Stress testing to determine prognosis of coronary heart disease
- Adelaide M Arruda-Olson, MD, PhD, FASE, FAHA
Adelaide M Arruda-Olson, MD, PhD, FASE, FAHA
- Assistant Professor of Medicine
- Mayo Clinic College 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
- Mark A Hlatky, MD
Mark A Hlatky, MD
- Professor of Health Research and Policy, Professor of Medicine (Cardiovascular Medicine)
- Stanford University School of Medicine
- Alan M Garber, MD, PhD
Alan M Garber, MD, PhD
- Provost/Harvard University
- Section Editors
- 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
- 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
Stress testing is an important modality for the evaluation of patients with known or suspected coronary heart disease (CHD). The main indications for performing a stress test are not only for the diagnosis of coronary artery disease but also for risk assessment and prognosis.
This topic will provide an overview of the utility of stress testing for estimation of prognosis and to guide management in patients with known or suspected CHD. The methodology, indications, and contraindications of stress testing, including exercise testing protocols, the endpoints of exercise testing, the electrocardiographic manifestations of exercise-induced ischemia, the role of stress testing for the diagnosis of stable CHD, for the estimation of prognosis in patients who have had a recent acute coronary syndrome, and in the evaluation of patients with a suspected acute coronary syndrome are discussed separately. (See "Exercise ECG testing: Performing the test and interpreting the ECG results" and "Stress testing for the diagnosis of obstructive coronary heart disease" and "Risk stratification after non-ST elevation acute coronary syndrome", section on 'Stress testing' and "Risk stratification after acute ST-elevation myocardial infarction", section on 'Stress testing' and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Rest and stress imaging tests'.)
INDICATIONS FOR STRESS TESTING FOR PROGNOSIS
All indications for performing a stress test for the diagnosis of CHD are also indications for performing a stress test for risk stratification and prognosis. The indications for stress testing are discussed in detail separately. (See "Selecting the optimal cardiac stress test", section on 'Indications for stress testing'.)
Exercise electrocardiogram (ECG) testing is a preferred component of stress testing in most patients. Exercise capacity or workload is one of the most important determinants of prognosis and, in some studies of exercise testing, has been the strongest predictor of mortality and cardiovascular events, particularly in older adults [1-4]. Among patients who undergo exercise stress, a number of variables, either alone or in combination, are associated with an increased risk of an adverse outcome in patients with CHD [2,5-12]. These include:
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- INDICATIONS FOR STRESS TESTING FOR PROGNOSIS
- EXERCISE ECG
- Exercise capacity
- Exertional hypotension
- Exertional hypertension
- Flat or downsloping ST depression
- Heart rate response to exercise
- Heart rate recovery after exercise
- BP recovery after exercise
- Ventricular arrhythmias
- Atrial arrhythmias
- Exercise-induced LBBB
- DUKE TREADMILL SCORE
- RADIONUCLIDE MYOCARDIAL PERFUSION IMAGING
- Normal rMPI
- Abnormal rMPI
- STRESS ECHOCARDIOGRAPHY
- Exercise echocardiography
- Dobutamine stress echocardiography
- Combination with Duke treadmill score
- OTHER RISK SCORES
- SUMMARY AND RECOMMENDATIONS