We’ve all seen a patient running on a treadmill during a stress test in a medical TV drama. But not everybody needs one – and they’re hardly dramatic. Dr. Sameer Chaudhari, a cardiologist at Novant Health Heart & Vascular Institute in Monroe, North Carolina, explains who needs the test, what kind of tests are available and what happens next.

What is a stress test?

“A stress test is a test in which a patient’s heart is stressed under medical supervision to see if their heart is able to tolerate the stressful condition,” said Chaudhari. “Once a patient is referred to a cardiology clinic, it’s up to the patient and physician to determine what type of test is most appropriate.”

Two main factors determine whether a patient may get a stress test ordered by their primary care physician or cardiologist: (1) patient profile and (2) symptoms. “It’s not meant for anybody and everybody, it’s mainly based on a combination of patient profile and symptoms,” Chaudhari said.

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What kind of patient profile may lead to a stress test referral?

People who have a higher risk of developing heart disease. That includes:

• A family history of heart disease.
• Ethnic minorities, elderly people, men and people of lower socio-economic status.
• Patients with risk factors including, but not limited to, high cholesterol, diabetes, high blood pressure (hypertension), obesity and tobacco use.

What types of symptoms may lead to a stress test referral?

The most common symptoms for referral are chest pain or shortness of breath with or without exertion. Less common symptoms that could suggest blood vessel blockages include dizziness, light-headedness, weakness, vomiting and a racing heartbeat.

“I usually see adults that are over 50 and have two or more risk factors,” Chaudhari said. “Most of the time, the patient goes to their primary care physician with symptoms, and the PCP will either refer the patient to our cardiology clinic or occasionally order the stress test, depending on the clinical picture.”

The stress test is used to reveal any issues with blood flow caused by a range of conditions such as blockages in arteries (atherosclerotic coronary artery disease), high blood pressure and risk of congestive heart failure.

What are the three types of stress tests?

• Exercise stress test: An exercise stress test using a treadmill and an electrocardiogram (EKG) is the simplest form of a stress test. The patient runs or walks on the treadmill to the best of their ability with a gradual step-up in the exercise while their heart is monitored by the EKG.
• Exercise stress test with cardiac imaging: A routine treadmill stress test can be enhanced with the inclusion of cardiac imaging. This can be done with the use of an echocardiogram (an ultrasound of the heart) before and after the stress test. Similarly, a nuclear stress test can be done, which involves an intravenous tracer (a small amount of radioactive material) and recording cardiac activity with a nuclear camera.
• Pharmacologic stress test: If a patient is unable to exercise on a treadmill due to arthritis or another medical condition, the stress test can be done with the use of certain medications administered through an IV. These medications can mimic the effect of exercise in the body by increasing blood flow. This is followed by either an echocardiogram or a nuclear imaging.

What are the three possible outcomes and next steps of stress tests?

• Normal: A normal, or negative, test means you have a highly unlikely chance of developing a heart attack in the next year. “In this case, we reassure the patient that their symptoms look noncardiac, so they can continue to focus on lifestyle improvements,” Chaudhari said. “But if symptoms persist, they should come back to see the cardiologist they were referred to."
• Abnormal: An abnormal, or positive, stress test leads to next steps specific to the patient’s needs and the complexity of their results. Chaudhari said, “Medications such as baby aspirin is usually recommended to help reduce the risk of heart attack. We also assess the underlying risk factors like high cholesterol, high blood pressure or diabetes that could benefit from medications. After optimization of medical treatment, further evaluation can be done with cardiac catheterization and angiography to assess for potential blockages in the arteries of the heart. This is discussed with the patient and the family in detail prior to proceeding with an invasive procedure.”
• Equivocal: This outcome is rare, but if the stress test is not completely negative or positive, the physician will reassess the patient’s condition. “If the suspicion for underlying heart disease is high, then we will do an angiography as mentioned above, using X-ray imaging to look at the heart's blood vessels,” Chaudhari said. “Or if the patient has no further symptoms and low likelihood of underlying heart disease, we may focus on their medications.”

How long does it take to get stress test results?

“You will get them within 24 hours of the test,” Chaudhari said. “However, if the stress test is very abnormal at the time of the test itself, then usually the technician gets the cardiologist into the room right away to discuss any concerns with the patient.”

What do you do while you’re waiting for test results?

“We ask patients to hold off on any strenuous physical workouts, but patients can continue routine household activities,” Chaudhari said.

Should you worry about getting a stress test?

Don’t show up for your stress test stressed out about it. “A stress test is a very low-risk and safe procedure,” Chaudhari said. “The chances of having any complication during the stress test are less than 1% (0.01%, or 1 in 10,000). That’s why it’s always done under supervision of a certified technician, with a cardiologist in the building or facility.”

Haven’t been ordered a stress test but think you need one?

“There is no general rule of thumb when it comes to ordering a stress test,” Chaudhari said. “If you have concerns, talk to your provider.”