Stress testing: The effect of medications and methylxanthines
- 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
- 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
For the majority of patients undergoing a stress test, the primary goal is to identify myocardial ischemia due to coronary heart disease (CHD). Depending on the stress test modality, ischemia may manifest in the form of symptoms, hemodynamic findings, electrocardiographic abnormalities, stress-induced perfusion defects, or regional wall motion abnormalities.
In patients with known or suspected CHD, the presence and extent of ischemia on stress testing are used to guide medical therapy and/or determine the need for further diagnostic and therapeutic procedures. Thus, factors that impact the sensitivity and specificity of stress testing for the detection of ischemia may lead to either patients not receiving appropriate therapy or to unnecessary procedures and treatment with their attendant risks and costs, respectively. Many factors (eg, pre-existing electrocardiographic abnormalities, sex, body habitus, etc) can affect a stress test’s ability to accurately identify myocardial ischemia.
The interaction between major cardiovascular medications, dietary factors, and stress testing and our recommendations for continuing or discontinuing the individual drug or dietary component will be discussed here. Indications and procedures for stress testing are discussed separately. (See "Selecting the optimal cardiac stress test" and "Stress testing for the diagnosis of obstructive coronary heart disease" and "Exercise ECG testing: Performing the test and interpreting the ECG results" and "Overview of stress radionuclide myocardial perfusion imaging" and "Overview of stress echocardiography".)
STRESS TESTING CONCEPTS
Before discussing the impact of medications and dietary factors on the detection of myocardial ischemia on stress testing, important concepts regarding stress testing for coronary heart disease (CHD) must be considered.
●The manifestations of CHD identified following stress with exercise or dobutamine require the ability to increase myocardial oxygen demand by increasing heart rate, blood pressure, and/or left ventricular contractility above a certain threshold to provoke myocardial ischemia. Vasodilator-stress induced manifestations of CHD depend on a hyperemic coronary blood flow differential between normal and abnormal coronary arteries, and are not dependent on increasing heart rate, blood pressure, or contractility. (See "Exercise ECG testing: Performing the test and interpreting the ECG results" and "Overview of stress radionuclide myocardial perfusion imaging" and "Overview of stress echocardiography".)
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- STRESS TESTING CONCEPTS
- OUR APPROACH TO MEDICATIONS AND STRESS TESTING
- MEDICATIONS THAT MAY REDUCE TEST SENSITIVITY
- Beta blockers
- Calcium channel blockers
- Angiotensin converting enzyme inhibitors and angiotensin receptor blockers
- MEDICATIONS THAT MAY REDUCE THE SPECIFICITY OF THE STRESS TEST
- SUMMARY AND RECOMMENDATIONS