How Often Should I Have a Stress Test?

By Julian Booker MD

As is my usual practice with blog entries, I try to give disclaimers. These disclaimers are designed to protect YOU!!

1. 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.
2. Your clinical situation is unique. This blog is an incomplete collection of generalized recommendations that might not be appropriate for every given scenario.
3. Stress testing is safe but not without risk
4. 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.

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