Dr Reza Moazzeni | Cardiologist Sydney (Westmead)
Cardiac Stress Tests
Table of Contents
Stress testing is an integral part of heart health assessment. By placing the heart under stress, we can reveal issues that may not be apparent during a regular resting examination.
Every stress test has two integral components: stress induction and subsequent testing. The process involves placing the heart under stress through physical exercise or administering specific medications to simulate the heart’s response to exertion. Once the heart has been subjected to this controlled stress, its function is evaluated using various testing modalities, such as ECG (Stress ECG), echocardiogram (Stress Echocardiogram), or nuclear imaging (Nuclear Stress Test). By combining the element of stress with advanced diagnostic techniques, we gain valuable insights into the heart’s performance and overall condition.
Importance of stress tests in diagnosing heart conditions
The importance of stress tests in diagnosing heart conditions lies in their ability to provide crucial information about the heart’s function and performance under stress. By placing the heart under increased physical or pharmacological stress, these tests can reveal problems that may not be evident during a regular resting examination. Some of the situations and conditions that stress tests are used to assess include:
Detecting coronary artery disease (CAD) and Guiding future treatments:
Stress tests can help identify inadequate blood flow to the heart muscle due to narrowed or blocked arteries. This can aid in the early diagnosis and treatment of CAD, potentially preventing heart attacks and determining the most suitable treatment plan, such as medications, angioplasty, stenting, or bypass surgery.
Evaluating exercise capacity:
A stress test can determine a patient’s exercise tolerance, which is particularly important for those with existing heart conditions or those starting an exercise program. This information can help us recommend appropriate exercise plans and monitor progress.
Identifying heart rhythm problems:
During a stress test, the heart’s electrical activity is monitored, enabling doctors to diagnose arrhythmias or abnormal heart rhythms that may only occur during physical exertion, such as SVT or Atrial Fibrillation (AF).
Assessing the effectiveness of treatment:
For patients with known heart conditions or those undergoing treatment for heart-related issues, stress tests can help determine the effectiveness of medications, procedures, or lifestyle changes.
Three different types of stress test
Stress ECG (Electrocardiogram):
A non-invasive test that monitors the heart’s electrical activity under stress, helping to detect irregular heart rhythms and diagnose potential heart issues.
Combines an exercise stress test with echocardiography, using ultrasound imaging to create detailed pictures of the heart’s structure and function under stress, offering a more accurate evaluation of blood flow and potential blockages.
Nuclear Stress Test:
It involves injecting a small amount of radioactive material into the bloodstream and utilizing specialized imaging techniques to evaluate blood flow and heart function under stress, providing detailed insights into the coronary arteries and overall heart health.
Stress ECG (Electrocardiogram)
Stress ECG, also known as exercise electrocardiogram or treadmill test, is a non-invasive diagnostic procedure that monitors the heart’s electrical activity under stress. The primary purposes of a stress ECG are to:
- Detect irregular heart rhythms (arrhythmias) that may only occur during physical exertion.
- Diagnose coronary artery disease by identifying inadequate blood flow to the heart muscle.
- Evaluate a patient’s exercise capacity.
- Assess the effectiveness of treatments for heart-related conditions and guide the selection of appropriate treatment options.
A brief history of stress ECG:
The concept of stress testing dates back to the early 20th century, but it was not until the 1960s and 1970s that stress ECG gained widespread acceptance and became a standard diagnostic tool in cardiology. Dr Robert Bruce, an American cardiologist, is considered the “Father of Exercise Cardiology” due to his development of the “Bruce Protocol” in 1963. The Bruce Protocol is a widely used, standardized exercise protocol for stress ECG, which involves gradually increasing the intensity of physical activity on a treadmill to stress the heart while monitoring the patient’s electrocardiogram, blood pressure, and symptoms. Over the years, the stress ECG has evolved, and alternative protocols have been developed to accommodate patients with varying levels of physical fitness and different medical needs.
Before undergoing a stress ECG, it is essential to prepare appropriately to ensure accurate results and a smooth testing experience. Here are some general guidelines to follow:
- Initial Consult: Discuss any medical conditions, medications, or supplements you are taking, as certain medications might need to be adjusted or temporarily stopped before the test.
- Clothing and footwear: Wear comfortable, loose-fitting clothes and athletic shoes suitable for walking or running, as you will exercise during the test.
- Fasting: Usually, you will be asked to avoid eating or drinking anything except water for 4 hours before the test.
- Avoid caffeine and smoking: Refrain from consuming caffeine (coffee, tea, soda, chocolate) and smoking for at least 24 hours before the test, as these substances can affect your heart rate and blood pressure.
Monitoring during a stress ECG test is a crucial aspect of the procedure. It helps us assess the heart’s response to increased stress and identify potential abnormalities or issues. Here are the primary components of monitoring during a stress ECG test:
- Electrocardiogram (ECG): Electrodes are attached to the patient’s chest, arms, and legs to record the heart’s electrical activity throughout the test. The ECG helps identify changes in heart rhythm, heart rate, or the electrical patterns associated with reduced blood flow to the heart muscle.
- Blood pressure: A blood pressure cuff is placed on the patient’s arm to monitor blood pressure at regular intervals during the test. This helps evaluate the cardiovascular system’s response to the increased workload and detect any abnormal fluctuations in blood pressure.
- Symptoms and subjective response: The patient’s symptoms, such as chest pain, shortness of breath, dizziness, or fatigue, are closely monitored throughout the test. Patients are encouraged to communicate any discomfort or unusual sensations they experience to the testing team, as this information can be crucial in determining the test’s outcome and safety.
- Oxygen saturation (optional): Sometimes, the patient’s blood oxygen saturation may be monitored using a pulse oximeter, a small device placed on the fingertip or earlobe. This helps ensure the patient receives adequate oxygen during the test and can provide additional information about the heart’s efficiency and overall function.
Advantages of Stress ECG:
The test does not require invasive procedures or injections, making it a safe and comfortable option for most patients.
Stress ECG tests are commonly performed in medical facilities, making them easily accessible for patients and healthcare providers.
Compared to other types of stress tests, such as stress echocardiograms or nuclear stress tests, stress ECG is generally more affordable.
Limitations of Stress ECG:
Stress ECG has a lower accuracy rate in detecting coronary artery disease than stress echocardiogram and nuclear stress test. False positives and negatives can occur, potentially leading to unnecessary further testing or missed diagnoses.
Certain factors, such as a pre-existing ECG abnormality, obesity, or specific medications, can make it difficult to interpret the results of a stress ECG, leading to inconclusive findings.
Not suitable for all patients:
Some patients might be unable to perform the required exercise, necessitating medication-induced stress testing or alternative diagnostic methods.
No direct visualization of heart structure:
Unlike stress echocardiogram and nuclear stress test, stress ECG does not provide direct visualization of the heart’s structure, limiting its ability to detect certain heart conditions.
Stress Echocardiogram (Stress Echo)
A stress echocardiogram, also known as stress echo or exercise echocardiography, combines an exercise stress ECG with an echocardiogram. It utilizes ultrasound imaging to create detailed pictures of the heart’s structure and function before and after exertion, helping to evaluate blood flow and detect any abnormalities under increased stress.
The primary purposes of a stress echocardiogram are similar to those of a stress ECG, with the added advantage of directly visualizing the heart’s structure and function. Some specific purposes include:
- Assessing the heart’s response to stress more accurately by visualizing the contraction and relaxation of the heart muscle and the functioning of the heart valves.
- Identifying regions of the heart with reduced blood flow due to blocked or narrowed coronary arteries allowing for more accurate detection of coronary artery disease.
- Evaluating the heart’s pumping efficiency and detecting conditions such as valve diseases, cardiomyopathies, or congenital heart defects that exercise may exacerbate.
Overall, a stress echocardiogram provides a more comprehensive assessment of the heart’s function under stress by combining the benefits of an exercise stress test with detailed ultrasound imaging. This can aid in detecting potential heart-related issues with greater precision and confidence. To learn more about the preparation and procedure, visit our detailed stress echocardiogram page.
Advantages of Stress Echocardiogram
Enhanced diagnostic accuracy:
By providing direct visualization of the heart’s structure and function during stress, a stress echocardiogram offers more accurate results in detecting coronary artery disease and other heart abnormalities than a stress ECG.
Non-invasive and radiation-free:
Stress echocardiogram is a non-invasive procedure that does not require radiation exposure, making it a safe option for most patients.
Ultrasound imaging during the test allows healthcare providers to observe the heart’s performance in real time, leading to a more accurate assessment of potential issues.
Stress echocardiogram not only evaluates blood flow and heart function but can also detect valve diseases, cardiomyopathies, or congenital heart defects that may be exacerbated by exercise.
Limitations of Stress Echocardiogram:
Limited image quality:
In some cases, factors such as obesity, lung disease, or the patient’s anatomy can result in suboptimal image quality, making it difficult to interpret the test results accurately.
Stress echocardiogram is generally more expensive than a stress ECG.
Stress echocardiogram may not be as widely available as stress ECG, as it requires specialized ultrasound equipment and trained technicians.
Similar to stress ECG, some patients might be unable to perform the required exercise, necessitating the use of medication-induced stress testing.
Nuclear Stress Test
A nuclear stress test, also known as myocardial perfusion imaging or radionuclide stress test, is a diagnostic procedure that combines an exercise stress test or a medication-induced stress test with advanced nuclear imaging techniques. It involves injecting a small amount of a radioactive tracer into the patient’s bloodstream to evaluate blood flow and heart function under stress. The primary purposes of a nuclear stress test include:
Detection of coronary artery disease:
By creating detailed images of blood flow to the heart muscle before and after stress, the nuclear stress test helps identify areas with reduced blood flow due to blocked or narrowed coronary arteries.
Evaluation of the heart’s function:
The nuclear stress test allows for the assessment of the heart’s pumping efficiency under stress, helping to detect conditions that may affect the overall function of the heart.
Monitoring treatment effectiveness:
For patients with known heart conditions, a nuclear stress test can be used to evaluate the success of treatments such as coronary artery bypass grafting, angioplasty, or medications and guide any necessary adjustments to the treatment plan.
The nuclear stress test can help determine the severity of a patient’s heart condition and establish an appropriate course of action, including further testing, lifestyle changes, or medical interventions. This kind of assessment is especially helpful prior to a non-cardiac surgery, when we need to assess patients’ cardiac function and whether they can tolerate the general anesthesia.
Nuclear Stress Test Procedure
♦ Resting imaging
Resting images in a nuclear stress test are the images taken when the patient’s heart is at rest, not under stress or exertion. These images serve as a baseline for comparison with the stress images captured after the patient’s heart has been subjected to exercise or medication-induced stress. Here’s a brief overview of the process:
- Patient preparation: The patient will be positioned comfortably on an imaging table or a reclining chair. An intravenous (IV) line will be inserted into the patient’s arm to administer the radioactive tracer.
- Radioactive tracer injection: The healthcare provider will inject a small amount of a radioactive tracer, such as technetium-99m or thallium-201, into the patient’s bloodstream through the IV line. The tracer will circulate through the blood and be absorbed by the heart muscle cells.
- Waiting period: The patient will be asked to wait for a specific period (typically 15-60 minutes) to allow the tracer to distribute evenly throughout the heart muscle.
- Image acquisition: The patient will be positioned under a gamma camera, a specialized imaging device that detects the gamma rays emitted by the radioactive tracer in the heart. The camera will take multiple images from different angles, creating a detailed, three-dimensional representation of the heart muscle’s blood flow at rest.
These resting images are then compared with the stress images to identify any discrepancies in blood flow between the two states, which may indicate the presence of coronary artery disease or other heart conditions. The comparison helps healthcare professionals assess the heart’s function and more accurately detect potential issues.
♦ Exercise or medication-induced stress imaging
In a nuclear stress test, stress can be induced through exercise or medication. The choice between the two depends on the patient’s physical ability and other medical considerations.
Exercise-induced stress: This is the preferred method when the patient can exercise. The patient is asked to walk or run on a treadmill, with the speed and incline gradually increasing to induce stress on the heart. Exercise continues until the patient reaches a target heart rate (based on age and physical condition) or experiences symptoms that require stopping the test, such as chest pain, shortness of breath, or extreme fatigue.
Medication-induced stress: For patients who cannot exercise or achieve an adequate level of exertion due to factors such as orthopedic limitations, severe lung disease, or physical disabilities, a medication-induced stress test is performed. Medications like adenosine, regadenoson, or dobutamine are administered intravenously to dilate the coronary arteries and increase the heart rate, mimicking the effects of exercise on the heart. The patient may experience side effects, such as flushing, shortness of breath, or chest discomfort, which are typically temporary and resolve after the test.
After inducing stress through either exercise or medication, the radioactive tracer is injected into the patient’s bloodstream. Then, a second set of images (stress images) is taken using the gamma camera. These images are compared to the resting images to evaluate the blood flow and overall function of the heart under stress, helping to detect potential issues and assess the patient’s heart health.
Advantages of Nuclear Stress Test
High diagnostic accuracy:
The nuclear stress test provides detailed images of the heart’s blood flow at rest and under stress, offering a more accurate assessment of coronary artery disease than a stress ECG but, more or less, similar to a stress echocardiogram.
The test not only evaluates blood flow and heart function but also helps monitor the effectiveness of treatments and guides future therapeutic decisions.
The nuclear stress test is a non-invasive procedure, although it does involve using a radioactive tracer.
Applicable to various patient conditions:
Since stress can be induced by exercise or medication, the nuclear stress test can accommodate patients with physical limitations preventing them from exercising.
Limitations of Nuclear Stress Test
The test involves using a radioactive tracer, which exposes the patient to a small amount of radiation. Although the exposure is typically low, it may still not be suitable for certain patients, especially pregnant or breastfeeding women.
The nuclear stress test is generally more expensive than a stress ECG or stress echocardiogram due to the advanced imaging techniques and radioactive materials involved.
The test may not be as widely available as other stress testing options since it requires specialized equipment and trained personnel.
Allergic reactions and side effects:
Some patients may experience allergic reactions to the radioactive tracer or side effects from the stress-inducing medications. However, such occurrences are generally rare and short-lived.
Comparing Stress ECG, Stress Echocardiogram, and Nuclear Stress Test
Stress ECG has moderate accuracy in diagnosing coronary artery disease. It primarily measures electrical changes in the heart during exercise but does not provide direct visualization of the heart or blood flow. Although stress ECG can help identify heart conditions, its diagnostic value is limited due to its reliance on electrical signals alone. It usually produces false positives or negatives that require further testing with more advanced techniques. As a result, most modern Cardiology centres have mostly discontinued performing Stress ECG alone, which almost always leads to further investigations due to low accuracy.
Stress echocardiogram has higher accuracy compared to stress ECG as it directly visualizes the heart’s structure and function during stress, making it more reliable in detecting coronary artery disease and other heart abnormalities. The stress echocardiogram provides a more comprehensive assessment by evaluating blood flow, heart function, valve diseases, cardiomyopathies, and congenital heart defects. Its diagnostic value is superior to that of stress ECG.
Nuclear Stress Test
Nuclear stress test is highly accurate for diagnosing coronary artery disease, similar to a “well-performed” stress echocardiogram. It provides detailed images of blood flow to the heart muscle before and after stress, enabling the identification of areas with reduced blood flow due to blocked or narrowed coronary arteries. The nuclear stress test offers a comprehensive evaluation of blood flow, heart function, treatment effectiveness, and risk stratification. It is the most reliable diagnostic tool among the three for detecting or ruling out coronary artery disease.
Sensitivity and Specificity
In our discussion comparing stress ECG, stress echocardiogram, and nuclear stress testing, it is crucial to understand the sensitivity and specificity of these tests. Sensitivity refers to the ability of a test to correctly identify patients with a particular condition, while specificity refers to its ability to identify patients without that condition. Here is a table comparing the sensitivity and specificity of these tests:
|Test||Sensitivity (%)||Specificity (%)|
|Nuclear Stress Test||85-90||80-85|
To illustrate this with a simple example, let’s say we have 100 people with suspected coronary artery disease (CAD). If all 100 underwent a stress ECG, about 65 to 70 patients with CAD would be correctly identified (sensitivity), and 70 to 75 patients without CAD would be correctly identified as not having the disease (specificity). Comparatively, a stress echocardiogram would correctly identify 80 to 85 patients with CAD and 80 to 85 without CAD. Finally, nuclear stress testing would correctly identify 85 to 90 patients with CAD and 80 to 85 without CAD.
Stress test quality
It is essential to consider the impact of test quality on the sensitivity and specificity of these tests. When performed properly, the numbers in our comparison table hold true. However, if the stress ECG or echo is conducted suboptimally—such as inadequate exercise time on the treadmill, rushing the test, fast-forwarding, or skipping Bruce protocol stages due to time constraints—the sensitivity and specificity may be significantly lower than presented.
As a reminder, clinicians should closely examine these parameters when reviewing test results to ensure accurate interpretation. Test quality is critical in diagnostic accuracy, and adhering to established protocols is vital for obtaining reliable results. This underscores the importance of consulting a healthcare professional when selecting the most suitable test and interpreting the outcomes.
Radiation exposure is a concern when it comes to medical tests and procedures. Understanding the radiation exposure associated with stress tests can help patients and healthcare providers make informed decisions about the most appropriate diagnostic tools.
Stress ECG: There is no radiation exposure associated with a stress ECG, as it solely relies on electrical signals to assess the heart’s function during exercise.
Stress Echocardiogram: Similarly, a stress echocardiogram does not involve ionizing radiation. It utilizes ultrasound waves to visualize the heart’s structure and function under stress.
Nuclear Stress Test: The nuclear stress test involves radiation exposure due to using a radioactive tracer, such as technetium-99m or thallium-201. The tracer is injected into the patient’s bloodstream, where it emits gamma rays that are detected by a gamma camera to create images of the heart.
The radiation exposure during a nuclear stress test is typically low and falls within what is considered medically acceptable. The effective dose varies depending on the tracer but is generally between 3 and 14 millisieverts (mSv). For comparison, natural background radiation contributes an average of 3 mSv per year, and a chest CT scan may expose a patient to approximately 6.1 mSv. However, radiation exposure is still a concern, particularly for pregnant or breastfeeding women, as ionizing radiation may pose risks to the fetus or nursing infant and is generally not recommended in these circumstances.
Functional Tests vs. Anatomical Tests: Understanding the Differences
In assessing heart health, there are two primary categories of diagnostic tests: functional stress tests and anatomical tests.
Functional stress tests, including stress ECG, stress echocardiogram, and nuclear stress tests, evaluate the heart’s performance and blood flow under stress. These tests reveal if a blockage is present and demonstrate how it impacts blood flow (restricting the flow) during exercise and periods of increased demand. They are generally less invasive with little or no radiation exposure.
Anatomical tests such as CT Coronary Angiograms and Invasive Angiograms deliver detailed images of the coronary arteries responsible for supplying the heart muscle. While these tests can pinpoint blockages, they do not offer insight into how these obstructions affect blood flow during stress, when the heart muscle’s demand for oxygen and flow is higher. They are more invasive compared to the functional tests.
Functional and anatomical tests in cardiology serve as complementary tools, often used in conjunction to obtain a thorough understanding of a patient’s condition. In many instances, anatomical tests may reveal a seemingly severe blockage in the coronary arteries. However, functional tests determine that the blockage is not limiting the blood flow, causing ischemia, or resulting in symptoms. Functional tests are crucial in such cases to help evaluate the true impact of the blockage on the heart’s function and determine the appropriate course of action.
Selecting the appropriate stress test is crucial for accurately diagnosing and managing heart conditions. Each stress test type has its advantages and limitations, and choosing the right test can significantly impact the patient’s overall health and treatment plan. Here are some reasons why it is essential to select the appropriate stress test:
- Diagnostic accuracy: Different stress tests provide varying levels of diagnostic accuracy. Selecting the most suitable test helps healthcare providers obtain more accurate and reliable information about a patient’s heart condition, leading to better-informed treatment decisions.
- Avoiding unnecessary procedures: Inaccurate or inconclusive results may lead to further testing, increasing the patient’s anxiety, exposing them to additional radiation (in the case of nuclear stress tests), and adding to healthcare costs. Choosing the appropriate stress test can help minimize the need for additional testing.
- Patient safety and comfort: Some stress tests may not be suitable for certain patients due to their physical abilities, medical history, or risk factors. Selecting the appropriate stress test can help avoid complications, minimize side effects, and ensure the patient’s safety and comfort during the procedure.
- Cost-effectiveness: Selecting the right stress test helps optimize healthcare resources, making diagnostic processes more efficient and cost-effective for patients and healthcare providers.