Review

Stress testing and noninvasive coronary imaging: What’s the best test for my patient?

Milad Matta, MD, Serge C. Harb, MD, Paul Cremer, MD, Rory Hachamovitch, MD, MSc and Chadi Ayoub, MD, PhD, FACC, FASE, FSCCT
Cleveland Clinic Journal of Medicine September 2021, 88 (9) 502-515; DOI: https://doi.org/10.3949/ccjm.88a.20068

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Stress echocardiogram from a 54-year-old woman with chest pain shows ischemia in the left anterior descending artery and right coronary artery territories. Panels A and B show the 4-chamber view before and after the stress test. On the poststress image (B), the arrows point to hypokinesis at the apex and distal septum; enlargement of left ventricular cavity suggests significant ischemia. In the long-axis view (C, D), arrows point to hypo-kinesis at the apex and distal septum. In the 2-chamber view (E, F), arrows point to hypokinesis on the mid and apical inferior wall.

  • Figure 2
    Figure 2

    Single-photon emission CT myocardial perfusion imaging in a 62-year-old man with diabetes and a 2-month history of dyspnea shows moderate left anterior descending coronary artery ischemia. Panels A, C, and E are poststress images that show perfusion defects in the apex, apical septum, and apical anterior wall (arrows). Panels B, D, and F show relatively normal perfusion at rest at the corresponding levels.

  • Figure 3
    Figure 3

    Coronary computed tomography angiography in a 40-year-old man who smoked and had a family history of premature coronary artery disease. Panel A is a 3-D rendering showing proximal left anterior descending (LAD) coronary artery stenosis (arrow). Panel B is a multiplanar reconstruction showing proximal LAD coronary artery stenosis with predominantly soft (lipid-laden) noncalcified plaque (arrow). Panel C shows the corresponding LAD lesion (arrow) on coronary catheterization.

    LCx = left circumflex artery; RCA = right coronary artery

  • Figure 4
    Figure 4

    Stress cardiac magnetic resonance imaging in a 67-year-old woman with diabetes and chest pain shows normal perfusion at rest (A). Panel B shows a poststress image with a perfusion defect in the inferior and inferoseptal segments (arrow), suggestive of ischemia in the right coronary artery territory. Panel C is a delayed gadolinium-enhanced image showing mild subendocardial enhancement (arrow) in the corresponding region, consistent with a small area of scar.

Tables

  • TABLE 1

    Testing for coronary artery disease

    FunctionalElectrocardiography exercise stress test
    Stress echocardiography
    Nuclear medicine myocardial perfusion imaging techniques
     Single-photon emission computed tomography
     Positron emission tomography
    Cardiac magnetic resonance imaging with stress perfusion
    AnatomicCoronary computed tomography angiography
    Invasive coronary catheterization
  • TABLE 2

    Common indications for stress testing and coronary computed tomography angiography

    Assessment for coronary artery disease
    Angina or anginal equivalent symptoms and negative cardiac enzymes
    Atypical symptoms in patients with diabetes or with high probability of diabetes
    New diagnosis of cardiomyopathy (to define whether the cause is ischemic or nonischemic)
    New or increasing heart failure symptoms despite adherence to medical therapy
    Re-evaluation of known heart failure (systolic or diastolic) in patients with a change in clinical status without a clear precipitating change in medication or diet
    Arrhythmias such as ventricular tachycardia or atrial fibrillation (to exclude ischemia as the cause) or new left bundle-branch block
    To exclude severe ischemia prior to noncardiac surgery in those with increased coronary artery disease risks, angina symptoms, or poor exercise capacity (< 4 metabolic equivalents)
    To define presence or absence of ischemia in those with moderate coronary stenosis (stress test or fractional flow reserve-computed tomography)
    Evaluation of anomalous coronary arteries
    Stress testing for indications other than coronary artery disease assessment
    Valve assessment
     Mitral valve stenosis or regurgitation severity (exercise stress echocardiography)
     Low-flow low gradient aortic stenosis (dobutamine stress echocardiography)
    Exercise-induced pulmonary hypertension or diastolic dysfunction (exercise stress echocardiography)
    Hypertrophic cardiomyopathy to demonstrate provocable left ventricular outflow tract obstruction (exercise stress echocardiography)
    Exercise-induced arrhythmia or chronotropic incompetence (exercise stress echocardiography)
    To define cardiopulmonary disease and aerobic exercise capacity (metabolic stress test)

    • Data from references 3 and 7–10.

  • TABLE 3

    Prognostic indicators on electrocardiography stress testing

    IndicatorComments
    Functional capacityStrongest prognostic indicator, reported as metabolic equivalents.7,14
    ST-segment depression or elevation> 1-mm ST deviation is suggestive of ischemia.13
    Exercise-induced hypotensionDefined as systolic blood pressure that is lower during exercise than while standing at rest before exercise, reflecting failure of cardiac output to increase during exercise.
    Associated with severe coronary artery disease or left ventricular systolic dysfunction.15
    Chronotropic incompetenceFailure of heart rate to increase as expected during exercise, defined as achieving < 80% of predicted heart rate (or < 62% for patients taking beta-blockers).16
    Associated with increased all-cause and cardiovascular mortality.17
    Impaired heart rate recoveryHeart rate fails to decrease normally after cessation of exercise.
    Predicts all-cause mortality and cardiovascular events, including sudden death.18
    Ventricular arrhythmiaSustained ventricular tachychardia or ventricular fibrillation.
    Associated with significant coronary artery disease or left ventricular dysfunction.19
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