In our ambulatory report this AM we discussed the presentation of chest pain in high risk patients with multiple risk factors. We reviewed chest pain differential, stress testing pros and cons, and contraindications for exercise treadmill testig. We also took a look at the primary literature on ASA as primary prevention of MI. I have included the pearls below. Enjoy!

Stress Tests – Pros and Cons

  Pros Cons
Exercise treadmill ·       Well established

·       Cheaper

·       Widely available

·       Assesses functional capacity/prognosis

·       Lower sensitivity than other stress tests

·       Cannot use if deconditioned

·       ECG changes can affect results or make it difficult to localize area or extent of ischemia

Exercise TTE ·       Sensitivity/specificity comparable to pharmacologic stress testing

·       Can tell extent of CAD

·       Lower cost than pharmacologic stress testing

·       Poor image can result from obesity/tachycardia and inability to interpret study

·       Subjective interpretations of results

Exercise perfusion imaging ·       Well validated to detect severe CAD and assess prognosis

·       Assesses LV size

·       Assess viability of myocardium

·       Expensive

·       Radiation exposure

·       Can have artifact from soft tissue

·       Low specificity if LBBB present

Pharmacologic Myocardial Perfusion Imaging ·       Can detect CAD in those unable to exercise

·       Safe

·       Can reverse SEs easily

·       Increased accuracy for detecting CAD in LBBB than exercise perfusion

·       Cannot assess functional capacity

·       Cannot take theophylline 72 hours prior and caffeine 24 hours prior to testing

Dobutamine Stress TTE ·       Can detect CAD in those unable to exercise

·       Safe

·       Can reverse SEs rapidly

·       Able to detect ischemia + viability

·       Cannot assess functional capacity

·       Less likely to get ECG abnormalities

·       May induce arrhythmias

Contraindications for Exercise Treadmill Test


  • ACS
    • Acute MI within 2 days
    • Active UA
  • Symptomatic severe AS
  • Decompensated heart failure
  • Aortic dissection
  • Acute myocarditis or pericarditis
  • Uncontrolled arrhythmias
  • Acute PE


  • Left main disease
  • Severe uncontrolled HTN
  • HOCM
  • High degree AV block

Baseline ECG findings that can obscure ETT results:

  • ST depression or elevation > 1mm
  • LVH
  • RVH
  • T wave inversions in multiple leads c/f strain or old injruy
  • LBBB
  • RBBB *not considered a contraindication to ETT
  • Prolonged QT interval

Aspirin as Primary MI Prevention in Patients with DM

We discussed at length today the data on Aspirin as Primary Prevention of MI in patients with type 2 DM. I have attached the original article from BMJ courtesy of Jeff Kohlwes.

Also, here is the link to the Decision Making Tool that Chelsea discussed this morning:


2 thoughts on “TO STRESS OR NOT TO STRESS”

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