As is my usual practice with blog entries, I try to give disclaimers. These disclaimers are designed to protect YOU!!
- Your doctor has your best interest at heart (pun intended). Trust your doctor. If you have any reservations about your care, talk to him/her.
- Your clinical situation is unique. This blog is an incomplete collection of generalized
recommendations that might not be appropriate for every given scenario.
- Stress testing is safe but not without risk
- If you are having new or worsening chest pain, shortness of breath or other symptoms that could be cardiac in nature, there is a pretty good chance that you will need a stress test and this blog entry is not for you.
Important Definitions
- Low Risk –Low risk for cardiac events. Your 10-year risk of cardiac events is less than 10%.
- Intermediate Risk – Average to slightly above average risk for cardiac events. Your 10-year risk of cardiac events is 10-20%.
- High Risk – High risk of cardiac events. Diabetes in a person older than 40, Peripheral Artery Disease (PAD,. I know you have seen the commercials), symptomatic or significant carotid artery disease, prior diagnosed coronary artery disease or a 10-year risk of greater than 20%.
- Ischemic Equivalent – Chest discomfort, Anginal Equivalent, or EKG changes concerning for heart blockages.
- Anginal Equivalent – Symptoms other than heart related chest pain that may signify heart blockage. These include but are not limited to chest or abdominal burning, shoulder pain, palpitations, jaw pain and shortness of breath.
To calculate your 10-year risk of cardiac events you can visit: myheart.net
The following represents my distillation of the American College of Cardiology’s recommendations on the appropriate use of nuclear stress testing. These recommendations are an outstanding guide for stress testing in general. There are numerous reasons that your physician may decide to order a stress test. For simplicity, I have decided to focus primarily on the situations where stress testing is usually NOT warranted.
Asymptomatic
I am low risk:
If you are low risk for coronary heart disease and are asymptomatic, there is almost no conceivable indication for stress testing. The most significant exceptions deal are if you have been diagnosed with certain types of heart failure. Some doctors may recommend a stress test “just to check.” The likelihood of finding a problem is so small that the risk of undergoing the stress test is probably not worth it.
I am intermediate risk:
Your doctor may elect to proceed with stress testing to help define your overall risk of heart disease. This is a very reasonable option. However, if you had a stress test within the past two years and you remain asymptomatic, there is no need to repeat the test until it has been at least two years.
I am high risk:
This is where it is a bit tricky. It is reasonable to undergo stress testing if you fall in the high risk category. If you had a normal stress test less than two years ago and you truly have no chest pain (or anginal equivalents) then you likely do not need to repeat your stress test. If you have documented coronary artery disease and are asymptomatic the same rules apply. After two years, it is okay to start thinking about stress testing again.
Here is where it gets scary so take a moment to digest it. For those who have undergone cardiac catheterization with stenting or coronary artery bypass AND it has been less than two years AND you are truly asymptomatic you do not need a stress test. Two years after stenting or five years after bypass, it is reasonable to start thinking about stress testing again even if you are asymptomatic. As with everything, there are caveats so talk with your doctor.
With Chest Pain and/or an Ischemic Equivalent
I am low risk:
If you are truly low risk then more than likely your chest pain may not be an anginal equivalent. If your EKG looks okay then a treadmill stress test may be in order. If your symptoms are atypical for heart disease, then your doctor may elect not to stress you all together.
I am intermediate to high risk:
Stress testing is in order here if you have never had one. If you recently had a stress test and your symptoms are not changing in frequency or severity, then you can safely wait for the two years that keeps popping up throughout this post.
Are your symptoms really unchanged? The last time I saw you in clinic you could walk 6 flights of stairs before you developed chest discomfort, now you can only walk 4 before developing symptoms.
I tend to err on the side of caution in the intermediate to high risk group. If I have a question about the whether your symptoms are truly stable, then further work-up is probably required.
**Public Service Announcement**
If you are able to walk and your doctor gives you the option to walk on the treadmill either alone or in combination with imaging such as nuclear or echocardiography, you owe it to yourself to do it and try your best. The treadmill provides powerful prognostic information that may help your doctor.
it tells me to visit this page. The page I am on.
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My Cardiologist gave me a nuclear stress test on 4/25/2017 my Primary wants me to have another 5/11/2017 is this safe?
It doesn’t make sense to me for a primary to order a test so soon after a specialist, i would discuss this with your cardiologist prior to proceeding.
Given the large amount of people we have been able to help here, we are starting a twitter to help keep heart patients up to date with advances and relevant information. Mine can be followed at @MustafaAhmedMD
I do have CHF,MITAL PROLAPSE HEART VAVLE AND CHEST PAIN COMES AND GOES
I find Dr. Bookers explanation rather useful.
I hope he can define better what a flight of steps implies, that is, number of steps and hight of each. Perhaps define better walking up a stairway in terms of actual time for the excercise to be meaningful. I mean how fast should one complete de 6 flights of steps or the 4 flight of steps. I currently do 8 flights at a leisure pace since a I have no specific reference time to compare with.
Thank you
I can’t stop worrying about my heart. I am 41. My mother had a heart attack at age 47, then died at 59 of another one. She smoked, was overweight and ate unhealthy.
I am 5’9 and 175 lbs, male, white, quit smoking in 2009. I had a stress echo test done in January 2015, and passed, though they said my heart took a little longer than usual to recover. I also had an ekg done one year ago, in January 2017, and that was normal.
My cholesterol numbers in January 2017 were 165 total cholesterol, 42 HDL, 107 LDL and 82 triglycerides. My blood sugar was in the low or mid 80s. My diet isn’t the best, but I avoid trans fat and I try to walk several times a week. Last March, while walking up a very steep flight of stairs, I noticed I was a little more winded than usual. Now I am paranoid, because of my family history, and plus, I have Frank’s sign, an earlobe crease, in my left ear but not my right one.
Given my cholesterol numbers and EKG were all normal a year ago, and that I passed a stress echo 3 years ago, how concerned should I be? Doctors I talk to seem to just keep saying it’s anxiety. From what i understand, with my numbers, I am at pretty low risk for coronary artery disease. Some reassurance would be nice, I guess, if you can offer any. I can walk 2 miles at a steady without becoming short of breath, which is another good sign. But when i played a little basketball last week, I had to slow a little down because I wasn’t used to it. Thanks!
Its good news that your risk stratification tests place you at low risk. There is nothing to be gained from worrying about things you cant control. Anyone is at risk of a heart event. What we know is that those who pay attention to risk factors – bp, smoking, diabetes, diet, exercise, lifestyle, etc do better. Know your symptoms, and if you develop any go see a Dr in a timely fashion.
you can follow my twitter at @MustafaAhmedMD
7 years ago went to ER with SOB. Admitted and all heart tests were normal. I am now having SOB with exercise, bending over and slight edema. Could I have developed heart issues in the last 7 years or is there unlikely?
I would recommend a cardiac evaluation.
you can follow my twitter at @MustafaAhmedMD
Hi, my cardiologist got my thallium scan done in Feb 2017 and it was OK. Thereafter I have regularly tested my cholesterol A1C and they are normal. Recently the ER doctor got my ECG and Trop I done on the complaint of heaviness in chest and both are OK. Should I get my thallium test repeated.
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This page refers to a “10 year risk” tool but searching for it links only back to this page.
Can you post a specific link?