DR. ALPERT: Hello, I’m Joseph Alpert. I’m Professor of Medicine at the University of Arizona College of Medicine and Editor-in-Chief of The American Journal of Medicine. I’m here with two of the most distinguished clinical and investigative cardiologists in the United States today: Dr. Ezra Amsterdam and Dr. Robert Harrington. I’m going to let them introduce themselves, and then we’re going to talk about a question that comes up every single day in clinical practice: Do we need to perform exercise stress tests—either routine electrocardiogram (ECG) or the more complex ones with imaging—in patients who are asymptomatic?
Dr. Amsterdam, why don’t we start with you?
DR. AMSTERDAM: I’m Professor of Internal Medicine at University of California—Davis and Associate Chief (Academic Affairs) of the Division of Cardiovascular Medicine, and currently Chair of the writing committee for full revision of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with non-ST-elevation acute coronary syndrome.
DR. HARRINGTON: I’m Bob Harrington. I’m Professor of Medicine at Stanford University and the Chairman of the Department of Medicine. I am also an interventional cardiologist.
DR. ALPERT: We are here today to talk about exercise testing or stress testing, as it’s often called, in patients who are asymptomatic. I participated a few years ago in preparing the ACC/AHA guidelines1 on the evaluation of patients with asymptomatic coronary disease; routine exercise testing in the asymptomatic patient was thought to be a class III indication. In other words, you don’t do it, because the information you get is going to be more confusing and may result in unnecessary further testing that could lead to complications. I always say, as per Alpert’s rule, that a least indicated test is more likely to be complicated and will, in some way, hurt the patient and make both of you feel terrible.
Do both of you agree that one shouldn’t perform routine exercise testing on asymptomatic patients with few, mild, or moderate coronary risk factors?
DR. HARRINGTON: The guidelines tell us that the routine use of an exercise test is not recommended. In fact, as you say, it’s a class III recommendation, which means it’s something we should not do; I agree with that. This recommendation is based on the evidence as it exists today, and I don’t understand why we would promote it in routine clinical practice.
We must consider this when the information garnered from an exercise test is helpful in defining how to approach that patient and what the patient would like to do with their activities?
DR. ALPERT: It’s not an absolute “no”; instead, it’s a “no” with a possible qualified “yes,” depending on circumstances.
DR. AMSTERDAM: I would agree completely with both of you, and I would also say that the answer is “no,” but it’s a qualified “no.” I think that probably even with those qualifications, the emphasis still has to be on class III, because as with many cardiac tests, more are being performed than are actually needed.
Even though there may be an indication, we have to carefully consider what we are going to do with the information and how it will help the patient.
DR. HARRINGTON: I’m an interventional cardiologist, so I see these patients when they’re referred to the catheterization laboratory after an exercise study for diagnostic coronary angiography. I think Dr. Amsterdam said something that is really important: you need to think about what you’re going to do with the information, because now you’re going down a road that leads to decision-making that might have been unnecessary to begin with, and I think we need to keep that in mind.
DR. ALPERT: These are excellent points, and it reminds me of my earlier years when I was a resident. The old-time clinicians used to tell us not to order a test unless we were going to do something about the result. A lot of that attitude has died out today, partly because of defensive medicine and partly because we are now aware that we need to be fully thorough. But, when we start picking up abnormal findings, for example, on routine computed tomography (CT) scans, we start going down a path that we probably don’t want to take, since in most instances, the findings are irrelevant, and it results in a lot of unnecessary testing, which is sometimes harmful to the patient.
DR. AMSTERDAM: I completely agree and I underscore the issue of the use of this information, which leads to the problem of a positive test. We have to be careful that a positive exercise treadmill test is not an automatic indication for cardiac catheterization for asymptomatic or even symptomatic patients.
DR. HARRINGTON: Yes, it’s a really interesting dilemma, isn’t it, Dr. Amsterdam? Here, you see people who are referred for a coronary angiography who have had a positive stress test. As we all know, the positive stress test indicates anything between a low risk to a very high risk. I do think that the caveats brought up by you and Dr. Alpert are the important ones for our audience to consider. You really need to know what you will do with this information.
As I make rounds with the fellows and the house officers, I always ask them to think through their decision-making analysis; if you get a positive result, what are you going to do? If you get a negative test, what are you going to do? Do this before you order further tests. There’s too much of an emphasis on ordering tests, and in many ways, the electronic medical systems have made that easier. You check the box and things happen.
DR. AMSTERDAM: I am a strong advocate of the treadmill test. I think it has important indications and uses. My caveats here are not because I don’t believe in the value of treadmill testing. I believe that, when appropriate and indicated, we should be doing more treadmill tests and fewer stress imaging studies. I think we do too many of the latter tests.