Author + information
- Received November 8, 2018
- Revision received January 14, 2019
- Accepted January 16, 2019
- Published online July 17, 2019.
- aDepartment of Cardiology, Mount Sinai St. Luke’s and Mount Sinai Heart, New York, New York
- bMedicine and Burns and Allen Research Institute, Cedars-Sinai Medical Center, Los Angeles, California
- ↵∗Address for correspondence:
Dr. Alan Rozanski, Department of Cardiology, Mount Sinai St. Luke’s Hospital, 1111 Amsterdam Avenue, New York, New York 10025.
• Although most cardiac stress tests are now nonischemic tests, long-term risk is quite heterogeneous.
• Risk factor burden, symptoms, exercise capacity, and the need for pharmacologic stress influence long-term risk.
• Other predictors include atherosclerosis (coronary calcium) burden, autonomic dysfunction, musculoskeletal status, and psychosocial risk factors.
• Optimal test reporting should integrate assessment of ischemia with these other determinants of patient risk.
Due to a marked temporal decline in inducible myocardial ischemia over recent decades, most diagnostic patients now referred for cardiac stress testing have nonischemic studies. Among nonischemic patients, however, long-term risk is heterogeneous and highly influenced by a variety of clinical parameters. Herein, we review 8 factors that can govern long-term clinical risk: coronary risk factor burden; patients’ symptoms; exercise capacity and exercise test responses; the need for pharmacologic stress testing; autonomic function; musculoskeletal status; subclinical atherosclerosis; and psychosocial risk. To capture the clinical benefit provided by both assessing myocardial ischemia and these additional parameters, we propose that a cardiac stress tests report have an additional component beyond statements as to the likelihood of obstructive coronary artery disease and/or magnitude of ischemia. This added component could be a comment section designed to make referring physicians aware of aspects of long-term risk that may influence clinical management and potentially lead to changes in the intensity of risk factor management, frequency of follow-up, need for further testing, or other management decisions. In this manner, the increasingly frequent normal stress test result might more commonly influence treatment recommendations and even patient behavior, thus leading to improvement in patient outcomes even in the setting of normal stress test results.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 8, 2018.
- Revision received January 14, 2019.
- Accepted January 16, 2019.
- 2019 American College of Cardiology Foundation
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