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Stress testing in pre-discharge risk stratification of patients with non-ST elevation acute coronary syndrome

Stephen G. Sawada, MD
Ronald Mastouri, MD, FACC
Section Editors
Gary V Heller, MD, PhD, FACC, MASNC
Patricia A Pellikka, MD, FACC, FAHA, FASE
Deputy Editor
Brian C Downey, MD, FACC


Patients with non-ST elevation acute coronary syndrome (NSTEACS) are treated with anti-ischemic, antiplatelet, and anticoagulant agents to provide immediate relief of ischemia and prevent further myocardial damage. In addition to aggressive medical therapy, two pathways of NSTEACS treatment have emerged: the early invasive strategy and the early conservative strategy. In the early invasive strategy, the more common approach in the modern treatment of NSTEACS, patients with high-risk features and without contraindications undergo coronary angiography and revascularization as deemed appropriate. Alternatively, there is a smaller group of patients with NSTEACS, generally those with low-risk features or at higher risk of complications from invasive angiography, who can be treated with an early conservative approach. In such conservatively treated patients, an ischemia-guided management strategy, dictated by stress test findings, results in outcomes similar to the early invasive strategy.

The role of stress testing in pre- and early post-discharge risk stratification of conservatively treated patients with NSTEACS will be reviewed here. The comprehensive risk stratification of patients with NSTEACS, as well as the approach to treatment, is discussed separately. (See "Risk stratification after non-ST elevation acute coronary syndrome" and "Overview of the acute management of non-ST elevation acute coronary syndromes" and "Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction".)


Our approach to the use of noninvasive stress testing following conservative treatment of patients with NSTEACS treated medically is consistent with the American Heart Association/American College of Cardiology guidelines for the management of patients with NSTEACS [1]. The primary role of stress testing is to distinguish between higher-risk subjects with severe and/or extensive ischemia who would have improved outcomes with revascularization, and lower-risk subjects with no or limited ischemia who would have comparable outcomes with medical therapy alone. Stress test findings also provide prognostic evaluation, guide activity prescription, and assess the effectiveness of therapy. In subjects with extensive myocardial injury, stress testing may also provide information on the presence and extent of myocardial viability.


Patients with recent NSTEACS may safely undergo a stress test provided they have been asymptomatic and clinically stable at least 12 to 24 hours for those with unstable angina and two to five days for those with non-ST elevation myocardial infarction [2]. The longer delay prior to stress testing (two to five days) may also be warranted in some patients with high-risk features such as advanced age, left ventricular (LV) systolic dysfunction, and peripheral vascular disease.

Most patients who require a stress test post-NSTEACS will undergo the test prior to discharge. However, early post-discharge testing may be considered in lower-risk patients including those who have been revascularized (culprit lesion) and those who have remained asymptomatic with normal levels of physical activity during hospitalization. Post-discharge testing may also be considered in stable patients who will transition to an intermediate care setting that provides ongoing monitoring and medical treatment of the patient’s cardiac problems and medical comorbidities.

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Literature review current through: Sep 2017. | This topic last updated: Oct 04, 2017.
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