Pharmacologic Stress Testing (Archived)
Pharmacologic Stress Testing (Archived)
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Original abstract
Cardiac stress testing is the most commonly used modality for diagnostic purposes in patients with known or suspected coronary artery disease (CAD). The utility of stress testing should be interpreted in light of the disease's likelihood. Patients with a low probability of disease have a high risk of false-positive results and may end up with further unnecessary invasive testing without changing patient outcomes. Those with high pretest probability have a high risk of false-negative results that can miss a critical diagnosis; therefore, these patients should proceed directly to more confirmatory testing, such as cardiac catheterization. Stress testing is most clinically useful in intermediate-risk patients with CAD, helping further reclassify them as low- or high-risk based on the stress test result. Stress testing can also be used to obtain prognostic information, determine the patient's response to optical medical therapy, measure exercise capacity, and evaluate ischemia in patients who are already started on medical therapy for known CAD. In general exercise, stress is preferred because it provides a gauge of functional capacity, exercise tolerance, and symptom provocation. Pharmacologic stress testing is an alternative modality in patients who are unable to exercise and have the following conditions: 1. Patients presenting with unstable angina. 2. History of heart failure that is not well controlled, and there is a concern for deterioration. 3. Poorly controlled blood pressure with systolic blood pressure significantly higher (>200 mmHg at rest). 4. Patients with a history of aortic stenosis, which is significantly worse on echocardiogram (aortic valve area <1.0 cm2 and mean gradient >40 mmHg), and have ongoing symptoms. 5. I had a myocardial infarction last week. 6. Acute pulmonary embolism. 7. Acute inflammation ofthe pericardium or myocardium. 8. Severe pulmonary hypertension. Exercise stress testing is also not very helpful in patients with an insufficient hemodynamic response to exercise due to abnormalities of the respiratory system and ongoing issues affecting muscles, bones, and peripheral vessels. Additionally, the exercise stress test is not useful when the baseline EKG is abnormal, such as left ventricular hypertrophy (LVH), left bundle branch block (LBBB), paced rhythm, Wolff-Parkinson-White (WPW) syndrome, or greater than 1 mm ST-segment depression. These patients are suitable candidates for testing involving pharmacologic agents. Pharmacologic stress testing is used in combination with imaging modalities such as radionuclide imaging and echocardiography.