Cardiac stress testing provides important diagnostic and prognostic information in evaluating suspected heart disease. The most common stress testing modalities include exercise electrocardiography with or without perfusion imaging.

Selecting the correct cardiac stress test depends on many factors. Patients who cannot exercise can undergo pharmacological stress testing with perfusion imaging. Things to consider in selecting the correct test modality are-

• the patients ability to exercise
• the resting ECG
• clinical indication for performing a stress test
• the patient’s body habitus
• the patient’s history of prior revascularization.

Risks in stress testing are few, but the testing is not risk free. There is a small risk of acute myocardial infarction (~1:5000 tests) and death (~1:10 000 tests). 

Absolute contraindications to cardiac stress testing include acute myocardial infarction, new LBBB, high-risk unstable angina, symptomatic severe aortic stenosis, uncontrolled arrhythmia causing symptoms or hemodynamic instability, unstable heart failure, acute pulmonary embolus, and acute aortic dissection.

Relative contraindications include-

• severe hypertension, SBP > 200 mmHg, DBP > 110 mmHg
• left main coronary artery stenosis
• severe electrolyte imbalance
• moderate to severe aortic stenosis
• obstructive hypertrophic cardiomyopathy
• 2^nd or 3^rd degree heart block
• stroke within one month

Choosing the correct modality to evaluate for underlying heart disease will provide the most accurate assessment in the safest manner. A good history will direct the provider to selecting the correct manner of testing.

See Sandra Keavey, MPAS, DFAAPA, PA-C speak in 2018 at a Skin, Bones, Hearts & Private Parts CME/CE Conference for NPs, PAs, MDs, and DOs.