Talk:Cardiac stress test

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I am unsure of the accuracy of this. It contradicts the opinion of several university researchers I spoke with about the stress test.

[edit] confusing, long Paragraphs

There are two real ways to confuse a user. One is to write a bunch of poorly connected or conveyed information. The other is to write in big, long, difficult to process junk.

This article has a few very big paragraphs. Short, one-sentence paragraphs appear childish; but very, very long paragraphs are difficult to break down. Paragraphs should be most ideally 3-6 sentences, each with a few clauses. Such a paragraph would be about the size of this one, perhaps a little shorter or a little longer; discretion with semi-colons is also important, as a single paragraph may be very long.

There are a few very, very large paragraphs in this article that need to be broken up and rewritten. This will aid in clarity. Check out Further Research especially; the contributors seem to have tried to address individual bullet points in single paragraphs, without brievarity. Try making better use of subsections.

[edit] inaccurate specificity figure given for nuclear stress test

Nuclear stress tests (thallium, Sestamibi, Cardiolyte, etc) do not have a specificity of 99%. The correct figure is something like 80-85%. The false positive rate is about 15-20%.(See review article pasted below.) Seven years ago at the age of 52, despite having only my gender and age as risk factors, with LDL cholesterol <100, HDL cholesterol >60, normal BP, and no family history of CHD, had a false positive treadmill stress test (at high level exertion after 15 minutes), then a false positive Sestamibi nuclear treadmill stress test (same situation), followed by a completely clean coronary artery catheterization.

128.249.29.35 19:46, 30 May 2006 (UTC)Michael Crouch, MD, MSPH, Family Physician, Baylor College of Medicine, Houston,TX

Comparing stress testing methods Available techniques and their use in CAD evaluation Tahir Tak, MD, PhD; Ricardo Gutierrez, MD VOL 115 / NO 6 / JUNE 2004 / POSTGRADUATE MEDICINE ________________________________________ CME learning objectives • To understand and be able to apply exercise stress testing in clinical practice • To review the uses for stress testing in combination with cardiac ultrasound • To become familiar with the merits and limitations of stress electrocardiography and stress echocardiography in clinical decision making The authors disclose no financial interests in this article and no unlabeled uses of any product mentioned. ________________________________________ Preview: Conventional exercise stress testing or stress echocardiography? Deciding between these two noninvasive cardiac evaluation techniques can be a regular occurrence, given the frequency of coronary artery disease (CAD) in the US population. When can you rely on exercise stress testing alone to do the job? What situations call for stress echocardiography? When should pharmacologic agents be substituted for exercise in stress echocardiography? In this comparison of the two techniques, Drs Tak and Gutierrez discuss indications, contraindications, and other issues that enter into selection of the appropriate test for the individual patient. Tak T, Gutierrez R. Comparing stress testing methods: available techniques and their use in CAD evaluation. Postgrad Med 2004;115(6):61-70 ________________________________________ The role of stress testing in detecting and evaluating CAD has changed considerably in recent years. The addition of myocardial imaging has significantly increased the diagnostic abilities in this area of cardiac assessment. In clinical practice, physicians are often faced with the need to better understand the role, indications, and limitations of exercise stress testing and stress echocardiography. Electrocardiographic (ECG) stress testing (exercise stress testing) has been applied for many years, and echocardiography can now be combined with exercise or pharmacologic stress testing to enhance diagnostic value. ECG stress testing ECG stress testing is one of the most widely used investigative techniques in cardiology and is less expensive than other imaging techniques. Used correctly, this method can help confirm the diagnosis of CAD in symptomatic patients. It is also useful in assessing functional capacity and provides prognostic information about patients with known CAD. Yet, exercise stress testing may not be helpful in some groups of patients, particularly when it is applied as a screening method. To understand this distinction, it is important to appreciate that predictive accuracy is affected not only by the test's sensitivity and specificity but also by the characteristics of the population studied. Overall, the sensitivity and specificity of exercise stress testing for CAD are about 63% and 74%, respectively (1,2). For prognostic diagnosis of serious disease (eg, left main-stem disease, three-vessel disease), the sensitivity improves to 86%. The indications and contraindications for exercise stress testing are listed in table 1. Equipment, medications, and trained personnel to provide advanced cardiac life support must be readily available. Exercise stress testing should be performed under the overall supervision of a physician appropriately trained to conduct exercise stress tests. Table 1. Indications and contraindications for exercise stress testing Indications Evaluation of chest pain Prognosis and severity of cardiovascular disease Evaluation of therapy Screening for latent coronary disease Early detection of labile hypertension Evaluation of congestive heart failure Evaluation of arrhythmias Preparticipation examination for sports Evaluation of congenital heart disease Stimulus to motivate change in lifestyle Contraindications ABSOLUTE Acute phase of uncomplicated MI or ACS* Acute myocarditis or pericarditis Rapid atrial or ventricular arrhythmias Symptomatic severe aortic stenosis Severe anemia, acute illness, and/or infection Hyperthyroidism Acute aortic dissection RELATIVE Hypertrophic obstructive cardiomyopathy Suspected left main-stem disease or equivalent coronary disease Severe hypertension (blood pressure, >200/110 mm Hg) Congestive heart failure Severe ST-segment depression in at-rest "ischemia" ________________________________________ ACS, acute coronary syndrome; MI, myocardial infarction.

  • Low-level stress test may be performed 48 hours after an uncomplicated MI or ACS. Symptom-limited stress test should preferably be delayed for 6 to 8 weeks after an MI.

________________________________________ Anginal chest discomfort induced by exercise stress testing is strongly predictive of CAD, especially when horizontal or downsloping ST-segment depression is seen on the electrocardiogram (figure 1). A fall in blood pressure also indicates significant CAD. Cardiac auscultation immediately after exercise can provide useful information about ischemia-induced left ventricular dysfunction. For example, a new mitral regurgitant murmur suggests papillary muscle dysfunction secondary to transitory myocardial ischemia. False-positive results may occur, especially in female patients and in certain clinical conditions (table 2). Table 2. Causes of false-positive results on exercise stress testing Left ventricular hypertrophy Cardiomyopathy with baseline ST-segment or T-wave abnormality Left ventricular outflow tract obstruction (eg, hypertrophic obstructive cardiomyopathy) Hyperventilation Left bundle branch block, preexcitation, use of digitalis Electrolyte abnormalities Coronary artery spasms Use of tricyclic antidepressants ________________________________________ Mortality is high in patients with a mean exercise capacity of 5 or fewer metabolic equivalents (METs). Conversely, the prognosis is considered good in patients with an exercise capacity of more than 5 METs, even in the presence of known CAD (3,4). Stress echocardiography Stress echocardiography is an established noninvasive diagnostic tool in CAD evaluation. Although exercise is the traditional form of stress, pharmacologic stress echocardiography has emerged as a promising technique in the past few years. Stress echocardiography aids in assessment of chest pain, viable myocardium, and functional capacity; in evaluation of cardiovascular risk before noncardiac surgery; and in risk stratification after myocardial infarction (MI). It is now part of the armamentarium of clinical cardiologists for assessment and risk stratification of patients with CAD. As a noninvasive method for evaluating known or suspected CAD, stress echocardiography has established value in determining the absence or presence of the disease. The test also is useful in assessing the impact of revascularization therapies, the viability of akinetic myocardial segments, and the presence or absence of miscellaneous heart disease (5) (table 3). It should not be used in patients with unstable angina pectoris. The diagnosis of ischemia is related to development of a detectable wall motion abnormality with exercise. Abnormal response is characterized by left ventricular dilatation, a decrease in ejection fraction and, most specifically, a lack of endocardial wall thickening. The converse is true in a normal response. Table 3. Indications for stress echocardiography Prior nondiagnostic ECG stress test High likelihood of false-positive result on ECG stress test (eg, women, patients taking digitalis) Conduction or repolarization abnormalities that make ECG stress test difficult to interpret* High pretest likelihood of disease (test is done to determine extent and/or location of ischemia) Permanent pacemaker** Need for prognostic information after MI (preferably 48 hr after uncomplicated event) Past or future intervention to assess physiologic significance of a lesion or to determine success of the intervention ________________________________________ ECG, electrocardiographic; MI, myocardial infarction.

  • Left bundle branch block exaggerates septal motion abnormalities.
    • Paced rhythm produces apical and septal wall motion abnormalities.

Information from Ryan and Feigenbaum (5). ________________________________________ Peak-stress echocardiographic images (figure 2) are obtained once a patient has reached 85% of predicted heart rate, which allows visualization of wall motion abnormalities during maximum workload. Recovery images should be obtained within 90 seconds of peak heart rate. This window into recovery is vital: sensitivity drops significantly if images are not obtained within the 90-second time frame. Interpretation of the echocardiographic study is based on a 16-segment model of the left ventricle, as recommended by the American Society of Echocardiography (5). Digital imaging has helped in the interpretation and yield of stress echocardiography (6-11). It permits side-by-side display of rest and exercise echocardiograms, which may enhance the detection of subtle abnormalities in regional wall motion. Digital imaging also permits creation and display of a cine loop--a series of images played in an endless loop sequence (5). This sequence can capture the entire cardiac cycle, or it can be limited to systole or diastole alone. Other recent developments proven to increase the yield of stress echocardiography include harmonic imaging and use of contrast agents (12,13). Harmonic imaging can remove noise in the far field and dramatically improve differentiation between blood and tissue. Exercise stress echocardiography can be performed using a traditional treadmill or bicycle ergometry (table 4). Important differences between these two methods should be considered. Treadmill stress is the most strenuous form of exercise available clinically, but patients can often exercise much longer on a treadmill than on a bicycle. As a result, the duration of intense ischemia is much longer (14). Table 4. Stress testing methods Exercise Isotonic (treadmill, bicycle) Isometric (handgrip) Nonexercise Pharmacologic (dobutamine

  [Dobutrex], dipyridamole
  [Persantine], adenosine
  [Adenoscan], arbutamine
  [GenESA])

Atrial pacing Afterload increase (pressor agents, cold pressor) Hyperventilation ________________________________________ If a patient can tolerate use of a treadmill, better prognostic information can be provided than with bicycle ergometry. Since it is difficult to obtain echocardiographic images during treadmill testing because of excessive movement and hyperventilation, images taken at rest and at peak heart rate are analyzed. Some investigators believe that the lack of peak-exercise imaging is balanced adequately by the higher workloads that most patients can achieve on the treadmill (6). Upright or supine bicycle ergometry can be used in exercise echocardiography for diagnosis and risk assessment in patients with known or suspected CAD (15). The advantage of bicycle ergometry is the ability to capture images during all stages of exertion and to detect the exact timing of the onset of wall motion abnormalities. The ability to take images at all levels of exercise enhances the test's sensitivity for transient ischemia. The disadvantages of bicycle ergometry are lower peak workloads and technically demanding imaging (15,16). Pharmacologic agents in stress echocardiography Suggested indications for pharmacologic stress echocardiography in comparison with exercise stress testing are listed in table 5. The commonly used agents are dobutamine (Dobutrex), dipyridamole (Persantine), adenosine (Adenoscan), and arbutamine (GenESA); the common side effects of dipyridamole, adenosine, and dobutamine are listed in table 6. Table 5. Suggested indications for pharmacologic stress echocardiography versus exercise stress testing Unable to exercise because of: • Intermittent claudication • Neurologic deficits • Rheumatologic or orthopedic conditions • Chronic lung disease • Debilitation, old age Simultaneous evaluation of ischemia and myocardial viability Preoperative risk assessment in major surgery Inability to achieve target heart rate during exercise because of therapy with beta-blocker or calcium channel blocker ________________________________________ Table 6. Side effects of pharmacologic agents commonly used in stress echocardiography Adenosine Arrhythmias (VT/VF) Bronchospasm Chest tightness Dizziness Dyspnea Flushing Hypertension Metallic taste Nausea Tightness in throat Dipyridamole Abdominal distress Allergic reaction Arrhythmias Bronchospasm Dizziness Flushing Headache Hypotension Myocardial infarction Stroke (transient ischemic attack) Dobutamine Arrhythmias (SVT/VT/VF) Dyspnea Headache Hypotension Nausea Nonspecific chest pain Palpitations Tremors ________________________________________ SVT, supraventricular tachycardia; VF, ventricular fibrillation; VT, ventricular tachycardia. Information from Physicians' Desk Reference. 57th ed. Montvale, NJ: Thomson, 2003. ________________________________________ Dobutamine In the United States, dobutamine infusion is the method used most often for pharmacologic stress echocardiography. Graded dobutamine infusion--10 to 40 micrograms/kg per minute in 3-minute stages--increases myocardial oxygen demand in a fashion similar to that of staged exercise. During the dobutamine infusion, it is apparent that heart rate, contractility, and blood pressure are increased. Dobutamine has the advantage of rapid onset of action, and its effects can be reversed by giving an intravenous beta-blocker. A synthetic catecholamine that has a relatively short half-life (about 2 minutes) (17), dobutamine has strong agonist activity at the beta1 receptor and mild agonist activity at the beta2 and alpha1 receptors. Atropine sulfate can be used to increase heart rate, if necessary, and is usually administered at the peak dobutamine dose. It is usually given as a 0.5-mg bolus and in 0.25-mg increments every 60 seconds (maximum dose, 1-1.5 mg) until the desired heart rate is achieved. Dobutamine infusion is stopped after images are acquired at peak heart rate--or sooner if the patient has tachyarrhythmias. Low-dose dobutamine (5, 7.5, and 10 mg) is used to study "hibernating" myocardium. A schematic showing various segments of the left ventricle and specific coronary arteries supplying blood to these segments is presented in figure 3. Dipyridamole This agent is often used for nuclear perfusion imaging. Dipyridamole chiefly acts by blocking the uptake and transport of adenosine into cells. As a result, the availability of adenosine is increased at the receptor site, leading to vasodilatation and flow maldistribution (18). Simultaneous two-dimensional echocardiography allows determination of wall motion abnormalities caused by reduced coronary flow distal to the coronary stenoses. Recommended protocols for dipyridamole echocardiography include continuous ECG and echocardiographic monitoring during a two-stage infusion. The first stage consists of dipyridamole given at 0.56 mg/kg over 4 minutes, after which imaging is done. Monitoring continues for 4 minutes more. If wall motion abnormalities have not developed, then an additional 0.28 mg/kg is infused over 2 minutes (maximum dose, 0.84 mg/kg). As with dobutamine echocardiography, atropine can be used to increase heart rate. Aminophylline (240 mg for intravenous delivery) should be available for immediate use in case of adverse dipyridamole-related events, such as heart block, severe chest pain, or any evidence of severe myocardial ischemia. Adenosine Adenosine is by far the most commonly used pharmacologic agent in nuclear perfusion imaging. It can be used like dipyridamole and is typically infused at a maximum rate of 140 mg/kg per minute during imaging. The mechanism of action is probably identical to that of dipyridamole. However, adenosine has a much shorter half-life, and thus an antidote is usually not necessary in the event of an adverse reaction. Arbutamine This agent is a potent nonselective beta-adrenergic agonist with mild alpha1 sympathomimetic activity. Arbutamine was developed specially for pharmacologic stress testing and increases both heart rate and myocardial contractility. It has an affinity for beta receptors that is 10-fold greater and a binding at the alpha-receptor level that is fivefold less than that of dobutamine (19). Recent reviews have shown that arbutamine stress echocardiography is an accurate and safe alternative to both exercise and dobutamine stress echocardiography in diagnosis of myocardial ischemia and CAD. However, to date no studies have reported that arbutamine is superior to dobutamine. In general, the arbutamine test has been shown to be similar in sensitivity and specificity to exercise and other modes of pharmacologic stress echocardiography. The high cost of this drug precludes its routine use over other available agents (19). Stress testing in women Obtaining accurate results during stress testing in women is a well-known challenge. Exercise-induced ST-segment depression is a less sensitive result in women than in men, which reflects both a lower prevalence of severe CAD and the inability of many women to exercise to maximum aerobic capacity (20). Women tend to release greater amounts of catecholamines during exercise than men, which is thought to potentiate coronary vasoconstriction and augment the incidence of false-positive test results (21). However, women have a low false-negative rate in exercise stress testing, which suggests that routine testing reliably rules out CAD in women with negative results (22). Because studies have reported a high prevalence of false-positive ST-segment depression in women, a common concern is whether this group should undergo standard ECG stress testing alone or should always undergo stress testing with echocardiography or nuclear imaging (3). Addition of some form of imaging to exercise stress testing markedly improves test accuracy in women (23). Use of single-photon emission computed tomography may not increase test accuracy in women as it does in men (24). Much of the inaccuracy of thallium scanning in women has been attributed to breast attenuation. In this regard, higher-energy isotopes, such as technetium Tc 99m sestamibi, may be better, but they are not perfect. In women, use of pharmacologic stress agents coupled with either echocardiography or nuclear imaging substantially improves test performance over electrocardiography alone. Stress echocardiography versus nuclear perfusion imaging Several studies have compared stress echocardiography with nuclear perfusion imaging (7,25). Overall, the sensitivity and specificity of the two techniques are comparable and range between 70% and 80%. Quinones and colleagues (25) reported that the overall sensitivity and specificity of stress echocardiography were 85% and 88%, respectively, compared with 85% and 81% for exercise thallium testing. The sensitivity of exercise echocardiography and exercise thallium testing for CAD in patients with one-, two-, or three-vessel disease was also similar (58%, 86%, and 94% versus 61%, 86%, and 94%, respectively). The negative predictive value for cardiac events--defined as death, nonfatal MI, and revascularization--of both techniques is excellent (ie, greater than 90%) (10,11,26). However, stress echocardiography may have a few advantages when compared with radionuclide imaging (27). First, echocardiography provides more complete assessment of left ventricular wall motion, because it is a tomographic, rather than planar, technique. Second, echocardiography is a real-time examination, allowing instantaneous imaging rather than averaging the image over several minutes. Third, stress echocardiography is noninvasive and includes no exposure to radiation, plus patients do not have to return to the imaging laboratory for redistribution imaging. Finally, the overall cost of stress echocardiography is lower than that of nuclear perfusion imaging, and additional information about cardiac valves, pericardium, and wall thickness is provided by echocardiography at no extra cost. Summary Exercise stress testing remains one of the most widely used techniques in assessing functional capacity and in confirming a diagnosis of CAD. Its sensitivity and specificity are approximately 63% and 74%, respectively. The technique is safe when administered and supervised by qualified personnel who are trained to recognize contraindications and other reasons for termination of the test. More recently, echocardiography has been combined with exercise stress testing. It is a well-tolerated and valuable procedure for noninvasive evaluation of CAD. The sensitivity and specificity of stress echocardiography are higher than those of exercise stress testing and comparable to those of nuclear perfusion imaging. Continuing improvements in digital image analysis, cost, and the availability of contrast agents promise to make noninvasive stress testing even more useful in the years to come. Newer contrast and concomitant perfusion agents are on the horizon and may prove to be a reality in the echocardiographic laboratories of the future. References 1. Marwick TH, Nemec JJ, Pashkow FJ, et al. Accuracy and limitations of exercise echocardiography in a routine clinical setting. J Am Coll Cardiol 1992;19(1):74-81 2. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30(1):260-311 3. Cardiovascular stress testing: a description of the various types of stress tests and indications for their use. Mayo Clinic Cardiovascular Working Group on Stress Testing. Mayo Clinic Proc 1996;71(1):43-52 4. Gill TM, DiPietro L, Krumholz HM. Role of exercise stress testing and safety monitoring for older persons starting an exercise program. JAMA 2000;284(3):342-9 5. Ryan T, Feigenbaum H. Exercise echocardiography. Am J Cardiol 1992;69(20):82-9H 6. Crouse LJ, Harbrecht JJ, Vacek JL, et al. Exercise echocardiography as a screening test for coronary artery disease and correlation with coronary arteriography. Am J Cardiol 1991;67(15):1213-8 7. Beleslin BD, Ostojic M, Stepanovic J, et al. Stress echocardiography in the detection of myocardial ischemia: head-to-head comparison of exercise, dobutamine, and dipyridamole tests. Circulation 1994;90(3):1168-76 8. Roger VL, Pellikka PA, Oh JK, et al. Stress echocardiography. Part I. Exercise echocardiography: techniques, implementation, clinical applications, and correlations. Mayo Clin Proc 1995;70(1):5-15 9. Armstrong WF, O'Donnell J, Ryan T, et al. Effect of prior myocardial infarction and extent and location of coronary disease on accuracy of exercise echocardiography. J Am Coll Cardiol 1987;10(3):531-8 10. Marwick TH. Use of stress echocardiography for the prognostic assessment of patients with stable chronic coronary artery disease. Eur Heart J 1997;18 Suppl D:D97-101 11. Marcovitz PA. Prognostic issues in stress echocardiography. Prog Cardiovasc Dis 1997;39(6):533-42 12. Reilly JP, Tunick PA, Timmermans RJ, et al. Contrast echocardiography clarifies uninterpretable wall motion in intensive care unit patients. J Am Coll Cardiol 2000;35(2):485-90 13. Marwick TH. Advances in exercise echocardiography: Can this technique still thrive in the era of pharmacologic stress testing? Echocardiography 1999;16(8):841-56 14. Klein J, Cheo S, Berman DS, et al. Pathophysiologic factors governing the variability of ischemic responses to treadmill and bicycle exercise. Am Heart J 1994;128(5):948-55 15. Smart SC, Sagar KB. Diagnostic and prognostic use of stress echocardiography in stable patients. Echocardiography 2000;17(5):465-77 16. Agati L, Arata L, Luongo R, et al. Assessment of severity of coronary narrowings by quantitative exercise echocardiography and comparison with quantitative arteriography. Am J Cardiol 1991;67(15):1201-7 17. Geleijnse ML, Fioretti PM, Roelandt JR. Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography. J Am Coll Cardiol 1997;30(3):595-606 18. Chaudhry FA. Adenosine stress echocardiography. Am J Cardiol 1997;79(12A):25-9 19. Ketteler T, Krahwinkel W, Wolfertz J, et al. Arbutamine stress echocardiography. Eur Heart J 1997;18 Suppl D:D24-30 20. Schlant RC, Blomqvist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the Joint American College of Cardiology/American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Exercise Testing). Circulation 1986;74(3):653-67A 21. Clark PI, Glasser SP, Lyman GH, et al. Relation of results of exercise stress tests in young women to phases of the menstrual cycle. Am J Cardiol 1988;61(1):197-9 22. Weiner DA, Ryan TJ, Parsons L, et al. Long-term prognostic value of exercise testing in men and women from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 1995;75(14):865-70 23. Hung J, Chaitman BR, Lam J, et al. Noninvasive diagnostic test choices for the evaluation of coronary artery disease in women: a multivariate comparison of cardiac fluoroscopy, exercise electrocardiography and exercise thallium myocardial perfusion scintigraphy. J Am Coll Cardiol 1984;4(1):8-16 24. Fintel DJ, Links JM, Brinker JA, et al. Improved diagnostic performance of exercise thallium-201 single photon emission computed tomography over planar imaging in the diagnosis of coronary artery disease: a receiver operating characteristic analysis. J Am Coll Cardiol 1989;13(3):600-12 25. Quinones MA, Verani MS, Haichin RM, et al. Exercise echocardiography versus 201TI single-photon emission computed tomography in evaluation of coronary artery disease: analysis of 292 patients. Circulation 1992;85(3):1026-31 26. Pozzoli MM, Fioretti PM, Salustri A, et al. Exercise echocardiography and technetium-99m MIBI single-photon emission computed tomography in the detection of coronary artery disease. Am J Cardiol 1991;67(5):350-5 27. Pellikka PA, Roger VL, Oh JK, et al. Stress echocardiography. Part II. Dobutamine stress echocardiography: techniques, implementation, clinical applications, and correlations. Mayo Clin Proc 1995;70(1):16-27 The authors thank Marshfield Medical Research and Education Foundation for its support through the assistance of Alice Stargardt, Doreen Luepke, and Graig Eldred in preparation of this manuscript. Dr Tak is staff cardiologist, department of cardiology, Marshfield Clinic, Marshfield, Wisconsin. Dr Gutierrez is a cardiology fellow, department of cardiology, Scott and White Clinic, Temple, Texas. Correspondence: Tahir Tak, MD, PhD, Department of Cardiology, Marshfield Clinic--Marshfield Center, 1000 N Oak Ave, Marshfield, WI 54449. E-mail: tak.tahir@marshfieldclinic.org.

[edit] Discussion of other screening techniques

I think there is too much of this article devoted to other screening techniques. Simply mentioning them as alternatives in a separate paragraphs and putting links may be more helpful to the reader, as there is a great quantity of information in the article already.

Also glaringly obvious: a lack of any description of protocols, expected findings, exercise tolerance measurements, and implications of any findings.

I will check references on Duke nomograms and their applicability to prognosis in populations. Duke nomograms quantify annual risk of CV mortality as contrasted with Framingham 10 year cumulative risk scores.

The reference to a person dropping dead after good performance on stress treadmill (Further Research: "However, there was also long-standing experience that some people could exercise all the way to maximum predicted heart rate, have no abnormal symptoms and completely normal stress test results, only to die of a massive heart attack within a few days to weeks." ) is anecdotal and not helpful in objective quantitation of risk or behavior modification.

Sw2727 14:47, 8 March 2007 (UTC)

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