Stress test vs flipping a coin: which is more accurate?

1 Mar

by Carolyn Thomas  @HeartSisters

You may not have any signs or symptoms of coronary artery disease while you are just sitting there quietly reading this post. In fact, your symptoms may occur only during exertion, as narrowed arteries struggle to carry enough blood to feed a heart muscle that’s screaming for oxygen under increased demand. Enter the diagnostic stress test, used to mimic the cardiac effects of exercise to assess your risk of coronary artery disease.

During stress testing, you exercise (walk/run on a treadmill or pedal a stationary bike) to make your heart work harder and beat faster.  An EKG (also called ECG) is recorded while you exercise to monitor any abnormal changes in your heart under stress, with or without the aid of medications to enhance this effect.

But consider this blunt warning from Dr. Kevin Klauer:  

“Exercise treadmill stress tests certainly aren’t perfect. Very few of our tests are. The key is not to consider their results in isolation. 50% of women and 25% of males with reversible perfusion defects detected by nuclear stress tests had a ‘normal’ exercise treadmill tests.”

Hoilund-Carlsen, P.F. et al, Am J Card 95:96, January 1, 2005

Dr. Klauer adds that despite clear clinical guidelines about using stress tests, concern and confusion apparently exist among physicians, according to his Special Report: The Truth About Stress Tests that he co-authored for the journal, Emergency Physicians.

For instance, he cites guidelines from the National Institute for Health and Clinical Excellence that state:

“Do not use exercise EKG to diagnose or exclude stable angina* for people without known coronary artery disease.”

Cardiologist Dr. Richard Fogoros also explains another potential limitation to the exercise stress test:

“The stress test can only help to diagnose coronary artery disease (CAD) that is producing partial blockages in the arteries – so-called obstructive CAD. But CAD often produces plaque in the arteries that may not actually be causing obstruction, and these non-obstructive plaques can (and do) rupture, causing acute blood clot formation, which produces an acute obstruction of the artery, often leading to myocardial infarction (heart attack).

“So it is certainly possible to have a ‘normal’ stress test while still having CAD.

“In some patients, EKG changes can occur even in the absence of CAD. (In other words, ‘false positive’ stress tests are not uncommon.) In other patients, no significant EKG changes are seen even in the presence of CAD. (So ‘false negative’ stress tests can be seen.)

False positive and false negative studies can significantly limit the usefulness of the stress test in many patients.

“By adding a nuclear perfusion study to the stress test, this limitation may be minimized, and the diagnostic capacity of the stress test is greatly improved.”**

It almost seems counter-intuitive, but preventive cardiologists like Dr. Seth Baum confirm that most heart attacks actually happen in what is called non-obstructive CAD (i.e. in vessels that are less than 70% blocked). He adds: 

“This actually is one of the reasons why stress testing is such a bad screening test.

“Stress tests detect lesions that are greater than 70%. If an individual has multiple 50% blocked arteries, you’re going to miss that on a stress test, yet that individual is likely at significant risk for a future cardiovascular event.”

And speaking of both false positive and false negative results, Kentucky electrophysiologist and writer Dr. John Mandrola has this to say about cardiac stress tests:

“Many non-cardiac conditions can cause the heart to look as though it is having trouble when it is actually not – things like abnormal electrolytes, fluctuations in blood pressure, breathing too fast, and certain medications. Not surprisingly then, false positive stress tests are a common problem.

“The opposite problem also occurs. False negatives happen when the stress test fails to reveal a potentially dangerous blockage. The supply/demand challenge of stress tests only identifies major blockages. But, the vexing way heart disease works is that most often it is the minor – not major – blockages that cause heart attacks or sudden death. Stress tests can’t see these minor blockages.

“The next sentence is not a typo: You can pass a stress test and have a major heart attack the next day.”

And cardiologist Dr. Martha Gulati, director for preventive cardiology and women’s cardiovascular health at the Ohio State University Medical Center, warns:

“What is surprising is the fact that all the research that describes stress testing, and that has gone on for more than 40 years, was done only on men.”

More recently, some researchers who have specifically studied accuracy in stress tests for female patients have made some interesting observations unique to women. For example:

  • In pre-menopausal women, EKG results taken during exercise appear to vary with the women’s menstrual cycles. (2)
  • Post-menopausal women receiving oral estrogen therapy are more likely to have exercise-induced EKG changes than post-menopausal women who aren’t on estrogen replacement(3).
  • Women are generally older when they undergo stress testing and may have decreased exercise tolerance, limiting the ability to accurately identify women with coronary artery disease (4)

Here’s how the National Heart Lung & Blood Institute lists the most common types of stress tests (and for a glossary of cardiac terminology, visit my patient-friendly, jargon-free glossary of cardiology terms and abbreviations):

  • Exercise echocardiogram or exercise stress echo
  • Exercise test
  • Myocardial perfusion imaging
  • Nuclear stress test
  • PET stress test
  • Pharmacological stress test
  • Sestamibi stress test
  • Stress EKG (or ECG)
  • Thallium stress test
  • Treadmill test

One of the most serious concerns about tests that are commonly used despite  important diagnostic accuracy issues is that, as in my own case when first presenting to the Emergency Department, an initial “normal” test may lead to misdiagnosis.

No further tests will be ordered.

Physicians like Duke University’s Dr. Pamela Douglas call this phenomenon “verification bias”.  As she warned in her editorial called  “Is Non-invasive Testing for Coronary Artery Disease Accurate?” in the journal Circulation:(5)

“Patients with positive tests are more likely to have their results verified with further testing, while those with negative tests are rarely referred for subsequent studies. False-negative results are unlikely to be discovered, and true-negative results will be less likely to be confirmed and therefore will be underrepresented.

“For every cardiovascular non-invasive test analyzed for the effects of verification bias (exercise ECG, exercise thallium, exercise radionuclide angiogram, and exercise echocardiography), results are similar, according to research by Roger et al.

“No type of test escapes this verification bias effect.”

Dr. Douglas then added that, in populations with sex-based differences in disease prevalence and extent, there will be sex-based differences in the accuracy of test results:

“This suggest that test results must be analyzed in a sex-specific fashion and that the decision to proceed to the anatomic gold standard of angiography must take into account sex-based differences in measures of test accuracy.”

The journal Emergency Physicians Monthly offers this straightforward conclusion:

“The stress test is the elemental unit of diagnostic cardiology, and patients know of stress tests all too well. Unfortunately, both doctors and laypeople have been taught and trained wrong.

“I, for instance, was trained to believe in the general utility of stress testing. This was wrong. I was taught to obtain a stress test history, and to be comforted by normal results. Also wrong. I was taught to believe in the power of stress tests to establish safety and identify disease in low risk chest pain patients before they leave the hospital. Wrong.

“Sensitivities and specificities for stress tests are often reported as being between 70% and 90%, but these numbers are misleading. Studies of stress tests have rarely used a proper gold standard (i.e. coronary angiography), and in the one reasonably sized, high quality study to be performed rigorously, the test’s sensitivity for coronary stenosis was only 45%.”

.* stable angina: chest pain or discomfort that comes on with exertion and lessens during rest, due to poor blood flow through narrowed or blocked coronary arteries
See my glossary for no-jargon, patient-friendly definitions of cardiac terminology

(1) Hoilund- Carlsen, P.F. et al. Usefulness of the exercise electrocardiogram in diagnosing ischemic or coronary heart disease in patients with chest pain. Am J Card 95:96, January 1, 2005
(2) Grzybowski A et al. How to improve noninvasive coronary artery disease diagnostics in premenopausal women? Am Heart J. 2008;156:e961–e965
(3) Morise AP et al.  The specificity of exercise electrocardiography in women grouped by estrogen status. Int J Cardiol. 1997;60:55–65
(4) Mieres JH et al.  Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease. American Heart Association. Circulation. 2005;111:682–696.
(5) Douglas PS: Is Noninvasive Testing for Coronary Artery Disease Accurate? American Heart Association.  Circulation. 1997; 95: 299-302 doi: 10.1161/01.CIR.95.2.299

Q: Have you ever had a “normal” stress test despite being later diagnosed with heart disease, as I was?

See also:




97 Responses to “Stress test vs flipping a coin: which is more accurate?”

  1. Kimberly December 2, 2018 at 6:52 pm #

    My mom had a nuclear stress done week ago. She continues with shortness of breath and now needing oxygen at all times. Says her heart feels funny that some shortness of breath and just walking to bathroom. Heart rate is elevated at times. It beats fast and skips a beat what could this be? They keep diagnosing her with COPD, lungs are clear and no test has been done. Her breathing is getting worse with tightness in chest then heart rate drops but it stays over 109-144.


    • Carolyn Thomas December 4, 2018 at 4:49 am #

      Hello Kimberly – your mom’s symptoms sound frightening, and it’s distressing to watch our mothers suffering. I’m not a physician so I’m unable to comment on her specific case. There are so many possible reasons for her symptoms. It sounds like she has been already diagnosed with COPD – Mayo Clinic has some useful information about this diagnosis that may be reassuring. Best of luck to you and to your mother …


  2. Kim November 17, 2018 at 8:47 pm #

    My mom has been having shortness of breath with exertion. If she walks short distance and even taking a shower. Family doctor treatment was for COPD which has never been confirmed. I made her a cardiologist appointment and echocardiogram was done and nuclear stress test. First scan was without medication and they put oxygen on her because they noticed shortness of breath. Second test with medication in IV without oxygen she seemed fine. She was done with test and walked down long hallway to leave, was able to get in car. No shortness of breath after medication was given. Had no shortness of breath for 45 minutes and stopped at a store and she had to sit down and catch her breath before using bathroom. Her doctor didn’t understand why her breathing was better it should have been worse with this test. Nuclear stress test came back negative for blockages. Now he wants to do lung test. My gut still says it’s a cardiac issue. What should we do next. Demand catheterizaton to be sure.

    Liked by 1 person

    • Carolyn Thomas November 18, 2018 at 5:06 pm #

      Hello Kim – I’m not a physician so cannot comment specifically on your mom’s unfortunate shortness of breath symptoms but I can tell you generally that shortness of breath is a symptom in a number of both lung and cardiac conditions.

      So much of medicine is simply trying to figure out what the problem is NOT, which is likely why the lung tests are being recommended. Not sure where you live, but where I am, patients cannot just “demand” catheterizations – a cath is an invasive procedure with some inherent risks which is why it’s not done as a routine screening tool. Your mother may have undergone pulmonary function tests as one way to confirm COPD diagnoses; if not, that could be why this is being ordered now. Best of luck to you and your mother…


  3. John H May 13, 2018 at 11:59 pm #

    I went to the hospital twice in 2016 with Chest, left arm pain. Light headedness. Had all the routine testing done. Blood work, EKG, echocardiogram, stress test. Then in January 2017 had a nuclear stress test. Followed up after that test with my Cardiologist on Feb 7 2017 and was told.. “you did great, I can’t believe you smoke because you did so well, you did 11 minutes on the treadmill and reached good numbers that we needed with no problem. I don’t see any cardiac issues so I’ll see you in a year unless you have any problems.”

    Well one week later on Valentine’s Day I had a heart attack in the shower. Find out I had 4 blockages at 30,70,90 and 100% with collaterals. Day later had a triple bypass at 52 years old.

    So to me, I wouldn’t ever trust a stress test not because they missed it, but because the person reading it missed it!! So maybe it’s lack of training or lack of taking it serious that’s the problem and not the test itself. Another Cardiologist “off the record” said they would have never read it as a normal study and it looked like I had damage from a prior event.

    My opinion is to Demand a heart cath if you feel you have a problem.


    • Carolyn Thomas May 14, 2018 at 2:18 pm #

      What a shocker that must have been, John! It is actually not uncommon for a heart attack to follow a ‘normal’ stress test – the culprit is usually the soft vulnerable plaques that can rupture suddenly and cause a major blockage, yes – even after everything looks perfectly “normal” on the EKG.

      And it’s relatively easy, in hindsight, for that cardiologist who offered you the off-the-record diagnosis, after the fact, to get it right the second time!


  4. Kim May 13, 2018 at 3:31 pm #

    I was told if my next echocardiogram numbers aren’t down I get no kidney transplant, is there anything I can do to help numbers go down? They say I have pulmonary hypertension.


    • Carolyn Thomas May 13, 2018 at 6:15 pm #

      Hello Kim – I’m not a physician so can’t comment on the specifics of your own case. Please contact your physician or kidney specialist to review all aspects of your condition and possible related treatments. I wish I could be more helpful during this stressful time for you…


  5. Liz Beall (@wildchildhood) April 12, 2018 at 1:44 pm #

    Hi Carolyn, I just found this thread looking for information on coronary artery disease and stress tests. I hope you still see these replies! I’m a 41 year old woman who just got the results of my nuclear stress test — it showed a small “anteroseptal perfusion defect” which my family doc says could be evidence of a previous heart attack.

    I had the test because about three weeks ago, I had an “episode” of intense nausea and radiating jaw pain, followed by a day or so of shortness of breath. I was at a conference, and didn’t think “heart attack” until I got home and my husband remarked that the symptoms sound like those described by women who experience CAD. All the symptoms resolved, and I feel well again – but clearly something happened, and my primary worry now is whether or not I’m a ticking time bomb. Despite a normal weight, a whole foods diet and a regular regimen of walking/hiking every day, I have familial HBP, a high heart rate, and two parents who had heart attacks before age 65 – so despite my age, I do have serious risk factors.

    I’m assuming, from these results and my risks, that the logical next step would be to get an angiogram ASAP to check for blockages.

    Now here’s the rub – my cave-dwelling county health provider has approved an appointment with a cardiologist – IN JULY, almost 3 months from now.

    Am I wrong in thinking it is MUCH more urgent than that?

    Liked by 1 person

    • Carolyn Thomas April 13, 2018 at 9:03 pm #

      Hi Liz – I’m not a physician so cannot comment specifically on what your distressing episode of symptoms meant three weeks ago, but I can say, generally speaking, what a wise cardiologist once told me: “It’s hard to improve on symptoms that aren’t there.”

      In other words, you seem to be feeling fine now, and it also seems that you’re already doing everything that women are advised to do if they were diagnosed with a confirmed heart condition and thus considered to be at risk. If you were seeing a cardiologist tomorrow instead of 3 months from now, I’m betting that this cardiologist would advise you to eat a heart-smart diet, exercise every day, maintain your healthy weight, etc. – as you are already doing. Possibly take a daily aspirin – maybe, maybe not?

      It’s unfortunate that you’re now feeling like a “ticking time bomb” (I hate that metaphor – as it provokes worry-related ongoing stress hormones like cortisol and adrenaline that are bad for your heart health). What sounds encouraging to me is that you’re able to go hiking/walking every day without provoking angina symptoms (angina typically worsens with exertion, goes away with rest).

      Unfortunately I can’t tell you if you should be getting an angio ASAP or not, or whether you’re wrong in thinking this case is urgent (and it’s good to keep in mind that angio is not a benign procedure – it is invasive and carries potential risk to the patient, which is why it’s not the first line of diagnostic test ordered in asymptomatic people).

      What I can add is that IF your symptoms recur, then that is the time the needle moves to urgent. Best of luck to you…


  6. Casey January 21, 2018 at 1:01 pm #

    Hi, Carolyn. Hopefully you are still responding to comments on this post. I understand you are not a physician; I am simply just looking for your opinion as you have extensive knowledge with cardiology.

    I am a 27 y/o female; overweight; borderline-high cholesterol; great blood pressure (110/65); no diagnosis of diabetes; minor family history of heart disease.

    I recently saw a cardiologist due to on-and-off mild chest pain. An echocardiogram was performed and was normal. The doctor then ordered an exercise stress test.
    I could not complete the stress test due to shortness of breath. The nurse practitioner performing the test increased the speed and incline twice and then asked me if I would be ok with another increase and I said no. The test was stopped shortly after and I asked her if I was short of breath because I am out of shape and she said yes. She said everything looked great and to follow-up as needed, such as if symptoms persisted or got worse. I’m not sure if she said it to make me feel better or not, but she said she pushed me harder than normal. Which doesn’t make sense to me because why would she ask me about another increase then? I normally don’t get short of breath on a daily basis, such as normal walking or walking up the stairs in my home, which I’m assuming is a good thing.

    What are your thoughts on this? Any feedback is appreciated. God bless and take care.


    • Carolyn Thomas January 21, 2018 at 4:19 pm #

      Hi Casey – YES, you knew what I was going to say (“I’m not a physician…”)

      I can say generally however that it’s not unusual for people who are “out of shape” to become short of breath on a treadmill. That’s to be expected. Higher exertion when increasing both speed and incline induces shortness of breath far more than simply normal walking or going upstairs would. My only feedback is to try this experiment: see what you can do to get into better shape (e.g. do regular – daily – sweat-producing activities that will raise your heart rate (like walking as quickly as you can up a hilly street in your neighbourhood every day). Do a bit more each day and you’ll find it will gradually become easier with far less huffing and puffing. Check with your GP first if you are nervous about doing so, but there is generally no downside in getting into better shape especially at your young age. In fact, moderate exercise (not just slow walking, for example) has been shown in many studies to improve longterm cardiovascular health even more than implanting a stent. Good luck to you…


  7. Kimberly Medeiros November 11, 2017 at 8:35 pm #

    I am very confused with my nuclear stress test, when I got there they put in an IV, pushed in the dye made me drink 2 glasses of water took a couple pics then hooked up everything on me, I then got on the treadmill it wasn’t to difficult my legs hurt a bit because I have PAD. After a couple minutes they asked if I could make it 1 more minute that I was almost to my peak I said yes, the whole thing lasted maybe 4 minutes, then they took everything off, gave me a drink and took a couple more pics, the next day the nurse left a voice mail saying everything looked good come back in 4 months, after several calls I finally managed to get a copy of my test, it says I asked them to stop the test because I was out of breath, that’s a lie, the test also called for the stuff they use to speed up your heart but I never got that because they said I reached my peak, in 4 minutes at a medium walk, that doesn’t make sense, I’m 52 average weight , female, I have chest pains almost everyday, get dizzy can’t breath and pulse races for no reason, I’m very confused


  8. Gerald Jeffrey September 29, 2017 at 10:59 am #

    I had a stress ECG and reached the required level for my age and was given the all clear. One hour later, I had a Heart Attack. I was then given a Angiogram which showed a right Major Coronary Artery was blocked. I had a stent fitted and later that day sent home.
    Scary stuff.

    Liked by 1 person

    • Carolyn Thomas September 29, 2017 at 7:26 pm #

      ONE HOUR LATER!?! Gerald, that is an amazing example of how ‘passing’ an ‘all clear’ stress test doesn’t necessarily mean you aren’t on the brink of a heart attack! Hope you are doing much better these days…


  9. Virginia May 2, 2017 at 12:10 pm #

    Hi, I just had a stress test performed today. My doctor suggested another stress test because she was concerned that my heart rate did not decrease enough when I was at rest. My questions: is a second test with dye necessary and can anxiety cause my heart rate to not decrease? By the way I’m 56 – I think I’m post menopausal at this point.


    • Carolyn Thomas May 4, 2017 at 2:08 pm #

      Hello Virginia – I’m not a physician so can’t address your specific question about the necessity of that second stress test. I can say generally that anxiety could cause an increased heart rate, but your physician would be the best person to discuss these questions with. Best of luck to you…


  10. John March 30, 2017 at 8:01 am #

    Had a nuclear stress test late January 2017. Sat with cardiologist on February 7th 2017 and he said I have no cardiovascular issues. That my problem may be GI related. One week later on February 14th I went to hospital with moderate heart attack. Heart catheter showed all 4 arteries were blocked at 30, 70, 90 and 100 percent!! And yes I’m only 52 years old.
    Had triple bypass done on February 16th. What good is a stress test when it doesn’t pick up those blockages? Or maybe it’s not the test but the person reading it.


    • Carolyn Thomas March 31, 2017 at 6:17 am #

      John, you’ve captured the key frustration in relying on stress tests as sole predictors of future cardiac events because of the nature of soft, vulnerable coronary artery plaque – the kind that can rupture and cause sudden blockages. As this post explains: “Non-obstructive plaques can (and do) rupture, causing acute blood clot formation, which produces an acute obstruction of the artery, often leading to myocardial infarction (heart attack). So it is certainly possible to have a ‘normal’ stress test while still having coronary artery disease.”


  11. Debra Brackeen October 23, 2016 at 7:01 am #

    In May of 2016 I suffered a Stress Induced Cardiomyopathy Heart Attack.😥 After spending 9 days in the hospital, I was sent home and told to do cardiac rehab. As of 10/2016 all my EKGs are normal and my ejection fraction went from 10% of the left ventricle to 50% of the left ventricle. A stress test was never done. My Dr. changes the subject when I tell him I’m still not feeling well. Neck pain, shoulder pain, fatigue, stomach pain!! Don’t know what direction to go…. 😥


    • Carolyn Thomas October 23, 2016 at 7:46 am #

      Hi Debra – I’m not a physician so cannot comment specifically on your own situation, but I can tell you generally that Takotsubo Syndrome (I believe that’s what you’re talking about when you say stress-induced cardiomyopathy) is a challenging diagnosis at the best of times.

      Although symptoms can exactly mimic those of heart attack, it’s very different from heart attack in a couple of ways. Most heart attacks are due to blockages/blood clots forming in the coronary arteries that can cause heart muscle cells to die, leaving the heart with permanent and irreversible damage. But the heart muscle cells in most patients with stress cardiomyopathy are only temporarily stunned (as illustrated by your EF drop to 10%) and, as also in your case, usually return to normal function (50%) shortly after the episode. Virtually all Takotsubo patients appear to have normal coronary arteries with no blockages or clots.

      Because the heart muscle is not permanently damaged with this syndrome, patients typically make a complete recovery. I wrote more about this syndrome here. Your symptoms sound distressing and should be addressed whether they are heart-related or not. If your doctor “changes the subject” when you want to discuss symptoms, you might want to change doctors. Seek a second opinion to discuss medications like diuretics or others that help to address heart muscle contraction and/or abnormal heart rhythms just to rule out these issues. Best of luck…


  12. Faye Wilson October 6, 2016 at 3:57 pm #

    False negative. 10 months later main artery is 90 some percent obstructed. 2 stents and minor heart damage. High cholesterol for decades. severe neck pain and spasms. Yet not ONE physician suggested it could be my heart although my medical history shows my dad having 2 open heart surgeries and died needing a third. .so very frustrating! Increased faith in the medical world. ..indeed!


    • Carolyn Thomas October 6, 2016 at 4:04 pm #

      Sorry you’ve had to go through all this, Faye. Frustrating for sure. Hope you are feeling better day by day (and also that you were referred to cardiac rehabilitation after hospital discharge). Best of luck to you…


  13. Cassidy T. September 11, 2016 at 3:34 pm #

    I’m a 25 y/o female; about 3 months ago I developed upper abdominal and chest pain along with nausea/loss of appetite. After it being consistent for a few weeks, I went to urgent care. They ordered an EKG, chest x-ray and blood work, all of which came back normal. Fast-forward a few weeks, I followed up with my PCP who referred me to a GI specialist. He ordered a CT scan of my abdomen with and without contrast, which surprise surprise, came back clear. Went back to my PCP who referred me to a cardiologist (I actually saw the nurse practitioner at the clinic). The first visit was mostly talking/history-taking. An EKG was performed which she said was normal. Because of my age and risk, there weren’t many tests she was able to order, but she said she would be able to do an exercise stress test if I wanted. She warned me that with young women, most of the time the test shows abnormalities (I asked why and she said she honestly wasn’t sure). So she said that we could do the test but if there were any abnormalities, we may need to go down a road of further testing we may not need to (if it ended up being a false-positive). So I agreed and did the test. I think they got my heart rate up to 170 something I believe and the only issue I had with the test was being a little out of breath (which isn’t out of the ordinary as I’m not much of an exerciser and I’m a bit overweight), but nothing significant where I couldn’t complete the test, and I also sweated a good amount. To my surprise, the nurse practitioner said she saw no abnormalities and she really didn’t have an answer for me regarding the chest pain. I know I’m young and a female, but heart attacks/heart disease isn’t all that uncommon for my gender at my age. I forgot to mention that I have normal blood pressure, never smoked a day in my life but my cholesterol is slightly elevated. I know you’re not a physician, but do you think this chest pain is something I should be concerned about?


    • Carolyn Thomas September 11, 2016 at 6:55 pm #

      You’re right, Cassidy – I’m not a physician so cannot comment on your specific symptoms. I can say, however that heart attacks in women your age are actually NOT common at all. The reason that dramatic stories about women in their 20s having heart attacks are widely covered is that they are so statistically rare. The average age of a woman having a heart attack is 70. Consider that about 435,000 women in the U.S. have heart attacks annually; of these, only 35,000 are under 55, and the number under 30 is even lower. So what should you do? You can continue to worry, or you can do what every woman diagnosed with heart disease, young or old, is told: make every cardioprotective lifestyle change you possibly can, starting with losing weight and starting to build in regular exercise every day. There is simply no downside in living life as if you were at very high risk of heart disease – even if you’re not. You could also start keeping a symptom journal: write down the time of day, description of symptom, and what you were doing/eating/feeling in the hours beforehand, even the weather or anything that might influence such symptoms. See if you can spot a pattern. You might also be reassured by knowing that over 85% of people admitted to hospital for chest pain turn out to have non-heart-related issues. Here’s a bit more on other possible reasons for chest symptoms. Best of luck to you…


      • Cassidy T. September 12, 2016 at 8:02 am #

        Hi, Carolyn. I appreciate your reply. Your statistics put me a bit at ease. But the fact that heart attacks at and around my age (while rare) can and do happen, that’s what makes me nervous. My biggest fear is that I somehow had/am having a silent heart attack(s) and the EKGs and stress test isn’t somehow picking it up. Maybe I’m just being paranoid, but it’s said that 2/3 of EKGs miss a heart attack, and young women are especially hard to diagnose. What are your thoughts on this?


        • Carolyn Thomas September 12, 2016 at 10:46 am #

          Hi again Cassidy. I think you already know my thoughts on this. Again, I’m not a physician so have no clue if your symptoms are heart-related or not, but it seems that you do have a choice here: you can continue trying to convince yourself that you’ve been having a heart attack for three months, making yourself anxious and preoccupied and basically ruining your quality of life, or you can try to reduce the anxiety by not obsessing. A “silent” heart attack has few if any symptoms at all, which is why it’s considered silent. Ironically, chronic ruminating as you describe can actually be dangerous to your heart health. And while it’s true that EKGs may not always be accurate in confirming heart disease, they are simply one diagnostic tool in the large toolbox of cardiac tests you’ve had so far. Please read this or this to see if any of it fits for you.

          Liked by 1 person

          • Cassidy T. September 12, 2016 at 1:16 pm #

            Both are great articles, but none of them really fit me. I of course don’t want to be diagnosed with a heart attack or heart disease, it’s really just me saying, “I know something’s wrong with my body and I’m amazed that tests aren’t showing anything.” Don’t get me wrong, I am very, very thankful for negative results. I read a bit on your history, could you tell me more about your heart attack? When you were misdiagnosed the first time with acid reflux, did they do an EKG at the hospital? And when you say your symptoms got worse over a few weeks, what exactly got worse? Like, what was it that made you say, “I know something isn’t right.” and go back to the hospital? Sorry if I’m being annoying, you just don’t know how good it feels to hear a voice. I try and talk to my husband and family and they aren’t any help at all and say, “it’s all in your head.”


            • Carolyn Thomas September 12, 2016 at 3:45 pm #

              Cassidy, I feel uncomfortable being asked to continue reinforcing your conviction, despite all evidence to the contrary, that you are in the middle of an undiagnosed heart attack. Again, I’m not a physician, and based on results here, nothing I’m saying seems to be acceptable to you unless I can somehow confirm your insistence that your symptoms are heart-related. I really hope they’re not, and that one of the many other possible non-cardiac reasons for your symptoms will emerge to put your mind at rest. Please see your family physician to review all your symptoms.

              Liked by 1 person

              • Cassidy T. September 12, 2016 at 4:14 pm #

                Sorry if I gave you that impression. I wasn’t asking you to continue to reinforce my conviction. I understand you’re not a physician. I never said you were and I even stated that I know you’re not. As I mentioned, I’ve already gone and seen my physician. I thought it would be nice to get an outside opinion and hear ideas from someone who’s actually gone through this experience. You have all of these articles (and a whole website) regarding heart attacks, etc, so I figured you would have a little knowledge from your personal experience and research. My apologies. Take care and best of luck to you in the future.


                • Carolyn Thomas September 12, 2016 at 4:33 pm #

                  I already did share several “ideas” with you, Cassidy, none of which you seem interested in (e.g. try keeping a symptom journal to see if you can detect a pattern, here’s a list of dozens of non-cardiac conditions that can also cause chest pain, etc. etc.) And yes I do have some knowledge I’ve gained from researching this specific topic for the past eight years (which is exactly why I know for a fact that NOT all chest pain means a heart attack) but I’m not a physician so couldn’t possibly diagnose you or anybody else online. It seems you might not be quite ready to entertain any other reason for your symptoms than the one and only one you have convinced yourself must be true for you. I know you’ve seen your family physician already, but if your medical team doesn’t suspect your heart, then it’s time to go back and discuss what else might be causing these symptoms, especially if they continue or worsen. I believe there’s nothing more I could tell you to encourage you to be open to all possible options. Good luck…


  14. Janice Rogers August 21, 2016 at 9:18 pm #

    As important as an accurate testing for heart disease is, why should insurance companies not be liable to allow heart MRI’s as the standard testing instead of these antiquated stress tests?


    • Carolyn Thomas August 22, 2016 at 5:46 am #

      Hi Janice – like all cardiac diagnostic tests, MRI is more accurate than other tests for certain heart conditions, but less accurate for others. It’s also a costly test that takes a long time, so those too are likely factors in deciding if it should become the ‘standard’. I’m a Canadian so can’t speak for U.S. insurance companies – but really, who can?


  15. Rosemarie June 15, 2016 at 9:57 am #

    My mommy years ago had a stress test, her Doctor just said live your life, then years later she moved away gained more weight then had another new Doctor give her a stress test saying she has 60% plaque in her heart, Surgeon in Boston saying only 40% in her heart, that the Doctor was wrong, then her Doctor gives her another stress test telling her she’s worse?????? As she has been on 3 blood thinners one is a blood pressure med and a cholesterol pill this past year, how can it be worse???????? 😢


    • Carolyn Thomas June 15, 2016 at 3:30 pm #

      Hello Rosemarie,
      Your mother’s experience is an example of how tricky stress tests can be. I’m not a physician so cannot comment on her specific case, but I can tell you generally that a cardiac stress test is designed to indicate a higher risk of coronary artery disease in people who have symptoms (typically caused by a blockage of at least 70%) but the test is not able to provide a clear percentage of the size of the blockage. Usually we wouldn’t even feel any symptoms unless a coronary artery was more than 70% blocked, nor do current cardiac guidelines generally recommend invasive treatment for a blockage smaller than 70% (medications only would likely be the most appropriate treatment choice). Your mother needs to sit down with her physician and get a careful explanation of what is and is not happening. Best of luck to her…


  16. Freelander February 4, 2016 at 1:55 pm #

    “Stress test v flipping a coin: which is more accurate?” is currently a spot on topic for me. I had an angiogram two years ago after two CPET tests were stopped due to S-T depressions of concern to the exercise cardiologist. I have been an athlete (an enthusiast) and healthy eater throughout my adult life (now 66) and continue to exercise daily at aerobic and anaerobic levels, 12 – 16 hours/week. A strong heart is vital to me. I take BP and cholesterol lowering meds. The angiogram showed several narrowings from 55-90%. In short, the cardiologist recommended revascularization by CABG (coronary artery bypass surgery).

    Interestingly, I experienced few, if any symptoms during exertion. It was hard to be excited about CABG which did and does not appeal to me. Plus, there is no guarantee that the S-T depression during vigorous exercise would go away after the invasive surgery. I went cross country to meet with an especially renown cardiologist. After viewing my tests, he ordered a stress echo. The stress echo showed no abnormalities in my heart wall motion, all was normal. His recommendation was that the stress echo ‘trumped’ the CPET, and that my collaterals must have found a way to keep the heart working well normally while under stress. His advice was to keep with the active exercising and healthy eating, the meds, etc. and I should never need CABG. When I told my cardiologist about this, he said the stress echo does not work well in fit people, and CABG is still needed. Who is right?

    Liked by 1 person

    • Carolyn Thomas February 4, 2016 at 4:28 pm #

      Good grief. You are in the unenviable position of having duelling cardiologists at play here. I’m not one, so cannot wade in with any form of medical opinion either way. I can say, however, that it’s difficult to understand how any physician (no matter how famous) could reliably guarantee that a 66-year old person with “several” coronary lesions up to 90% will “never need CABG”. I’ve met 40-something triathletes who had bypass surgery, so such a “never” guarantee seems to smack of hubris.

      Regarding one cardiac test “trumping” another, as Harvard cardiologist Dr. Ron Blankstein explains: “No single test is better than another, and no test is appropriate for everyone.” My only suggestion now is to do your homework, and then seek a third opinion to help break this unfortunate professional standoff.


      • Freelander February 5, 2016 at 6:29 am #

        If you could run this by an appropriate party at the Mayo and get back to me that would be great.

        You’ve done a good service here.


        • Carolyn Thomas February 5, 2016 at 7:05 am #

          The “appropriate parties” at Mayo would be in exactly the same boat: they don’t know you, are not your physicians, don’t have you or your specific medical records/diagnostic results handy, don’t know anything about the specifics of your case, or why one cardiologist decided A and the other decided B. A third opinion must be an in-person appointment for you. Best of luck…


    • Janet February 22, 2016 at 12:52 pm #

      “He said the stress echo does not work well in fit people”

      This is the part I’m interested in. I had a heart attack four years ago, and they rebuilt all five arteries. I went to rehab and have faithfully followed an exercise regime that includes both cardio and strength training (all of which I also did before I had the heart attack, I must point out).

      My heart rate has steadily decreased with exercise over time. My doc wanted me to take an echo stress test after my last check up just because he’d like to see what my heart is doing, and I protested vigorously, because the first two I ever had almost killed me! I really thought I would not be able to get my breath, and it was so awful. And I can’t understand it, nor the technician, except that he was working to get my heart rate up to 150, which seemed quite unreal to me since at the top of my exertion my heart rate hardly gets above 120, and my rehab program started to get nervous and bossy at 110 or thereabouts! 150??

      So, last week I was on the treadmill next to someone much heavier than I am, and we were going the same rate, 3.6 miles per hour, and he had his hands on the heart rate monitor (which works on the machine he was on, as I tested them all against a chest strap monitor that calibrated with my doc’s office) and his heart rate at 3.6 miles per hour was 145! And mine was 95! So he only had five upclicks to go to get to 150, I had fifty five! No wonder it almost kills me! I know the article doesn’t address this, but it seems related as to why the test isn’t a good predictor for ‘fit people.’ Because it almost kills them! Shouldn’t they set a lower maximum number for people whose hearts are trained a little more?

      Liked by 1 person

      • Carolyn Thomas February 22, 2016 at 6:57 pm #

        Hi Janet – YES they should! There are a number of reasons that some people may exhibit lower heart rates than others. We know that athletes or those who exercise a lot often have a much lower resting heart rate (average 40-60) compared to other who are less fit. We also know that some cardiac meds (e.g. beta blockers) can cause a lowered heart rate. It’s also impacted by sex, age and overall health. That echo tech typically will stop the treadmill when a patient achieves a target heart rate (85% of the maximum heart rate predicted for his/her age, using the standard “220 minus your age” formula). BUT the common sense rule is that any test should be stopped prior to achieving this target heart rate if the patient develops significant chest discomfort, shortness of breath, dizziness, or EKG changes. Best of luck to you…


      • Freelander February 24, 2016 at 1:51 pm #

        A reason I was given for the stress ECG not being effective in fit/athletic people is that from the time the treadmill stops to the time the patient is laying on the gurney and having the ultra sound, the heart rate in fit/athletic people drops much quicker than in ‘average’ people. The exercise cardiologist likes the CPET as a better indicator, even if the stress ECG shows negative results.

        Hope this helps.

        Liked by 1 person

    • Ray Schulte August 13, 2016 at 9:10 am #

      I had terrible angina and went to the E.R., stayed overnight and had a nuclear stress test. The stress test showed normal, but since I had terrible chest pain the night before they did an angiogram later in the day because my wife asked for a Cardiologist, demanding that I should not be released until further tests. Lo and behold I had a 95 percent blockage in the right coronary artery which they stented. Stress test are a to in toss! If you have a history or DNA of CAD an angiogram is the only accurate test!


      • Carolyn Thomas August 14, 2016 at 7:24 am #

        Thank goodness your wife was so persistent in asking for that cardiologist, Ray. Angiograms are often called the “gold standard” of diagnostic cardiac tests, but even an angio can miss certain types of heart disease. Hope you are doing well now…


        • Ray Schulte August 14, 2016 at 8:01 am #

          I feel great now. I had a stent put in in 2002 and have been complaining of terrible fatigue the last two years. My cardiologist said my EKG was normal and the fatigue was from something other than my heart. All I can say is, if you don’t complain of serious chest pains you’re not going to get the proper tests done because the insurance industry is restricting the Doctors to really do what’s necessary. It actually took a heart attack to get an angiogram done.

          Liked by 1 person

          • Carolyn Thomas August 14, 2016 at 4:41 pm #

            I agree, Ray. Chest pain does tend to get all the attention (despite the reality that, for example, 40% of women in mid-heart attack do not experience ANY chest symptoms). We shouldn’t have to wait until damage is done to get appropriate diagnostic tests….


  17. Cynthia January 26, 2016 at 3:21 pm #

    I do not have any trust in a stress test. I had a stress test in November 2012 and had a massive heart attack Jan 2013. I had 100% blockage of my LAD artery, the one they call the Widow Maker. I am a very active person the Doctors call fit! I don’t smoke and eat healthy, I have danced and taught dance most of my adult life. I had 3 small heart attacks and my Dr. told me: “You’re reading too many Oprah magazines!” when I said I was concerned about about my symptoms. I wound up with 15% heart function because I trusted Doctors.

    My question is now they want to do a 4th stress test. Should I demand an echo only? Stress test have never shown I had an issue.


    • Carolyn Thomas January 26, 2016 at 5:18 pm #

      Hi Cynthia! I guess your doctor’s assessment that “you’re reading too many Oprah magazines” turned out to be quite wrong. Sheeeesh…. I’m not a physician so cannot advise you one way or the other re your 4th stress test. I can tell you generally that the stress test and the echocardiogram test for different things: the echo looks at how your heart and its valves are functioning, while the stress test looks for abnormal heart rhythms (arrhythmias), the presence or absence of coronary artery disease, and how the heart responds to exertion. The choice of test depends on what your doctor is looking for. Ask for an explanation of the recommendation and also if there are other tests that (in your specific case) might also be options.


  18. Steve September 16, 2015 at 11:12 am #

    My name is Steven. I am a 49 year old man. I am 5 ’10 and weigh 185 lbs basically for the last 30 years. The only exercise I have really ever done was lifting weights. (Basically looked in great shape my whole life). Through my years I had never really watched what I have eaten. I’m not saying I ate McDonalds every day but love to eat bagels, pizza, lots of bread and lots of coca cola. Ate my fair share of junk food like chips and candy but not that much. As far as alcohol, I didn’t drink every day but on weekends especially in my late teens up to about 30, did a lot of binge drinking. From 30 on I was still binge drinking but only at parties. Always went for physicals every couple of years and they always told me my cholesterol was borderline high. Numbers were about 230. The good and bad cholesterol were pretty bad too, as well as my trigylcerides. About 5 months ago I was lifting something very heavy with my son through the snow. I got so winded that it took a good ten minutes to get back to normal.

    So a couple of weeks later I went to my internist. I explained to him what was going on. He took blood and scheduled some other tests with a cardiologist. My internist told me that my chol was 245 and my trigl were 455. I said to myself I have to change my eating habits, which I really didn’t mind because I’m an avid weightlifter. I said to myself I will finally go after the six pack in my stomach that I never had. I went to a cardiologist and he did a stress test and echocardiogram & both tests passed with flying colors So for 3 months I didn’t eat any bread, pizza, soda, alcohol, and I mean zero for all of these. About 3 weeks ago I felt something funny in my upper stomach but didn’t think much of it. Two days later I was playing cards with my friends( and I was winning LOL). I felt that same pain but more intensified, then my chest felt tight. Then I started to sweat really bad. I told my friends I’m out of here. I got up and couldn’t go anywhere. I laid on the couch, my friend took my blood pressure (home made one not sure of accuracy) 80/60. They called 911 and I went in the ambulance and they gave me some aspirin and iv. I started feeling better. When I got to the hospital they took blood and my cardiac enzymes were elevated and a couple hours later they went up even more. That is when they basically told me that I’d had a heart attack. Of course I was devastated. I was then transferred to another hospital where they had put in a stent. They said my main atery was 95 percent blocked. Now I’m on aspirin, lipitor, blood thinner and beta blocker (from being a guy who never took a pill in his life). I slowly am starting to lift again (of course against doctors orders) slowly. I feel like my life will never be the same.


    • Carolyn Thomas September 17, 2015 at 8:54 pm #

      Steven, please tell me that your cardiologist referred you to a supervised cardiac rehabilitation program before resuming your weightlifting. If not, request a referral immediately. You need somebody with you who has experience monitoring heart patients (especially when lifting anything above your head). In a way, you are right: your life won’t be “the same” anymore – but you need to be smart about the choices you make from now on. Your only job is to become the world expert in your particular condition. Read, research, learn as much as you can. Knowledge is power. And you can still get that six-pack even with a heart condition – but get expert help along the way.


  19. Debra April 17, 2015 at 10:50 am #

    Hi, here is my story: I have spent the last few years in and out of the hospital for high blood pressure and chest pains. There is a family history of heart disease and the doctors were well aware. A resident doctor came to me and stated that something was wrong with my heart but it could be treated on an outpatient basis. I refused to leave the hospital until they found out what was wrong. The head cardiologist came to see me within an hour, made the resident stay in the hall. He told me and my husband that I was fine, that nothing was wrong with my heart and that the test they took was read backwards,

    Just to be safe, I followed up with the cardiologist 2 – 3 months later and he ordered a sit down nuclear stress. The doctor told me that the test was fine and that nothing was wrong with my heart (I took a sit down test because of leg cramps and pain).

    24 months later, I had a heart attack; they checked my arteries and found that 3 were 70+% blocked and one artery was 90% blocked. I am 51 years old and had a quad bypass in November 2014.

    What happened? With having a family history of heart disease, I strongly believe that other measures could have been taken to protect me. Thanks for any advice you can give – it has been a long struggle healing with my setbacks.

    Liked by 1 person

    • Carolyn Thomas April 18, 2015 at 8:04 am #

      Hello Debra and thanks so much for sharing that story. Tragic, yet sadly not surprising. Unfortunately, no doctors have a crystal ball that can accurately predict a heart attack two years down the road. Often, they can’t identify one that’s happening right now, never mind years from now. It’s also tough to pinpoint when your coronary artery blockages happened (for example, did they happen suddenly just before November, or did they gradually build up undetectable for years? No way to tell).

      Family history is just one cardiac risk factor – for example, many people with significant family history never have a heart attack, while many with no family history at all (like me) do end up having heart disease. There is no one clear one-size-fits-all rule, which is why heart disease is so challenging to diagnose. I hope you continue to recover and improve.


  20. Trina March 23, 2015 at 7:47 am #

    About 6 months ago I went to my doctor complaining about my left shoulder pain, the pain traveled down my arm even numbing it at times. I would experience headaches, dizziness, and pains not just on my left side but sometimes in my legs and right arm. My doctor didn’t know what was wrong with me and seemed to just blow it off. I managed my pain by keeping my stress level down and tried not to overwork myself so my heart rate wouldn’t go up.

    It seems to work but the lack of exercise has caused me to gain weight. Well l recently went to my doctor we started talking about my weight gain and she suggested diet pills. She ordered me an EKG which is routine before prescribing me the pills. The EKG showed I have had a mini heart attack at one point. I am 31 and all I keep hearing is that you are too young to have had a heart attack and that the EKG had to be wrong. My doctor ordered a stress echocardiogram and I was told my heart was fine, oxygen levels fine and basically nothing’s wrong. I sometimes have a sharp pain in my chest which makes it hard to breathe or move, it only last a few minutes then goes away. The pain can come at any time. I can’t pinpoint anything that brings it on. I just don’t know what to do. I feel like I am being blown off because of my age.

    Liked by 1 person

    • Carolyn Thomas March 23, 2015 at 8:29 am #

      Hello Trina,
      I’m not a physician so cannot comment specifically on your case, but let’s just generally review the facts as you’ve outlined them here.
      (a) Your symptoms make it impossible for you to exercise.
      (b) You’ve gained weight due to (a).
      (c) Your doctor – instead of investigating (a) that she has previously “blown off” within the past six months, or discussing changes in your diet – prescribes DIET PILLS!?

      It may be time for a second opinion. It’s entirely possible, especially given your age, that your symptoms are not heart-related at all, but SOMETHING is causing symptoms.

      And any symptoms that make it impossible to exercise need to be investigated.


  21. Darlana February 26, 2015 at 11:07 am #

    Hello, I’m just trying to get opinions on my situation. About 3 weeks ago I was shopping and all a sudden i got this pain in my chest, upper back, and my jaw. Had to leave store. Lasted about 5 mins. Same thing happened a week ago. Went to ER, 3 EKG’S were abnormal. Had stress test yesterday. Whole test lasted about 6 mins. Dr said it was negative for blockages. How can they tell by a 6 min test? Crazy! These pains are caused from something. Not sure what to do from here.

    Liked by 1 person

    • Carolyn Thomas February 26, 2015 at 1:05 pm #

      Hello Darlana – I’m not a physician so cannot comment on your specific case, but I can tell you generally that if 3 EKGs were “abnormal”, you might want to speak to a physician for a follow-up visit, especially if troubling symptoms continue.


      • Darlana February 26, 2015 at 3:06 pm #

        Hi, thank you for responding. I went to my dr who also did an ekg in office that was abnormal, that’s why he sent me for stress test. I go back next week but, with a negative stress test result I’m sure he’ll just brush it off. Which if he does, I am showing him this link about these stress test. Thanks again.

        Liked by 1 person

        • Carolyn Thomas February 26, 2015 at 3:14 pm #

          Good news that you have an appointment next week! Best of luck to you in getting a satisfactory explanation of your abnormal EKGs. Don’t hesitate to ask for a referral for a second opinion if you don’t get one.

          Liked by 1 person

  22. Debbie Alcorn January 21, 2015 at 2:52 pm #

    I was recently admitted to hospital with high blood pressure (170/115), pain in jaws and chest. Was given blood panel tests, stress test, echocardiogram, and ultrasound of heart. All was normal. Because of strong family history of heart disease I was sent to Cath lab next. Cardiologist went through my wrist and inserted 3 stents in artery in back of heart which was 90% blocked. She forgot to give me blood thinner and clot formed causing heart attack for several hours. She tore artery in wrist and that caused 8 blood clots and dangerous compartment syndrome wound. I have hired an attorney. Have not been seen by cardiologist since this happened in November. No one will see me until March or April. Have been to two hospital ERs with extremely high blood pressure, arrhythmia, chest and jaw pain. Again normal tests and sent home. I sweat, feel dizzy, chest tight upon any exertion. Don’t know what to do. On meds from hospital in November with no oversight by any doctor. Any suggestions would be appreciated. My faith in prayer keeps me going.

    Liked by 1 person

    • Carolyn Thomas January 21, 2015 at 3:55 pm #

      What a story, Debbie! When you say “no oversight by any doctor”, I hope this doesn’t mean you are not seeing your family physician. If not, make an appointment right away while you are waiting for that cardiology appointment. And you might consider seeking the services of a patient advocate/navigator to help out. Trisha Torrey is an example of this role. Best of luck to you…


      • Debbie Alcorn January 21, 2015 at 6:04 pm #

        Thank you so much, Carolyn! I have seen my family physician who referred me to cardiology group who won’t see me until end of March. I truly appreciate your suggesting a patient advocate and will be looking into that avenue of assistance.

        Liked by 1 person

    • mara May 20, 2016 at 2:17 pm #

      Debbie are you ok?


  23. Stella Alexandri September 22, 2014 at 6:08 am #

    I wonder if a treadmill stress test is enough to exclude coronary disease? I had a stress test 2 weeks ago. My HR at rest was 116 and blood pressure 130/80. During the second part of the test HR increased to 155 and at the beginning of the 3rd part reached 179, which is considered as maximum for my age (42 yrs). There was an ST depression during the second part of the test 1, 1mm and 2,8mm at the 3rd. But it was signed as negative. The total time was 7:16 minutes. There was not enough time to see the reaction of my body. It was a completely confusing result.

    The point that I usually have a very high heart rate at rest was not taken into account. The fact that I asked the doctor to stop the test because I was up to collapse was not taken into account too. I am still not sure if it was really negative. I still have chest pain and shortness of breath when I walk fast, or when I carry things, or when I am under emotional stress. The stress test was signed as negative but Duke Treadmill score was -5 meaning moderate risk of having CAD.

    Liked by 1 person

    • Carolyn Thomas September 22, 2014 at 6:57 am #

      Hello Stella and thanks for sharing your experience here. As the cardiologists in this post remind us, stress testing is certainly not enough to exclude a diagnosis of coronary artery disease. If your symptoms continue, seek further medical help.


    • forcryingoutloud May 22, 2016 at 12:55 pm #

      Have you considered asking about MicroVascular Disease? I have coronary artery disease with 4 stents and now also MVD which sounds like your story.


    • Jane January 29, 2017 at 6:55 pm #

      Non-medical person here. I have the thought, for myself, that my diaphragm doesn’t function properly when I move quickly, and that I have shortness of breath and pain because of it. No doc so far as thought it worth pursuing as a cause.


  24. Elizabeth Y., RN, BSN August 25, 2014 at 6:05 am #

    The Physicians Assistant I see for cardiac is insisting I have another Treadmill Stress test in the near future, as the last stress test (nuclear) was over a year ago. I fail to see the benefit in this as I am walking/jogging 3-4 miles 6 days a week with no chest pain. I ride my bicycle all over town on weekends, no chest pain. But, she insists it is important.

    I hate treadmill tests…

    Liked by 1 person

    • Carolyn Thomas August 25, 2014 at 6:58 am #

      Hi Elizabeth! Send her a copy of this article (including the list of journal references) and see what she thinks. Good luck!


      • Elizabeth Y., RN, BSN August 25, 2014 at 9:07 am #

        Thank you, Carolyn! I’ll send her the link!

        Liked by 1 person

  25. Nancy June 21, 2014 at 8:09 am #

    So if the stress test is not very useful as a first stop diagnostic tool for women after an EKG, what is? (Recently referred for nuclear stress test, do not want to do it)

    Liked by 1 person

    • Jane Kleba January 23, 2015 at 8:37 am #

      Cedars Sinai says the gold standard for women is cardiac MRI


  26. Eve Zavodnick March 4, 2014 at 4:52 am #

    The thing about Stress Tests for those of us with known heart disease is that it’s like a check up every 2 to 3 years. I had one recently and my own situation hasn’t changed. I still have an EF of only 14, but I function and appear as “normal” as anyone else. People are still floored when I tell them that I nearly died from a serious heart attack 3 years ago. The “funny” part about all of this was the look on the Nuclear Tech’s face when he saw the scans after the comparisons. All of a sudden, he was looking at me as if I had one foot in the grave. He really needs to work on his poker face!

    Liked by 1 person

    • Carolyn Thomas March 4, 2014 at 5:24 am #

      An ejection fraction of 14% is indeed enough to “floor” most techs, for sure. No wonder he couldn’t keep a poker face during your nuclear stress test! It’s amazing that you’re able to function and appear “normal” – given that normal is typically in the 55-70% range! Good luck to you…


      • Stella Alexandri September 22, 2014 at 6:15 am #

        EF 14% is very low. I had 56% and they thought it was not enough.

        Liked by 1 person

        • Carolyn Thomas September 22, 2014 at 7:01 am #

          56% EF sounds within normal limits, Stella. As Eve demonstrates, you can still function and appear as “normal” even with an EF that may at first glance appear to be in the heart transplant zone! Conversely, a significant number of patients with heart failure have a “normal” EF. It’s just one number.


  27. Nitro Mama March 3, 2014 at 11:20 am #

    My feelings about stress tests are confused. A few months ago the cardiologist I saw prescribed one for me. I chose not to take it. I know I have ischemia, I couldn’t understand what could that test could tell me that isn’t already known. I decided after that visit that I will see another cardiologist in the future. He was so rushed, was annoyed when I had questions about my medications.

    Liked by 1 person

    • Carolyn Thomas March 3, 2014 at 11:35 am #

      Hello Nitro Mama – getting a second opinion is always an option, particularly when you’re experiencing a doc who’s “rushed” and “annoyed”. Good luck to you…


  28. Deborah Walker March 2, 2014 at 10:35 am #

    Don’t get me started about stress tests!

    My mother, who had angina and then suffered a heart attack, was hospitalized for the latter. In the hospital she was given a stress test on a treadmill. During the exercise, increased blood pumping, etc., an undiagnosed blood clot elsewhere in her body broke loose and entered her brain, causing a stroke! We learned later that this is quite common and yet none of her care providers bothered to consider that she might be at risk for this kind of thing; even though her family history was chock full of heart and stroke victims and this history was recorded in detail on her chart.

    My dear mom went from a lively intelligent person to a confused little old lady overnight.

    Now I’m going to be all Canadian and apologize for the rant, but I wanted your readers to know about the stroke risk connected to stress tests too.

    Liked by 1 person

    • Carolyn Thomas March 2, 2014 at 12:33 pm #

      Hello Deborah – I’m so sorry about your mother’s experience. We know that there is indeed a link between elevated blood pressure during this test and stroke risk for some patients (a Finnish study published in the journal, Stroke – a study done on men, mind you – suggested that a systolic blood pressure rise two minutes after exercise began was “directly and independently associated with the risk of stroke”.

      Liked by 1 person

  29. Deanna Rush March 1, 2014 at 4:51 pm #

    I too, have had negative stress tests, and I had angina while on the treadmill!

    The last one 10 weeks prior to having emergency triple bypass surgery. One artery was 100% occluded and two were 99% occluded.

    That was 4 years ago and after a very long recovery period I am doing well. I tell my family and friends no matter what the outcome of your stress test, if you continue to have symptoms you need to have further testing.

    Your articles are very informative, and at times humorous; please continue. They have been very beneficial for me.

    Thank you.

    Liked by 1 person

    • Carolyn Thomas March 1, 2014 at 10:20 pm #

      Thanks Deanna – your story is a good example of why some doctors (like the ones quoted in my post) consider treadmill stress tests to be “not very good tests” for many patients. Glad you are now doing well. Take care…


    • Stella Alexandri September 22, 2014 at 6:23 am #

      Very useful advice. Why do they sign as negative tests that are inconclusive? That’s my question. It is a great risk to say a test is negative if you have experienced angina during it. There are some signs on the ekg that are usually neglected because they are based on the fact that you managed to pass it and that you are a woman. They tend to exclude CAD in women just because of the sex.

      Liked by 1 person

  30. Tricia March 1, 2014 at 10:57 am #

    My cardiologist stopped my stress test after being on the tread mill 2 minutes. He honestly felt I would have a heart attack right there and then! He immediately called the intervention team to schedule a heart cath. He said the stress test EKG showed blockage and I would need a triple bypass.

    Yikes! Imagine my delight when the heart cath showed 50% blockage and surgery would not be necessary at this time. In the future I will need bypass, but for now I’m ok! Testing false positive was nerve racking to say the least.

    Liked by 1 person

    • Carolyn Thomas March 1, 2014 at 11:19 am #

      Thanks Tricia for this example: stress tests can indeed show false positives as well as false negatives. As for predictions that your blockages will “need bypass” in the future, few if any doctors could accurately promise this outcome for 50% blockages. Best of luck to you!


  31. cave76 March 1, 2014 at 7:35 am #

    Wow—- thanks for yet another informative post that points out the problems with ‘established’ tests. (Not that ALL tests are wrong, I want to make clear!)

    Liked by 1 person

    • Carolyn Thomas March 1, 2014 at 7:40 am #

      Good point, Cave. Even stress tests get it right on occasion!


      • Barbara Keddy March 2, 2014 at 6:27 am #

        Hi Carolyn:

        I keep wondering why I ask health professionals questions when I eventually get the real and detailed information from you!

        During my stay in hospital after my heart attack and stent I heard the cardiac team outside my cubicle door decide I would have a MiBi instead of a tread mill stress test. New language for me!

        No one explained to me the difference, nor why I was now having one. I didn’t ask many questions cause I was still in shock over everything that had happened. The words MiBi were new ones I was too exhausted to ask about.

        Other than telling me that I was on a ‘blood thinner’ and HAD to come off it in 365 days (!) I don’t remember any discussion about anything of consequence. Maybe I was too rattle brained to absorb much but they were very adamant about the blood thinner, a detail I was too stressed to care about at the time.

        I recently saw the cardiologist, at my request to the family doctor, for a referral since I had not seen one for a year. I asked him for a stress test so I could see how my heart has healed (or not) on the advice of a friend, a retired cardiologist. During the cardiologist visit he told me some of the information that this blog of yours explains (thankfully in detail). Otherwise, I would not have known nor thought anything much about stress tests and their unreliability. He would not order one for me.

        As an added problem unrelated to stress tests, I have just found out that I cannot be insured for the stent for travel outside the country until one year AFTER I have come off the Plavix! However, the whole year I was on it I could have been granted health insurance, had I not had a heart attack. One is required to wait one year after a heart attack and one year after coming off the blood thinner. So, in essence for travel outside the country one has to wait two years before being eligible to buy travel insurance following a heart attack and stent.

        NO ONE EXPLAINED THAT TO ME! I have been very anxious about even leaving my city let alone the country, now that I want to test my courage I find these loopholes! Guess the safest is to stay inside Canada where I don’t need travel insurance(blessedly) !

        What else don’t I know about heart disease and all that condition entails? Plenty, I suspect.

        Without you I would have been in the dark about so many things!
        Thank you, thank you once again!

        Liked by 1 person

        • Carolyn Thomas March 2, 2014 at 6:52 am #

          Thanks for this, Barbara. You bring up such an important point – that overwhelming shock following a catastrophic diagnosis like heart attack that makes it so challenging to comprehend what’s going on or even being said to us! I recall trying to explain to my daughter after being discharged from hospital that I had seen the cardiologist’s lips moving and I’d heard sounds coming out of his mouth, but it was as if he were speaking Swahili to me . . .

          That’s amazing about your out-of-country travel insurance! Does this depend on your insurance company? I flew from my home here in Canada to the U.S. five months after my MI (and while taking Plavix) to go to Mayo Clinic, and that Plavix issue didn’t come up while I was purchasing my out-of-country medical insurance.


          • Barbara Keddy March 2, 2014 at 3:07 pm #

            It is the same with all travel insurance companies. As long as you are on Plavix it is ok but after you come off of it they will not insure for one year!?



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