When will exercise test help to evaluation of chest pain?

Exercise test is recommended only for patients with moderate suspected CAD. It will help if pre test probability of CAD is 25% - 75%. For low probability it could cause false positive. For high probability it could cause false negative. These charts show the pre-test probability of CAD for each group. In the green area exercise test is recommended. The last chart shows post-test probability.

   

Female with typical chest pain

Male with typical chest pain

Patient with atypical chest pain

Charts translated from Finnish cardiology reference book.

Coronary CT:

When CAD probability is small (<25%), but chest pain is typical and exclusion of CAD is important, the coronary CT could be ideal choice.

An example; A below 40 y. old female with typical chest pain and without risk factors has pre-test probability below 25%, so exercise test is not recommended and coronary CT is a good exam for exclusion of CAD. But if the coronary CT is not accessible, you can check again the history of sign and symptom and if exclusion of CAD is important, at first exercise test could be done. If it is negative then further examination is not necessary. If it is positive, it could be false positive and diagnostic angiography could be recommended, because you do not have coronary CT or Perfusion cardiac scan. You can use stress echo instead of perfusion cardiac scan, but the exam detriment is that its result is highly user experience dependent.

 

Isotope exercise test (Perfusion cardiac scan) Indications:

  1. ECG abnormalities like: LBBB, Pacemaker rhythm, WPW-syndrome, >1mm ST-depression at rest
  2. Physical problems and exercise test is not possible
  3. Q-wave infarction in history
  4. When you want to know the ischemic region for revascularization plan.

 

Stress Echocardiography:

We can use stress echo instead of perfusion cardiac scan. The exam benefit is that you could find likely other cause of chest pain and evaluate also valvular disease. The exam detriment is that its result is highly user experience dependent.

Compilation by Dr. Samad Ali Moradi, According to Duodecim Finnish cardiology reference book & ESC SCAD guideline & author work experience.