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:
- Do you know the difference between V.T. and T.V? (a patient’s basic glossary of cardiac terms)
- Coronary Microvascular Disease: a “trash basket diagnosis”?
- Misdiagnosis: the perils of “unwarranted certainty”
- Heart attack misdiagnosis in women
- Misdiagnosed: women’s coronary microvascular and spasm pain
.
.
Heart Sisters 
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?
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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?
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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???????? 😢
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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…
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“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?
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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.
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Carolyn,
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.
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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…
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“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?
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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…
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Janet,
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.
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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!
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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…
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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.
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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….
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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…
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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.
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Debbie are you ok?
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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.
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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.
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Have you considered asking about MicroVascular Disease? I have coronary artery disease with 4 stents and now also MVD which sounds like your story.
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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.
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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…
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Hi Elizabeth! Send her a copy of this article (including the list of journal references) and see what she thinks. Good luck!
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Thank you, Carolyn! I’ll send her the link!
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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)
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Cedars Sinai says the gold standard for women is cardiac MRI
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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!
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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…
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EF 14% is very low. I had 56% and they thought it was not enough.
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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.
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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.
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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…
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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.
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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”.
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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.
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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…
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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.
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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.
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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!
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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!)
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Good point, Cave. Even stress tests get it right on occasion!
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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!
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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.
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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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