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Impact of medications and methylxanthines on stress testing

Gary V Heller, MD, PhD, FACC, MASNC
Section Editor
Patricia A Pellikka, MD, FACC, FAHA, FASE
Deputy Editor
Brian C Downey, MD, FACC


Medications and patient diet may alter hemodynamics, electrolyte levels, or endothelial function, and potentially limit the accuracy of any stress testing modality for determining the presence of significant coronary heart disease (CHD). Certain medications may lead to "false negative" results while others may yield "false positive" results. Thus the decision to discontinue medications or dietary components is an integral part of ordering these tests, with the decision to withdraw medication based on the clinical circumstances, the indications for stress testing, and the type of stress testing performed.

The interaction between major cardiovascular medications and stress testing will be discussed here. Indications and procedures for stress testing are discussed separately. (See "Selecting the optimal cardiac stress test" and "Stress testing for the diagnosis of obstructive coronary heart disease" and "Exercise ECG testing: Performing the test and interpreting the ECG results" and "Overview of stress radionuclide myocardial perfusion imaging" and "Overview of stress echocardiography" and "Stress testing to determine prognosis of coronary heart disease".)


A false negative stress test result occurs when a stress test fails to detect clinically significant coronary heart disease (CHD). In contrast, a false positive stress test result suggests underlying clinically significant CHD when no such disease exists. Medications and patient diet may result in false negative or false positive stress test results. Patients with false negative results may not receive appropriate medical therapy, potentially leading to worse clinical outcomes. In contrast, patients with false positive results may be subjected to further noninvasive or invasive testing with possible adverse outcomes. False positive results may also lead to treatment with unnecessary medical therapy and its associated risks and costs. Therefore, understanding the mechanisms by which medications and dietary ingestions can alter stress test results is critical to optimizing the information obtained from stress testing.

Stress testing is performed using exercise or medications to increase coronary artery blood flow and/or myocardial oxygen requirements. Coronary blood flow increases to various degrees depending on the type of stress testing and the degree of stenosis. Exercise induces vasodilation and a two- to threefold increase in blood flow in normal coronary arteries [1]. Exercise also induces paradoxical vasoconstriction in stenotic segments, (secondary to endothelial dysfunction), which results in a myocardial oxygen demand/supply mismatch in stenotic segments and heterogeneity in the perfusion of normal and stenotic segments [2-10]. Vasodilators used in stress testing increase flow in normal coronary arteries three- to fivefold, while arteries with a significant stenosis are not able to increase flow to the same extent, thus creating a heterogeneity in flow and tracer uptake [11,12].

A stress test is interpreted as positive or negative based upon patterns seen on the electrocardiogram (ECG) and, when performed, an accompanying imaging study (eg, myocardial perfusion imaging, echocardiographic imaging). False results can be seen on either of these studies. Medications and dietary ingestions can yield false negative results on the ECG, the imaging study, or both, and false positive results on the ECG. While false positive imaging results may occur (ie, due to soft tissue attenuation or adjacent bowel activity), medications and dietary ingestions have not been shown to yield false positive results on the imaging portion of a stress test.


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Literature review current through: May 2017. | This topic last updated: Oct 25, 2012.
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