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A cardiac stress test (also referred to as a cardiac diagnostic test , cardiopulmonary exercise test , or abbreviated CPX test ) is a cardiological test that measures the heart's ability to respond to external stress in a controlled clinical environment. The stress response is induced by exercise or by intravenous pharmacological stimulation. Cardiac stress tests compare the coronary circulation while the patient is at rest with the same patient's circulation during maximum cardiac exertion, showing any abnormal blood flow to the myocardium (heart muscle tissue). The results can be interpreted as a reflection on the general physical condition of the test patient. This test can be used to diagnose coronary artery disease (also known as ischemic heart disease) and assess patient prognosis after a myocardial infarction (heart attack). Exercise-induced stressors are most commonly either exercise on a treadmill or pedalling a stationary exercise bicycle ergometer. The level of stre

A stress test may be accompanied by echocardiography. The echocardiography is performed both before and after the exercise so that structural differences can be compared. A resting echocardiogram is obtained prior to stress. The images obtained are similar to the ones obtained during a full surface echocardiogram, commonly referred to as transthoracic echocardiogram. The patient is subjected to stress in the form of exercise or chemically (usually dobutamine). After the target heart rate is achieved, 'stress' echocardiogram images are obtained. The two echocardiogram images are then compared to assess for any abnormalities in wall motion of the heart. This is used to detect obstructive coronary artery disease.

The best known example of a nuclear stress test is myocardial perfusion imaging. Typically, a radiotracer (Tc-99 sestamibi, Myoview or thallous chloride 201) may be injected during the test. After a suitable waiting period to ensure proper distribution of the radiotracer, scans are acquired with a gamma camera to capture images of the blood flow. Scans acquired before and after exercise are examined to assess the state of the coronary arteries of the patient. Showing the relative amounts of radioisotope within the heart muscle, the nuclear stress tests more accurately identify regional areas of reduced blood flow. Stress and potential cardiac damage from exercise during the test is a problem in patients with ECG abnormalities at rest or in patients with severe motor disability. Pharmacological stimulation from vasodilators such as dipyridamole or adenosine, or positive chronotropic agents such as dobutamine can be used. Testing personnel can include a cardiac radiologist, a nuclear med

The American Heart Association recommends ECG treadmill testing as the first choice for patients with medium risk of coronary heart disease according to risk factors of smoking, family history of coronary artery stenosis, hypertension, diabetes and high cholesterol. In 2013, in its "Exercise Standards for Testing and Training", the AHA indicated that high frequency QRS analysis during ECG treadmill test have useful test performance for detection of coronary heart disease. Perfusion stress test (with 99mTc labelled sestamibi) is appropriate for select patients, especially those with an abnormal resting electrocardiogram. Intracoronary ultrasound or angiogram can provide more information at the risk of complications associated with cardiac catheterization.

The common approach for stress testing by American College of Cardiology and American Heart Association indicates the following: Treadmill test: sensitivity 73-90%, specificity 50-74% (Modified Bruce protocol) Nuclear test: sensitivity 81%, specificity 85-95% (Sensitivity is the percentage of people with the condition who are correctly identified by the test as having the condition. Specificity is the percentage of people without the condition are correctly identified by the test as not having the condition). To arrive at the patient's post-test likelihood of disease, interpretation of the stress test result requires integration of the patient's pre-test likelihood with the test's sensitivity and specificity. This approach, first described by Diamond and Forrester in the 1970s, results in an estimate of the patient's post-test likelihood of disease. The value of stress tests has always been recognized as limited in assessing heart disease such as atherosclerosis, a c

Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care. Some estimates show that such screening accounts for 45% of cardiac stress imaging, and evidence does not show that this results in better outcomes for patients. Unless high-risk markers are present, such as diabetes in patients aged over 40, peripheral arterial disease; or a risk of coronary heart disease greater than 2 percent yearly, most health societies do not recommend the test as a routine procedure. Absolute contraindications to cardiac stress test include: Acute myocardial infarction within 48 hours Unstable angina not yet stabilized with medical therapy Uncontrolled cardiac arrhythmia, which may have significant hemodynamic responses (e.g. ventricular tachycardia) Severe symptomatic aortic stenosis, aortic dissection, pulmonary embolism, and pericarditis Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction Decompen

Side effects from cardiac stress testing may include Palpitations, chest pain, myocardial infarction, shortness of breath, headache, nausea or fatigue. Adenosine and dipyridamole can cause mild hypotension. As the tracers used for this test are carcinogenic, frequent use of these tests carries a small risk of cancer.

Pharmacologic stress testing relies on coronary steal. Vasodilators are used to dilate coronary vessels, which causes increased blood velocity and flow rate in normal vessels and less of a response in stenotic vessels. This difference in response leads to a steal of flow and perfusion defects appear in cardiac nuclear scans or as ST-segment changes. The choice of pharmacologic stress agents used in the test depends on factors such as potential drug interactions with other treatments and concomitant diseases. Pharmacologic agents such as Adenosine, Lexiscan (Regadenoson), or dipyridamole is generally used when a patient cannot achieve adequate work level with treadmill exercise, or has poorly controlled hypertension or left bundle branch block. However, an exercise stress test may provide more information about exercise tolerance than a pharmacologic stress test. Commonly used agents include: Vasodilators acting as adenosine receptor agonists, such as adenosine itself, and dipyridamole

The stress test does not detect: Atheroma Vulnerable plaques The test has relatively high rates of false positives and false negatives compared with other clinical tests.

Increased spatial resolution allows a more sensitive detection of ischemia. Stress testing, even if made in time, is not able to guarantee the prevention of symptoms, fainting, or death. Stress testing, although more effective than a resting ECG at detecting heart function, is only able to detect certain cardiac properties. The detection of high-grade coronary artery stenosis by a cardiac stress test has been the key to recognizing people who have heart attacks since 1980. From 1960 to 1990, despite the success of stress testing to identify many who were at high risk of heart attack, the inability of this test to correctly identify many others is discussed in medical circles but unexplained. High degrees of coronary artery stenosis, which are detected by stress testing methods are often, though not always, responsible for recurrent symptoms of angina. Unstable atheroma produces "vulnerable plaques" hidden within the walls of coronary arteries which go undetected by this t