) it is monitored using an electrocardiogram (ECG) monitor. This measures the heart's electrical rhythms and broader electrophysiology. Pulse rate, blood pressure and symptoms such as chest discomfort or fatigue are simultaneously monitored by attending clinical staff. Clinical staff will question the patient throughout the procedure asking questions that relate to pain and perceived discomfort. Abnormalities in blood pressure, heart rate, ECG or worsening physical symptoms could be indicative of coronary artery disease. [2]

Stress testing does not accurately diagnose all cases of coronary artery disease, and can often indicate that it exists in people who do not have the condition. The test can also detect heart abnormalities such as arrythmias, and conditions affecting electrical conduction within the heart such as various types of fascicular blocks. [3]

A "normal" stress test does not offer any substantial reassurance that a future unstable coronary plaque will not rupture and block an artery, inducing a heart attack. As with all medical diagnostic procedures, data is only from a moment in time. A primary reason stress testing is not perceived as a robust method of CAD detection — is that stress testing generally only detects arteries that are severely narrowed (~70% or more). [4] [5] [6]

Stress testing and echocardiography

A stress test may be accompanied by echocardiography. [7] The echocardiography is performed both before and after the exercise so that structural differences can be compared.

A resting echocardiogram is obtained prior to stress. The ultrasound images obtained are similar to the ones obtained during a full surface echocardiogram, commonly referred to as transthoracic echocardiogram. The patient is subjected to stress in the form of exercise or chemically (often dobutamine). After the target heart rate is achieved, 'stress' echocardiogram images are obtained. The two echocardiogram images are then compared to assess for any abnormalities in wall motion of the heart. This is used to detect obstructive coronary artery disease. [8]

Cardiopulmonary exercise stress testing

Cardiopulmonary exercise test using a treadmill. Ergospirometry laboratory.jpg
Cardiopulmonary exercise test using a treadmill.

While also measuring breathing gases (e.g., oxygen saturation, maximal oxygen consumption), the test is often referred to as a cardiopulmonary exercise test. Common indications for a cardiopulmonary exercise test include evaluation of shortness of breath, workup before heart transplantation, and prognosis and risk assessment of heart failure patients.

The test is also common in sport science for measuring athletes' maximal oxygen consumption, V̇O2 max. [9] In 2016, the American Heart Association published an official scientific statement advocating that cardiorespiratory fitness, quantifiable as V̇O2 max and measured during a cardiopulmonary exercise test, be categorized as a clinical vital sign and should be routinely assessed as part of clinical practice. [10]

The CPX test can be done on a treadmill or cycle ergometer. In untrained subjects, V̇O2 max is 10% to 20% lower when using a cycle ergometer compared with a treadmill. [11]

Stress testing using injected nuclear markers

A nuclear stress test uses a gamma camera to image radioisotopes injected into the bloodstream. The best known example is myocardial perfusion imaging. Typically, a radiotracer (Tc-99 sestamibi, Myoview or thallous chloride 201) may be injected during the test. After a suitable waiting period to ensure proper distribution of the radiotracer, scans are acquired with a gamma camera to capture images of the blood flow. Scans acquired before and after exercise are examined to assess the state of the coronary arteries of the patient. By showing the relative amounts of radioisotope within the heart muscle, the nuclear stress tests more accurately identify regional areas of reduced blood flow. [12]

Stress and potential cardiac damage from exercise during the test is a problem in patients with ECG abnormalities at rest or in patients with severe motor disability. Pharmacological stimulation from vasodilators such as dipyridamole or adenosine, or positive chronotropic agents such as dobutamine can be used. Testing personnel can include a cardiac radiologist, a nuclear medicine physician, a nuclear medicine technologist, a cardiology technologist, a cardiologist, and/or a nurse. The typical dose of radiation received during this procedure can range from 9.4 to 40.7 millisieverts. [13]

Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts. StressECG STDepression.jpg
Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts.

The American Heart Association recommends ECG treadmill testing as the first choice for patients with medium risk of coronary heart disease according to risk factors of smoking, family history of coronary artery stenosis, hypertension, diabetes and high cholesterol. In 2013, in its "Exercise Standards for Testing and Training", the AHA indicated that high frequency QRS analysis during ECG treadmill test have useful test performance for detection of coronary heart disease. [14]

Diagnostic value

The common approach for stress testing recommended by the American College of Cardiology [17] [18] and the American Heart Association [19] involves several methods to assess cardiac health. These methods provide information for diagnosing and managing heart-related conditions. Two primary stress tests utilized are a treadmill test using ECG/electrophysiology metrics and nuclear testing, each have unique sensitivity and specificity values.

The treadmill test, employing the modified Bruce protocol, [20] demonstrates a sensitivity range of around 73-90% and a specificity range of around 50-74%. Sensitivity refers to the percentage of individuals with the condition correctly identified by the test, while specificity denotes the percentage of individuals without the condition correctly identified as not having it. [21] The nuclear stress test exhibits a sensitivity of 81% and a specificity ranging from 85 to 95%. [22]

To arrive at the patient's post test likelihood of disease, the interpretation of the stress test result necessitates the integration of the patient's pretest likelihood with the test's sensitivity and specificity. This method, initially introduced by Diamond and Forrester in the 1970s, provides an estimate of the patient's post-test likelihood of disease. [23] [24] Stress tests have limitations in assessing the significance and nature of cardiac problems, they should be seen in context - as an initial assessment that can lead to a number of other diagnostic approaches in the broader management of cardiac diseases. [25]

According to data from the US Centers for Disease Control and Prevention (CDC) common first systems of coronary artery disease is a heart attack. According to the American Heart Association, a significant percentage of individuals, approximately 65% of men and 47% of women, present with a heart attack or sudden cardiac arrest as their first symptom of cardiovascular disease. Consequently, stress tests performed shortly before these events may not be highly relevant for predicting infarction in the majority of individuals tested. [26] [27]

Contraindications and termination conditions

Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care. [28] Some estimates show that such screening accounts for 45% of cardiac stress imaging, and evidence does not show that this results in better outcomes for patients. [28] Unless high-risk markers are present, such as diabetes in patients aged over 40, peripheral arterial disease, or a risk of coronary heart disease greater than 2 percent yearly, most health societies do not recommend the test as a routine procedure. [28] [29] [30] [31]

Absolute contraindications to cardiac stress test include:

Indications for termination: A cardiac stress test should be terminated before completion under the following circumstances: [33] [34]

Absolute indications for termination include:

Relative indications for termination include:

Adverse effects

Side effects from cardiac stress testing may include[ citation needed ]

Use of pharmacological agents to stress the heart

Pharmacologic stress testing relies on coronary steal. Vasodilators are used to dilate coronary vessels, which causes increased blood velocity and flow rate in normal vessels and less of a response in stenotic vessels. This difference in response leads to a steal of flow and perfusion defects appear in cardiac nuclear scans or as ST-segment changes. [36]

The choice of pharmacologic stress agents used in the test depends on factors such as potential drug interactions with other treatments and concomitant diseases.

Pharmacologic agents such as adenosine, regadenoson (Lexiscan), or dipyridamole is generally used when a patient cannot achieve adequate work level with treadmill exercise, or has poorly controlled hypertension or left bundle branch block. However, an exercise stress test may provide more information about exercise tolerance than a pharmacologic stress test. [37]

Commonly used agents include:

Regadenoson or dobutamine is often used in patients with severe reactive airway disease (asthma or COPD) as adenosine and dipyridamole can cause acute exacerbation of these conditions. If the patient's asthma is treated with an inhaler then it should be used as a pre-treatment prior to the injection of the pharmacologic stress agent. In addition, if the patient is actively wheezing then the physician should determine the benefits versus the risk to the patient of performing a stress test especially outside of a hospital setting. Caffeine is usually held 24 hours prior to an adenosine stress test, as it is a competitive antagonist of the A2A adenosine receptor and can attenuate the vasodilatory effects adenosine.[ citation needed ]

Aminophylline may be used to attenuate severe and/or persistent adverse reactions to adenosine and regadenoson. [39]

History

Cardiac stress testing, used since the 1960s, has a history rooted in the diagnostic and prognostic assessment of patients with suspected coronary artery disease. It has evolved to evaluate inducible myocardial ischemia as an indicator of adverse outcomes. The factors influencing mortality risk have changed over time due to decreasing angina symptoms, increasing prevalence of conditions like diabetes and obesity, and the rise in pharmacologic testing for patients unable to exercise during stress tests. [40]

See also

Related Research Articles

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Coronary artery disease</span> Reduction of blood flow to the heart

Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the cardiac muscle due to build-up of atherosclerotic plaque in the arteries of the heart. It is the most common of the cardiovascular diseases. Types include stable angina, unstable angina, and myocardial infarction.

<span class="mw-page-title-main">Angina</span> Chest discomfort due to disorder of the heart muscles

Angina, also known as angina pectoris, is chest pain or pressure, usually caused by insufficient blood flow to the heart muscle (myocardium). It is most commonly a symptom of coronary artery disease.

<span class="mw-page-title-main">Echocardiography</span> Medical imaging technique of the heart

Echocardiography, also known as cardiac ultrasound, is the use of ultrasound to examine the heart. It is a type of medical imaging, using standard ultrasound or Doppler ultrasound. The visual image formed using this technique is called an echocardiogram, a cardiac echo, or simply an echo.

Microvascular angina (MVA), previously known as cardiac syndrome X, also known as coronary microvascular dysfunction(CMD) or microvascular coronary disease is a type of angina (chest pain) with signs associated with decreased blood flow to heart tissue but with normal coronary arteries.

<span class="mw-page-title-main">Dipyridamole</span> Anticoagulant drug

Dipyridamole is a nucleoside transport inhibitor and a PDE3 inhibitor medication that inhibits blood clot formation when given chronically and causes blood vessel dilation when given at high doses over a short time.

<span class="mw-page-title-main">Variant angina</span> Cardiac chest pain at any time, not just periods of exertion

Variant angina, also known as Prinzmetal angina,vasospastic angina, angina inversa, coronary vessel spasm, or coronary artery vasospasm, is a syndrome typically consisting of angina. Variant angina differs from stable angina in that it commonly occurs in individuals who are at rest or even asleep, whereas stable angina is generally triggered by exertion or intense exercise. Variant angina is caused by vasospasm, a narrowing of the coronary arteries due to contraction of the heart's smooth muscle tissue in the vessel walls. In comparison, stable angina is caused by the permanent occlusion of these vessels by atherosclerosis, which is the buildup of fatty plaque and hardening of the arteries.

<span class="mw-page-title-main">Myocardial perfusion imaging</span> Nuclear medicine imaging method

Myocardial perfusion imaging or scanning is a nuclear medicine procedure that illustrates the function of the heart muscle (myocardium).

The Canadian Cardiovascular Society (CCS) is the national voice for cardiovascular physicians and scientists in Canada. The CCS is a membership organization that represents more than 1,800 professionals in the cardiovascular field. Its mission is to promote cardiovascular health and care through knowledge translation, professional development and leadership in health policy.

<span class="mw-page-title-main">Coronary ischemia</span> Medical condition

Coronary ischemia, myocardial ischemia, or cardiac ischemia, is a medical term for abnormally reduced blood flow in the coronary circulation through the coronary arteries. Coronary ischemia is linked to heart disease, and heart attacks. Coronary arteries deliver oxygen-rich blood to the heart muscle. Reduced blood flow to the heart associated with coronary ischemia can result in inadequate oxygen supply to the heart muscle. When oxygen supply to the heart is unable to keep up with oxygen demand from the muscle, the result is the characteristic symptoms of coronary ischemia, the most common of which is chest pain. Chest pain due to coronary ischemia commonly radiates to the arm or neck. Certain individuals such as women, diabetics, and the elderly may present with more varied symptoms. If blood flow through the coronary arteries is stopped completely, cardiac muscle cells may die, known as a myocardial infarction, or heart attack.

<span class="mw-page-title-main">Myocardial infarction</span> Interruption of cardiac blood supply

A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops in one of the coronary arteries of the heart, causing infarction to the heart muscle. The most common symptom is retrosternal chest pain or discomfort that classically radiates to the left shoulder, arm, or jaw. The pain may occasionally feel like heartburn.

Technetium (<sup>99m</sup>Tc) tetrofosmin Chemical compound

Technetium (99mTc) tetrofosmin is a drug used in nuclear medicine cardiac imaging. It is sold under the brand name Myoview. The radioisotope, technetium-99m, is chelated by two 1,2-bis[di-(2-ethoxyethyl)phosphino]ethane ligands which belong to the group of diphosphines and which are referred to as tetrofosmin.

<span class="mw-page-title-main">Myocardial bridge</span> Birth defect of a coronary artery through the heart muscle

A myocardial bridge (MB) is a common congenital heart anomaly in which one of the coronary arteries tunnels through the heart muscle (myocardium) itself.

A diagnosis of myocardial infarction is created by integrating the history of the presenting illness and physical examination with electrocardiogram findings and cardiac markers. A coronary angiogram allows visualization of narrowings or obstructions on the heart vessels, and therapeutic measures can follow immediately. At autopsy, a pathologist can diagnose a myocardial infarction based on anatomopathological findings.

<span class="mw-page-title-main">Cardiac magnetic resonance imaging perfusion</span>

Cardiac magnetic resonance imaging perfusion, also known as stress CMR perfusion, is a clinical magnetic resonance imaging test performed on patients with known or suspected coronary artery disease to determine if there are perfusion defects in the myocardium of the left ventricle that are caused by narrowing of one or more of the coronary arteries.

Cardiac imaging refers to minimally invasive imaging of the heart using ultrasound, magnetic resonance imaging (MRI), computed tomography (CT), or nuclear medicine (NM) imaging with PET or SPECT. These cardiac techniques are otherwise referred to as echocardiography, Cardiac MRI, Cardiac CT, Cardiac PET and Cardiac SPECT including myocardial perfusion imaging.

The instantaneous wave-free ratio is a diagnostic tool used to assess whether a stenosis is causing a limitation of blood flow in coronary arteries with subsequent ischemia. iFR is performed during cardiac catheterisation (angiography) using invasive coronary pressure wires which are placed in the coronary arteries that are to be assessed. Pressure wires are commonly used by interventional cardiologists to guide decisions to perform revascularization, either by stenting or bypass surgery.

Overscreening, also called unnecessary screening, is the performance of medical screening without a medical indication to do so. Screening is a medical test in a healthy person who is showing no symptoms of a disease and is intended to detect a disease so that a person may prepare to respond to it. Screening is indicated in people who have some threshold risk for getting a disease, but is not indicated in people who are unlikely to develop a disease. Overscreening is a type of unnecessary health care.

Duke Treadmill Score is one of the tools for predicting the risk of ischemia or infarction in the heart muscle. The calculation is done based on the information obtained from an exercise test by this formula:

Mental stress-induced myocardial ischemia (MSIMI) is a medical condition in which acute psychological stress can trigger a transient myocardial ischemia, which is a state of reduced blood flow to the heart muscle, often without the presence of significant coronary artery disease (CAD). It is distinct from conventional stress ischemia caused by physical exertion or pharmacological agents. MSIMI is often silent and detected through specific cardiac function tests during mental stress challenges.

References

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