Stress testing in pre-discharge risk stratification of patients with non-ST elevation acute coronary syndrome
- Stephen G. Sawada, MD
Stephen G. Sawada, MD
- Feigenbaum Professor of Cardiology
- Krannert Institute of Cardiology, Indiana University School of Medicine, IU Health
- Ronald Mastouri, MD, FACC
Ronald Mastouri, MD, FACC
- Assistant Professor of Clinical Medicine
- Krannert Institute of Cardiology
- Indiana University Schoo
- Section Editors
- Gary V Heller, MD, PhD, FACC, MASNC
Gary V Heller, MD, PhD, FACC, MASNC
- Section Editor — Noninvasive Cardiac Imaging
- Division of Cardiovascular Medicine Morristown Medical Center
- 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
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 RISK STRATIFICATION
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 . 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.
WHO NEEDS A STRESS TEST AND WHEN SHOULD IT BE PERFORMED
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 . 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.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:
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139.
- Larsson H, Areskog M, Areskog NH, et al. Should the exercise test (ET) be performed at discharge or one month later after an episode of unstable angina or non-Q-wave myocardial infarction? Int J Card Imaging 1991; 7:7.
- de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095.
- Fuller CM, Raizner AE, Verani MS, et al. Early post-myocardial infarction treadmill stress testing. An accurate predictor of multivessel coronary disease and subsequent cardiac events. Ann Intern Med 1981; 94:734.
- 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.
- Starling MR, Crawford MH, Kennedy GT, O'Rourke RA. Treadmill exercise tests predischarge and six weeks post-myocardial infarction to detect abnormalities of known prognostic value. Ann Intern Med 1981; 94:721.
- Marwick TH, Anderson T, Williams MJ, et al. Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol 1995; 26:335.
- Mahmarian JJ, Shaw LJ, Filipchuk NG, et al. A multinational study to establish the value of early adenosine technetium-99m sestamibi myocardial perfusion imaging in identifying a low-risk group for early hospital discharge after acute myocardial infarction. J Am Coll Cardiol 2006; 48:2448.
- Carlos ME, Smart SC, Wynsen JC, Sagar KB. Dobutamine stress echocardiography for risk stratification after myocardial infarction. Circulation 1997; 95:1402.
- Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627.
- Shaw LJ, Berman DS, Picard MH, et al. Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging. JACC Cardiovasc Imaging 2014; 7:593.
- Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). J Am Coll Cardiol 1999; 33:2092.
- Pellikka PA, Nagueh SF, Elhendy AA, et al. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007; 20:1021.
- OUR APPROACH TO RISK STRATIFICATION
- WHO NEEDS A STRESS TEST AND WHEN SHOULD IT BE PERFORMED
- Pre-discharge stress testing
- Early post-discharge stress testing
- WHO DOES NOT NEED A STRESS TEST?
- CONTRAINDICATIONS TO STRESS TESTING
- WHICH STRESS TEST IS PREFERRED?
- INTERPRETING THE STRESS TEST RESULTS
- MANAGEMENT FOLLOWING STRESS TESTING
- SUMMARY AND RECOMMENDATIONS