What is the efficacy of exercise tolerance testing for cardiac assessment?

Updated: Nov 20, 2018
  • Author: Richard S Krause, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

Answer

Exercise tolerance testing has the advantages of a long history of experience, widespread availability, relatively low cost compared to other forms of noninvasive cardiac testing, and no radiation exposure. Multiple studies have validated the safety and efficacy of exercise testing in low-risk chest pain patients. [10]  It has even been shown to be safe when performed immediately in low-risk patients with a normal ECG and a single negative cardiac biomarker measurement. [11]

A meta-analysis of the diagnostic accuracy of 147 published reports involving 24,045 patients who underwent both exercise tolerance testing and coronary angiography by the American College of Cardiology and American Heart Association (ACC/AHA) showed a mean sensitivity of 68% and mean specificity of 77%. [12] Despite the low sensitivity when compared to angiography results, the purpose of stress testing in the context of the emergency department (ED) evaluation of chest pain is not to rule out CAD but to be used as short-term prognostic tool to aid the safe disposition of patients.

The 2014 AHA/ACC guidelines for the management of non-ST-elevation myocardial infarction (NSTEMI) and acute coronary syndrome (ACS) state that “Noninvasive stress testing is recommended in low- and intermediate-risk patients who have been free of ischemia at rest or with low-level activity for a minimum of 12 to 24 hours.” [13] Additionally, the 2010 ACC/AHA guidelines for the management of low-risk chest pain note that if follow-up ECGs and cardiac marker measurements are normal, a stress test (exercise or pharmacologic) to provoke ischemia may be performed in the ED, in a chest pain unit (CPU), or on an outpatient basis shortly before discharge. Low-risk patients with a negative stress test can be managed as outpatients. [14]

These recommendations are based on expert literature review and consensus. The recommendations are predicated on the concept that a negative exercise test has the ability to confer an excellent short-term (1-6 month) cardiovascular prognosis for patients having presented with chest pain.


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