Simultaneously, echocardiography or radionuclide imaging is performed. experience more of the other symptoms, such as. Hermann LK, Avoid using stress echocardiography on asymptomatic patients who meet low-risk scoring criteria for coronary disease. Copyright © 2020 American Academy of Family Physicians. women are somewhat more likely than men to experience heart attack that does not coronary heart disease that are noninvasive? ; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Marwick TH, Hunink MG. Address correspondence to Kathryn K. Garner, MD, 2501 Capehart Rd., Offutt Air Force Base, NE 68113 (e-mail: kathryn.k.garner2.mil@mail.mil). 29. During a coronary angiogram (also termed a coronary catheterization), a small catheter (a thin hollow tube with a diameter of 2-3 mm) is inserted through the skin into an artery usually in either the groin or the arm. See the CME Quiz Questions. Levine EJ, 5. Ordering and understanding the exercise stress test. The doctor will have detailed information regarding what testing involves and the implications of the results for each individual. U.S. Preventive Services Task Force. Screening tests are of particular importance for 2012;66(5):477–492. Lamanna A, Exercise treadmill score for predicting prognosis in coronary artery disease. 22. There are two basic types of stress tests; those that involve exercising the patient to stress the heart (exercise cardiac stress tests), and those that involve chemically stimulating the heart directly to mimic the stress of exercise (physiologic stress testing). Banerjee A, Exercise stress testing is often better at excluding CAD than confirming it. 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. 17. 7. Hoeks SE, note: Typical angina is defined as having all of the following: substernal chest pain or discomfort, provocation by exertion or emotional stress, and relief with rest or nitroglycerin. Myocardial infarction in previous two days, Uncontrolled cardiac arrhythmia with hemodynamic compromise, Acquired complete heart block (left bundle branch block), Hypertrophic obstructive cardiomyopathy with severe resting gradient, Recent stroke or transient ischemic attack, Resting systolic blood pressure > 200 mm Hg or diastolic blood pressure > 110 mm Hg, Tachyarrhythmia with uncontrolled ventricular rate. Fleischmann KE, individuals, pharmacological stress testing is often used. A prospective study (n = 44,000) of men and women, including blacks, with a mean age of 53 years showed a strong association between decreasing exercise systolic BP response, all-cause death, and MI.27 The lower the patient's rise in systolic BP in response to exercise, the higher the incidence rate of MI per 1,000 person-years (increase of more than 20 mm Hg above baseline = 3.9 incidence rate [95% CI, 3.6 to 4.1], 1 to 20 mm Hg above baseline = 8.0 [95% CI, 7.0 to 9.1], and decrease from baseline = 12.5 [95% CI, 10.2 to 15.4]).27 Therefore, it is recommended that exercise stress testing be discontinued if systolic BP decreases by more than 10 mm Hg. What if a person is unable to exercise adequately for an exercise cardiac Ho A, Testing without imaging is the primary initial choice for risk stratification for most women and men. Ross C, This article updates previous articles on this topic by Fletcher, et al.,29 and by Darrow.30. Alternatively, nuclear stress testing with thallium 201 or technetium 99m … Savino JA, JAMES J. ARNOLD, DO, FACOFP, FAAFP, is the senior associate program director at the National Capital Consortium Family Medicine Residency and an assistant professor of family medicine at the Uniformed Services University of the Health Sciences. / Vol. et al. Otahal P, 21. et al. The standard Bruce protocol is preferred for exercise stress testing3  (eTable A). Symptoms of Cleland VJ, Do not perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. ; Angiographic images accurately reveal the extent and severity of all coronary arterial blockages. 16. Napoli AM. Heneghan C. Guided with the assistance of a fluoroscope (a special X-ray viewing instrument), the catheter is then advanced to the opening of the coronary arteries, the blood vessels supplying blood to the heart. 2013;128(8):882. ; 2014;63(4):388, with additional information from reference 2. Alternatively, a medicine called adenosine is administered, which simulates the physiology of the coronary artery circulation during exercise. Shaw LJ, O'Neal WT, Curr Cardiol Rep. Pellikka PA. American Academy of Family Physicians. Askew JW, In a person at high risk for 8. Stress-induced ST-segment elevation in patients without prior Q-wave myocardial infarction. Detrano R, 18. Belyea CM, Greenslade JH, The most common symptom is centrally located chest pain, often radiating to the left shoulder or angle of the jaw, crushing, central and associated with nausea and sweating. Consensus opinion from the ACCF/AHA is that exercise stress testing can be used for exercise prescriptions, but data on patient-oriented outcomes are lacking, Exercise stress testing is generally inappropriate for detection of ischemia in asymptomatic patients with no history of revascularization. If a coronary arterial blockage results in decreased blood flow to a part of the heart during exercise, certain changes (for example, ST segment depressions) may be observed in the EKG, as well as in the response of the heart rate and blood pressure. If you have a heart condition or concern, your doctor may discuss different ways to diagnose or monitor it, including an electrocardiogram (ECG), cardiac catheterization, echocardiogram (ultrasound), radionuclide stress test, coronary CT angiogram, radionuclide myocardial perfusion imaging, or cardiac magnetic resonance imaging (MRI). Califf RM, Stress echocardiography and exercise SPECT are appropriate in symptomatic patients at intermediate or high risk of CAD and in those with difficult-to-interpret electrocardiography results.1 Symptomatic patients with a history of percutaneous coronary intervention or coronary artery bypass grafting should undergo exercise SPECT, stress echocardiography, or coronary angiography as clinically indicated.1, A 2012 systematic review of 34 prospective studies found that exercise stress testing and stress echocardiography were better at excluding CAD than confirming it (likelihood ratio [LR] of ruling out CAD via exercise stress testing = −0.34; 95% confidence interval [CI], 0.28 to 0.41; LR for stress echocardiography = −0.24; 95% CI, 0.17 to 0.32).9 Of the two testing modalities, stress echocardiography was better at ruling in CAD (LR = 7.94 vs. 3.57 for exercise stress testing).9  Sensitivity and specificity for CAD detection increase when imaging is performed with exercise stress testing (Table 3).10–14 The prevalence of severe CAD is higher in older patients; exercise stress testing has a sensitivity of 84% in this population but a decreased specificity of 70%.3 SPECT is no better at detecting severe CAD than exercise stress testing, but it stratifies more intermediate-risk patients as low risk.15 SPECT is superior to echocardiography for attaining images diagnostic for CAD in obese patients and in those with chronic obstructive pulmonary disease.16, Preferred test, allows for detection and intervention, Exercise single-photon emission computed tomography, Cannot assess myocardium or valves, heart rhythm irregularities may affect results, soft tissue attenuation artifacts, requires radiation, Assesses myocardial perfusion and regional/global function at rest and during stress, good prognostic data and negative predictive value, Requires normal baseline electrocardiography, not recommended for patients with history of percutaneous coronary intervention or coronary artery bypass grafting, Less expensive, limited equipment required, good prognostic data and negative predictive value, Image quality affected by body habitus and dependent on operator, limited time for imaging postexercise, Assesses cardiac structure, global and segment function at rest and during stress, relatively inexpensive, does not require radiation, good prognostic data and negative predictive value.
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