Risk Stratification in CAD

Courtesy Dr. Johnathan Lindner

Courtesy Dr. Johnathan Lindner

The decision to perform exercise or pharmacologic stress testing or coronary CT angiography is based on the patient's:

    pretest likelihood of CAD

    baseline ECG

    ability to exercise

    comorbid illnesses that limit pharmacologic testing

Stress testing is most useful in patients at intermediate pretest likelihood of CAD (10% to 90%).

    In patients with low pretest probability, a normal test result only confirms that the patient is low risk (an abnormal stress test result is most likely a false-positive).

    In patients with a high pretest likelihood, the use of stress testing for diagnostic purposes is not indicated (an abnormal result confirms the presence of disease and a normal result likely to indicate a false-negative). 

Contraindications and Situations Where Use Is Not Advised

    All Forms of Stress: Active ischemic CP, ACS, Recent STEMI, DecompensatedCHF, Aortic dissection, Severe arrhythmias

    Exercise: Inability to exercise, poor conditioning, instability, claudication, COPD, Myocarditis, pericarditis

    Dobutamine; Severe hypertrophy or HOCM, Severe ventricular arrhythmias, severe hypertension

    Dipyridamole/Adenosine: Reactive airways dz, Wheezing, Hypotension (SBP<95), Advanced AV block, Allergy, Recent caffeine