Stress testing choices — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 61-year-old woman has suspected chronic coronary syndrome, with constricting retrosternal chest discomfort brought on by exertion and relieved by rest within 5 minutes (all three chest pain characteristics: symptom score 3). She is a former smoker with hypertension, dyslipidaemia and diabetes (four risk factors). Her body mass index is 41 kg/m², she has chronic obstructive pulmonary disease, and her resting ECG shows left bundle branch block. Functional imaging and CCTA are available locally and supported by local expertise.^[1] Her risk factor-weighted clinical likelihood of obstructive CAD on ESC 2024 Figure 4 (women aged 60–69, symptom score 3, 4–5 risk factors) is 19%.^[1]

1. Explain why an exercise ECG should not be used to diagnose CAD in her, giving the two ESC 2024 rows that apply, with their class and level. (2)^[1]
2. Name the three ESC 2024 functional imaging options at her likelihood, with the class and level of each row. (2)^[1]
3. Give two ESC 2024 statements relevant to stress echocardiography in a patient with obesity and chronic obstructive pulmonary disease. (2)^[1]
4. Which nuclear modality does ESC 2024 particularly recommend in obese patients, and why? Give the extra measurement ESC 2024 recommends in patients selected for PET or SPECT. (2)^[1]
5. Her stress PET perfusion study shows ischaemia in 12% of the LV myocardium. State what this means under ESC 2024 and the recommended next step, with class and level. (2)^[1]

Model answers — SAQ 1

1. ESC 2024 says exercise ECG is not recommended for diagnostic purposes in patients with ≥0.1 mV ST-segment depression on resting ECG, left bundle branch block or who are being treated with digitalis (Class III, Level C) (1 mark).^[1] ESC 2024 also says that in individuals with a low or moderate (>5%–50%) pre-test likelihood of obstructive CAD, an exercise ECG is not recommended to rule out CAD if CCTA or functional imaging tests are available (Class III, Level C) (1 mark).^[1] Not marked, but the reason: an exercise ECG is of no diagnostic value when resting ECG abnormalities such as LBBB prevent interpretation of the ST-segment changes during stress.^[1]
2. In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood, if available and supported by local expertise: stress echocardiography is recommended to diagnose myocardial ischaemia and to estimate the risk of MACE; stress SPECT or, preferably, PET myocardial perfusion imaging and stress CMR perfusion imaging are recommended to diagnose and quantify myocardial ischaemia and/or scar and estimate the risk of MACE (1 mark).^[1] Each is Class I, Level B (1 mark).^[1]
3. ESC 2024: compromised image quality, especially in obese people and those with chronic obstructive pulmonary disease, is a significant limitation of stress echocardiography; ultrasound contrast agents may be required in these patients and must be used in all cases if it is evident at baseline that all segments may not be visible during stress (1 mark).^[1] ESC 2024 row: when two or more contiguous myocardial segments are not visualized, it is recommended to use commercially available intravenous ultrasound contrast agents (microbubbles) to improve diagnostic accuracy (Class I, Level B) (1 mark).^[1]
4. If available, PET-CT perfusion is particularly recommended in obese patients, due to the high photon energy (1 mark).^[1] In patients selected for PET or SPECT, ESC 2024 recommends measuring CACS from the unenhanced chest CT used for attenuation correction, to improve detection of both non-obstructive and obstructive CAD (Class I, Level B) (1 mark).^[1]
5. ESC 2024 lists an area of ischaemia ≥10% of the LV myocardium on stress SPECT or PET as a result that identifies high risk of adverse events (Class I, Level B), so 12% places her at high risk (1 mark).^[1] In individuals at high risk of adverse events (regardless of symptoms), ICA, complemented by invasive coronary pressure (FFR/iFR) when appropriate, is recommended to refine risk stratification and improve symptoms and cardiovascular outcomes by revascularization (Class I, Level A) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 70-year-old man with chronic coronary disease on optimized GDMT has had a change in symptoms over two months that persists despite GDMT. He had a stent five years ago.^[3][1]

1. Give the AHA/ACC 2023 row on stress imaging in this situation, with its COR and LOE. (2)^[3]
2. Give the ESC 2024 row on risk stratification with new or worsening symptoms in established CCS, and how its 2019 version differed. (2)^[1]
3. If nuclear perfusion imaging is chosen, which modality does AHA/ACC 2023 prefer, and what can be added to stress PET or stress CMR? Give COR and LOE. (2)^[3]
4. He cannot exercise, and vasodilator stress nuclear perfusion imaging is planned. List four contraindications that would stop it, from the stress nuclear column of the AHA/ACC 2021 contraindications table. (2)^[2]
5. A year later he is stable on optimized GDMT with no change in clinical or functional status. Should he have a routine stress test? Give the AHA/ACC 2023 row and the related ESC 2024 statement after PCI. (2)^[3][1]

Model answers — SAQ 2

1. AHA/ACC 2023: in patients with CCD and a change in symptoms or functional capacity that persists despite GDMT, stress PET/SPECT MPI, CMR imaging, or stress echocardiography is recommended to detect the presence and extent of myocardial ischemia, estimate risk of MACE, and guide therapeutic decision-making (1 mark).^[3] COR 1, LOE B-NR (1 mark).^[3]
2. ESC 2024: risk stratification is recommended in patients with new or worsening symptoms, preferably using stress imaging (Class I, Level C) (1 mark).^[1] The 2019 version recommended risk stratification in patients with new or worsening symptom levels, preferably using stress imaging or, alternatively, exercise stress ECG (Class I, Level B); ESC 2024 lists the change in its table of revised recommendations (1 mark).^[1]
3. When selected for rest/stress nuclear MPI, PET is reasonable in preference to SPECT, if available, to improve diagnostic accuracy and decrease the rate of nondiagnostic test results (COR 2a, LOE B-R) (1 mark).^[3] In patients with CCD undergoing stress PET MPI or stress CMR imaging, the addition of myocardial blood flow reserve (MBFR) can be useful to improve diagnostic accuracy and enhance risk stratification (COR 2a, LOE B-NR) (1 mark).^[3]
4. Any four of: high-risk unstable angina, complicated ACS or AMI (<2 d); or, listed under contraindications to vasodilator administration, significant arrhythmias (for example VT, second- or third-degree atrioventricular block) or sinus bradycardia <45 bpm; significant hypotension (SBP <90 mm Hg); known or suspected bronchoconstrictive or bronchospastic disease; recent use of dipyridamole or dipyridamole-containing medications; use of methylxanthines (for example aminophylline, caffeine) within 12 h; known hypersensitivity to adenosine, regadenoson; and severe systemic arterial hypertension (for example ≥200/110 mm Hg), the last item in the same column (half a mark each, 2 marks).^[2]
5. No: in patients with CCD without a change in clinical or functional status on optimized GDMT, routine periodic testing with coronary CTA or stress testing with or without imaging is not recommended to guide therapeutic decision-making (COR 3: No benefit, LOE B-R) (1 mark).^[3] ESC 2024: routine functional testing is not recommended for asymptomatic post-PCI patients, as it has not been shown to improve outcomes compared with standard care after 2 years (1 mark).^[1]