Patient needs stress test

GXT with treadmill

Pharmacologic stress with nuclear myocardial perfusion imaging⁷

Pharmacologic echo⁸

End

Nuclear imaging with stress exercise

Bicycle echo

Stress test criteria

24 hours caffeine free for chemical test. Beta-blocker within 48 hours may reduce sensitivity of chemical stress test.
Two sets of negative cardiac markers.
Patient is able to exercise and has appropriate footwear.
In patients with higher levels of clinical suspicion, consider adding nuclear myocardial perfusion imaging to improve sensitivity.

DEFINITIONS:

¹ Typical angina: (1) Substernal chest pain or discomfort that is (2) provoked by exertion or emotional stress and (3) relieved by rest and/or nitroglycerin

² Cardiac marker timing: based on symptom onset; in cases of uncertainty assume symptom onset at ED arrival

³ ECG normal: no significant ST depression/T wave inversions, BBB, LVH with repolarization, conduction defect, digoxin effect

⁴ Anginal equivalent:

Any symptoms that the physician feels may represent ACS
Exertional dyspnea—most common anginal equivalent symptom

⁵ ACS:

STE-ACS—1 mm ST elevation in 2 leads
NSTE-ACS

NSTEMI—positive cardiac biomarkers
Unstable angina—ischemia with negative biomarkers

NSTEMI—positive cardiac biomarkers
Unstable angina—ischemia with negative biomarkers

⁶ New significant ECG changes:

ST s 0.5 mm; resolve when asymptomatic
ST depression 1 mm in 2 leads
T wave inversion 2 mm in 2 leads

⁷ Regadenoson is preferred agent for chemical nuclear stress test. Technetium Tc 99m tetrofosmin is the preferred tarcer.

Can patient exercise?

Yes

No

ECG normal; absence of DM³

Yes

No

ACS, Acute coronary syndrome; BBB, bundle branch block; DM, diabetes mellitus; ECG, electrocardiogram; echo, echocardiography; ED, emergency department; GTX, graded exercise test; LVH, left ventricular hypertrophy; NSTE, non-ST-segment elevation; NSTEMI, NSTE myocardial infarction; STE, ST-segment elevation; y/o, years old.

Is patient <40 y/o?

Yes

No

Is patient <40 y/o?

Yes

No