What are the contraindications for exercise tolerance testing?

Updated: Nov 20, 2018
  • Author: Richard S Krause, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Many patients should not undergo exercise tolerance testing. If a patient’s probability of coronary disease is very low, the chance of a false-positive result exceeds the chance of a true-positive test, therefore stress testing is not indicated. This is also the rationale behind the recommendation that stress testing not be used for screening in asymptomatic patients or those who have had no change in status since a prior stress test. Likewise, if the result of a stress test will not change management, it should not be performed. Stress testing is not the initial test of choice in high-risk patients, as even a negative test would not eliminate the need for angiography.

Other specific contraindications to exercise electrocardiography include patients with:

  • Resting ECG abnormalities (eg, left bundle branch block, paced rhythm, pre-excitation syndromes, or ≥1-mm ST depression at rest),
  • Inability to exercise (better suited to pharmacologic testing)
  • Medications such as digoxin, beta-blockers, and some calcium channel blockers may blunt the ischemic response to stress. When feasible, these agents may be held and the patient monitored until the test can be performed. However, abrupt withdrawal, especially of beta blockers, may be harmful.
  • Acute myocardial infarction (MI)
  • Sustained ventricular arrhythmias or high-grade heart block
  • Wellens syndrome (see the image below)
    Classic Wellens syndrome T-wave changes. This ECG Classic Wellens syndrome T-wave changes. This ECG represents a patient after becoming pain free secondary to medications. Notice the deep T waves in V3-V5 and slight biphasic T wave in V6 in this chest pain free ECG. The patient had negative cardiac enzyme levels and later had a stent placed in the proximal left anterior descending (LAD) artery.
  • Hemodynamically significant aortic stenosis
  • Severe hypertension
  • Serious coexisting illness (such as pneumonia or diabetic ketoacidosis [DKA])
  • Symptomatic congestive heart failure (CHF)
  • Active venous thromboembolic disease (deep venous thrombosis [DVT] or pulmonary embolism [PE])
  • Pericarditis, myocarditis, or endocarditis

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