Stress testing for the diagnosis of obstructive coronary heart disease
- Alan M Garber, MD, PhD
Alan M Garber, MD, PhD
- Provost/Harvard University
- Mark A Hlatky, MD
Mark A Hlatky, MD
- Professor of Health Research and Policy, Professor of Medicine (Cardiovascular Medicine)
- Stanford University School of Medicine
- Panithaya Chareonthaitawee, MD
Panithaya Chareonthaitawee, MD
- Associate Professor of Medicine
- Mayo Clinic College of Medicine
- J. Wells Askew, MD
J. Wells Askew, MD
- Assistant Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
The diagnosis of coronary heart disease (CHD) as the cause of chest pain (or other anginal-type symptoms of cardiac origin) requires the use of a careful clinical history as well as additional investigation. Invasive coronary angiography is considered the "gold standard" for the diagnosis of CHD involving the epicardial coronary vessels, but it is limited by its invasive nature, attendant risks, inability to assess the microcirculation, and cost. Invasive angiography is therefore indicated as the first diagnostic test for CHD only in select, high-risk patient populations [1,2]. Computed tomography coronary angiography (CTCA), which can noninvasively image the epicardial coronary vessels, overcomes some of the risk associated with invasive angiography, but CTCA also has its own limitations (eg, inability to assess the microcirculation, artifact). (See "Outpatient evaluation of the adult with chest pain", section on 'Evaluation' and "Noninvasive coronary imaging with cardiac computed tomography and cardiovascular magnetic resonance".)
The evaluation of patients presenting with chest pain or suspected CHD usually relies upon non-invasive testing. Several tests are available clinically that vary in accuracy, availability, and cost. The optimal testing strategy, including the possible use of more than one test, differs according to the patient population [3,4]. (See "Selecting the optimal cardiac stress test".)
The use of stress testing for the diagnosis of obstructive CHD will be reviewed here. The overall approach to the patient who presents with chest pain, including those with known or suspected CHD, the advantages and limitations of the different stress testing modalities, and the use of stress testing for prognosis and management are discussed separately. (See "Outpatient evaluation of the adult with chest pain" and "Selecting the optimal cardiac stress test" and "Stress testing to determine prognosis of coronary heart disease".)
OUR APPROACH TO DIAGNOSTIC STRESS TESTING
Our approach to diagnostic stress testing varies with the pretest probability of disease, which is the estimate of the likelihood of coronary heart disease (CHD) based upon the age, gender, symptom characteristics, and clinical history prior to stress testing. Because pre-test probability of disease influences post-test likelihood of disease (figure 2B), we highly recommend that clinical assessment of pretest probability, based upon data from large studies, be made prior to testing (table 1). This estimate of pretest probability of CHD can then be used to determine the need for and the optimal initial diagnostic approach to testing in the patient with known or suspected CHD.
Estimating pretest probability — Several studies with varying methodologies have contributed to how the pretest probability of CHD is estimated [5-11]. As examples:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- OUR APPROACH TO DIAGNOSTIC STRESS TESTING
- Estimating pretest probability
- Using the pretest probability
- Posttest probability
- Test accuracy
- - Sensitivity and specificity
- - Epicardial disease versus microcirculatory disease
- - Post-test referral (verification) bias
- - Challenges in women
- AVAILABLE NON-INVASIVE TESTS
- Exercise ECG testing
- - Advantages of exercise testing
- - Limitations of exercise ECG testing
- Radionuclide myocardial perfusion imaging
- - Advantages of rMPI stress testing
- - Limitations of rMPI stress testing
- Stress echocardiography
- - Advantages of stress echocardiography
- - Limitations of stress echocardiography
- Stress cardiac magnetic resonance imaging
- TEST SELECTION
- Comparison of stress testing options
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS