While American Heart Month takes place each February, we continue to focus on the ever-important topic of heart disease, as well as the heart-healthy habits that can help you reduce your risk of developing this life-threatening condition. This month, we’d like to take a closer look at cardiac stress testing, how these tests work, what you can expect during these procedures, and more.
What Is Cardiac Stress Testing and What Is Its Purpose?
Cardiac stress tests are used to determine how a person’s heart responds when performing its hardest. Because the heart pumps more rapidly and intensely during exercise or other physical activity, cardiac stress tests can reveal issues with the heart’s blood flow that were not apparent at rest (as well as other issues such as chest discomfort, shortness of breath, dizziness, etc). A cardiac stress test can also help evaluate issues with:
- A person’s heart muscle and valves
- The adequacy of blood supply to the heart overall and to specific regions
- The electric stability of a person’s heart
Physicians can also use these tests to determine whether a patient needs additional more invasive testing to confirm a diagnosis, determine the treatment options for someone who has developed heart disease, and whether or not that treatment is effective for a specific person.
When Is A Cardiac Stress Test Recommended?
Healthcare providers can learn a lot of valuable information about the health of a person’s heart from the results of a cardiac stress test. While the test is not necessary or suitable for everyone, cardiac stress tests are often recommended by a healthcare provider to:
- Check the heart before or after a surgery
- Diagnose coronary artery disease
- Diagnose heart rhythm issues
- Evaluate exercise-induced symptoms like shortness of breath
- Guide in the treatment of heart disorders
- Look into recurrent fainting spells
If you are unable to complete an exercise-based cardiac stress test due to a medical condition, your doctor may recommend a pharmacologic-based cardiac stress test instead.
What Types of Cardiac Stress Tests Can Be Performed?
When it comes to exercise-based cardiac stress tests, there are a few options that can be considered:
- Standard Cardiac Stress Test (often referred to as a stress ECG test)
- Stress Echocardiograms
- Nuclear Stress Tests
- Pharmacologic Stress Tests
- Electrophysiologic Stress Tests (less common)
In most cases, cardiac stress tests are performed either on a treadmill or stationary bike. As previously stated, if you are unable to perform an exercise-based stress test, your doctor may recommend a different type of stress test involving administration of medicines that either increases heart rate directly or increases blood flow to certain areas of the heart.
During cardiac stress tests, a cardiologist will monitor how fast your heart is beating (using an electrocardiogram or ECG), as well as your blood pressure levels. Imaging-based stress tests are more advanced than standard stress tests, providing more detailed information with imaging of a person’s heart.
How to Prepare for a Cardiac Stress Test
In most cases, your healthcare provider will provide you with specific instructions on how to prepare for your stress test. Generally speaking, you may be asked to:
- Arrange for transportation post-exam (depending on the type of exam)
- Avoid drinking, eating and smoking for a specific amount of time beforehand
- Avoid consuming caffeine the day before and the day-of
- Bring a list of your current medications and dosages
- Bring any inhaler (for asthma or other breathing issues) that you may use
- Pause taking certain medications the day before and the day-of
- Wear or bring comfortable clothes and walking shoes
Be sure to let your doctor know if you are currently taking any medications. It’s important to note that you should not stop taking medications unless your doctor instructs you to do so. Before you start your test, your doctor will likely ask you a few medical-related questions to help assess your current state and the appropriate level of exercise (if any).
Standard Cardiac Stress Tests
Generally speaking, stress tests are:
- Performed in a doctor’s office, an out-patient clinic or a hospital
- Completed within an hour
Before the exam starts, a cardiologist will review your medical history and ask a few questions about any heart-related symptoms you may be having. Following this, your healthcare provider will ask you to undress from the waist up. Once you’re ready, they will adhere small conductors (electrodes that monitor electricity leaving or entering the body) to your bare upper torso and chest. Patients will generally wear a hospital gown to cover their chests. For those with thicker body hair, small sections of the chest may need to be shaved in order to ensure that the electrodes will adhere properly.
During most cardiac stress tests, you will most likely be asked to wear a blood pressure monitor around your arm, as well as an oxygen monitor on your pointer finger. After a baseline recording of your heart rate and blood pressure is taken, the health care provider will ask you to begin to exercise. Every few minutes the intensity of the workout will increase until it is too difficult for you to continue exercising or you are out of breath and unable to continue.
Generally, you will be asked to finish with a few minutes of slow walking/riding as a cool down. Once completed, you will be asked to stay still quietly for roughly 15-20 minutes, while your heart rate, ECG, blood pressure and oxygen saturation continue to be monitored and return to baseline. This process allows the doctors to get an in-depth idea of how your body (specifically your heart) responds to exercise. Your cardiologist will evaluate your ECG at rest and during and after exercise to look for arrhythmias, conduction changes, ischemic changes (often referred to ST segment depression or elevation and T wave changes), and other abnormalities in the electrical activity of the hear.
Echocardiogram and Nuclear Cardiac Stress Tests
Stress echocardiography and nuclear cardiac stress tests are similar to standard stress tests but are more advanced and can provide doctors with more detailed information about your heart.
Note that a stress echo uses an ultrasound to produce images of the heart, whereas a nuclear stress echo uses a radioactive material (usually referred to as a radioisotope or radiopharmaceutical) injected into the bloodstream. Another notable difference between these two tests and the standard test is that these tests include imaging of the heart, in addition to monitoring heart rate, oxygen saturation and blood pressure,
Pharmacologic Cardiac Stress Tests
When an exercise stress test is not feasible, a pharmacologic stress test is recommended. During pharmacologic cardiac stress tests, medication is used instead of exercise to increase your heart rate and/or modify blood flow to certain regions of the heart.
Electrophysiology Stress Test
Electrophysiology tests are more invasive than the aforementioned stress tests and involve advancement of catheters and electrodes through blood vessels to the heart chambers. These tests are far less commonly used than the non-invasive stress tests described earlier. This can help doctors identify the origins of rhythm irregularities in the heart and the underlying mechanisms for the conduction abnormalities. Exercise electrophysiology studies are performed with the patient on their back in a highly sophisticated cardiac laboratory.
What Are the Risks?
Although a cardiac stress test is generally safe, complications can occur. Potential adverse effects include:
- Allergic reaction to any of the administered materials (radioactive or otherwise)
- Chest pain
- Irregular heart rhythms (arrhythmias)
- Myocardial infarction (heart attack)
- Low blood pressure (hypotension)
- Shortness of breath
What Happens After a Cardiac Stress Test?
Although it may not be immediate, after any cardiac stress test, your cardiologist will review test findings with you to determine next steps.
- If your results come back normal, your cardiologist may not recommend any further testing (of course, subject to your symptoms, if any, and your family history).
- If your results are normal, but you are still experiencing symptoms, your cardiologist can order further testing to investigate what other diseases might be causing these issues or a repeat study with one of the imaging methods discussed, or repeat testing at a later date.
- If your results are abnormal, that information can inform a treatment plan and potentially the need for additional more invasive diagnostic tests, such as cardiac catheterization and coronary angiography or cardiac CT, both with contrast.
Although additional testing is often required for definitive diagnosis, abnormal stress results indicate that you may have one or more forms of heart disease. In addition to developing a treatment plan, your doctor may recommend you consider making heart-healthy lifestyle changes to help prevent the development or worsening of any heart-related issues.
Heartlanta: How It’s Changing The Cardiac Stress Test Experience for Women and Why It Matters
For those experiencing a standard cardiac stress test for the first time, you may be unaware that these tests are typically performed shirtless or in a hospital gown (meaning no bran for women). For some, this may not be cause for concern. For most women, this can be an extremely uncomfortable, awkward and embarrassing experience. These tests were originally designed for the male physique. Historically, the field of cardiology has been male-dominated, which has led to some unfortunate oversight and gender bias, impacting the treatment of and the screening of heart disease compared to other diseases like cancer.
According to the American Heart Association, more women die from heart disease than from all other cancers combined, and the number of women getting screened for heart disease is widely underreported. Although cardiovascular disease is the leading cause of death for women in America, women only make up 38% of participants in all heart-related research studies nationwide.
Thankfully, heart disease awareness has been on the rise in recent years. That said, screening, prevention, and early detection are critical components of fighting this life-threatening condition. The Heartlanta Bra may become an important way of creating inclusive, accessible screening for heart disease for all people. The Heartlanta company strives to improve the experience of stress echocardiograms for all, and advocates for women’s heart health.
The Heartlanta Bra is the only patented bra specifically designed to be compatible with the stress echocardiogram and other cardiac stress tests. This bra effortlessly lifts breast tissues away from electrodes and provides ready access for ultrasound imaging using a hook-and-loop closure at the center. The bra is designed to feel comfortable to the wearer while providing sufficient support during the exam.
In addition to the bra providing a better experience for women, it also aims to provide more accurate test results. A recent article in the Journal of Cardiovascular Imaging reports that 24% of stress echos result in a false positive interpretation. By lifting up and removing breast tissues from the area of electrodes and providing better access for the ultrasound transducer, cardiologists have observed less interference on readouts, allowing for more accurate results.
The Mission of Heartlanta
Inspired by actor and women’s advocate Jennifer Beals’ own personal experience with the stress echocardiogram, the Heartlanta Bra was developed in collaboration with three dedicated physicians – Ob-Gyn Sherry Ross, MD, cardiologist Nicole Weinberg, MD., and cardiologist and imaging specialist Harvey Berger, MD.
The Heartlanta Bra mission is simple:
- Empower women to have a more dignified, comfortable stress echocardiogram experience.
- Offer a first-of-its-kind medical bra to be worn during a stress echocardiogram, providing comfort to female patients as well as more accurate test results for physicians.
- Demystify stress echocardiogram procedures for women and increase access to better health.
To learn more about Heartlanta, visit their website here. To learn more about heart disease and what you can do to prevent and/or lower your risk, consider my previous article: Everything You Need to Know About Heart Disease
Disclosure: I am a shareholder in and unpaid advisor to the Heartlanta Bra company. I have worked with co-founders, Dr. Ross and Ms. Beals for several years focusing on medical, regulatory and business matters.