Kennebec Region Health Alliance

Summary: Stress testing selection and appropriateness can be a source of confusion for ordering providers and when inappropriate, may lead to additional testing, inappropriate care, and cost to the health care system.
When faced with a decision about whether any test is indicated and which type to order, several considerations are important:

1. Screening stress tests in asymptomatic patients should generally be discouraged except in special circumstances:
   1. High risk patients where information would also change management
   2. Specific occupations such as airline pilots
   3. Arrhythmia assessment (long QT syndrome) or Pre-1c antiarrhythmic med therapy
   4. Valve disease evaluation
   5. Follow up 5 years post CABG
2. If the patient has active or suspected symptoms (e.g. chest, jaw, arm, back or epigastric pain or equivalents like nausea, diaphoresis, or dyspnea) stress testing should be considered for patients of intermediate or high risk based on ACC/AHA Risk Guidelines. (see table below)
   
   ACC/AHA Guidelines for Exercise Testing: Executive Summary
   
   Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms1
   
   High indicates >90% risk of CAD; intermediate, 10-90%; low, <10%; and very low, <5%.
   1 No data exist for patients <30 or >69 y, but it can be assumed that prevalence of coronary artery disease increases with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities slightly outside the high or low range.
3. If a stress test is indicated, select type based on stress test algorithm.
   The following algorithm (next page) is provided to serve as a guide to test ordering.
   The example of a patient’s ability to exercise to a high workload is having the ability to walk, do their own shopping/housework unassisted >3-4 minutes (>4 METS).

Reference:
Duke Test: http://www.zunis.org/Duke%20Chest%20Pain%20-%20CAD%20Predictor.htm

Practice Guidelines and Standard Processes Disclaimer
To promote the provision of efficient and effective healthcare services, Kennebec Region Health Alliance helps develop and disseminates practice guidelines for use by its member practices. Such guidelines are based upon various sources that KRHA believes to be reliable, which may include but is not limited to, guidelines from widely recognized professional societies, boards and colleges such as the American Medical Association (AMA). Practice guidelines are reviewed at least every two years and updated as necessary to reflect changes in medical practice.
These practice guidelines are not meant to express standards of care and should not be regarded as evidence of such standards. These Guidelines describe criteria for general operating practice and procedure and are for voluntary use. Guidelines are not a substitute for a physician’s or healthcare professional’s independent judgment.
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