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:
- Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354.
- Qaseem A, Fihn SD, Williams S, et al. Diagnosis of stable ischemic heart disease: summary of a clinical practice guideline from the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons. Ann Intern Med 2012; 157:729.
- Lee TH, Boucher CA. Clinical practice. Noninvasive tests in patients with stable coronary artery disease. N Engl J Med 2001; 344:1840.
- Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873.
- Weiner DA, Ryan TJ, McCabe CH, et al. Exercise stress testing. Correlations among history of angina, ST-segment response and prevalence of coronary-artery disease in the Coronary Artery Surgery Study (CASS). N Engl J Med 1979; 301:230.
- Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300:1350.
- Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981; 64:360.
- Pryor DB, Harrell FE Jr, Lee KL, et al. Estimating the likelihood of significant coronary artery disease. Am J Med 1983; 75:771.
- Pryor DB, Shaw L, McCants CB, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993; 118:81.
- Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010; 362:886.
- Cheng VY, Berman DS, Rozanski A, et al. Performance of the traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography: results from the multinational coronary CT angiography evaluation for clinical outcomes: an international multicenter registry (CONFIRM). Circulation 2011; 124:2423.
- Mieres JH, Gulati M, Bairey Merz N, et al. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350.
- Morise AP, Diamond GA. Comparison of the sensitivity and specificity of exercise electrocardiography in biased and unbiased populations of men and women. Am Heart J 1995; 130:741.
- Melin JA, Wijns W, Vanbutsele RJ, et al. Alternative diagnostic strategies for coronary artery disease in women: demonstration of the usefulness and efficiency of probability analysis. Circulation 1985; 71:535.
- Alexander KP, Shaw LJ, Shaw LK, et al. Value of exercise treadmill testing in women. J Am Coll Cardiol 1998; 32:1657.
- Williams MJ, Marwick TH, O'Gorman D, Foale RA. Comparison of exercise echocardiography with an exercise score to diagnose coronary artery disease in women. Am J Cardiol 1994; 74:435.
- Sketch MH, Mohiuddin SM, Lynch JD, et al. Significant sex differences in the correlation of electrocardiographic exercise testing and coronary arteriograms. Am J Cardiol 1975; 36:169.
- Shaw LJ, Mieres JH, Hendel RH, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation 2011; 124:1239.
- Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:1883.
- Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation 2003; 108:1404.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- Mark DB, Hlatky MA, Harrell FE Jr, et al. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987; 106:793.
- Pennell DJ, Underwood SR, Ell PJ. Safety of dobutamine stress for thallium-201 myocardial perfusion tomography in patients with asthma. Am J Cardiol 1993; 71:1346.
- Shaw LJ, Iskandrian AE. Prognostic value of gated myocardial perfusion SPECT. J Nucl Cardiol 2004; 11:171.
- Heller GV, Links J, Bateman TM, et al. American Society of Nuclear Cardiology and Society of Nuclear Medicine joint position statement: attenuation correction of myocardial perfusion SPECT scintigraphy. J Nucl Cardiol 2004; 11:229.
- Taillefer R, Ahlberg AW, Masood Y, et al. Acute beta-blockade reduces the extent and severity of myocardial perfusion defects with dipyridamole Tc-99m sestamibi SPECT imaging. J Am Coll Cardiol 2003; 42:1475.
- Crouse LJ, Cheirif J, Hanly DE, et al. Opacification and border delineation improvement in patients with suboptimal endocardial border definition in routine echocardiography: results of the Phase III Albunex Multicenter Trial. J Am Coll Cardiol 1993; 22:1494.
- Nagel E, Lehmkuhl HB, Bocksch W, et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 1999; 99:763.
- Greenwood JP, Maredia N, Younger JF, et al. Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial. Lancet 2012; 379:453.
- 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