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Stress test accuracy
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Stress test accuracy

Hello,

One of my family members (late 70's in age but active and an exerciser) recently had a NORMAL nuclear stress test with no signs of ischemia. There was no chest pain, SOB or other symptoms. No fatigue during the test. Because of some benign palpitations, they also had a series of other testing....EKG's, blood work, echo, 2 24 hour Holter's -- all normal.

A couple weeks following the normal stress test, an E.R. visit for some chest pressure. Again, labs, EKG etc. were normal but because of symptoms and other discusssions a catheterization was performed, a very signficant blockage was found in the LAD and a stent was placed.

A stress test to follow up the stent weeks later was also NORMAL. Here's my question: If there are a very small percentage of false negatives, as I understand, with stress tests (and this was one case) is it appropriate to then follow-up the placement of a stent with a stress test?  Would catheterization be in order here?  It would seem to me that if the stress test was normal to begin with, it would be "normal" again even if there was a problem.  Thank you.
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239757_tn?1213813182
volare,

thanks for the post.

There are a few reasons why your test didnt show anything. First, stress testing is not perfect. The are false positives and false negatives with the test. The more likely a person is to have significant coronary disease increases the risk of a false negative. That said, stress testing itself can be prognostic, even if the test is negative. For instance, if a patient can exercise to an adequate level, then the stress is predicitve of better outcomes.

Second,  there is a chance that your family member had an unstable plaque in the artery that ruptured leading to thier chest pains. Usually, the plaques that cause these problems are not the severe ones that show up on a stress test. Given, his presentation, this scenario may be more likely. Once the blockage was opened, then the repeat stress would be normal.

hope this helps....either way your family member needs to make sure he/she is doing all the things to prevent other blockages from progressing like lifestyle and risk factor modification.

good luck
23 Comments
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Avatar_n_tn
It will be interesting to hear what the doctor says about the accuracy of the stress test, but this is what I found

http://www.heartsite.com/html/regular_stress.html

What is the reliability of a Regular Stress Test? If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% or 2/3 rd of patients with coronary artery disease. The accuracy is lower (about 50%) when patients have narrowing in a single coronary artery or higher (greater than 80%) when all three major arteries are involved. Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease
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129317_tn?1189759421
Hello all.  As usual, I completely agree w/ Al Dente.  I am living proof that a stress test is not necessarily an accurate indicator.  I had my 6th heart cath over a 5 month period last week, and they did angioplasty to relieve a 95% blockage in my LAD and added my 5th stent.  I have passed all of my stress tests (except for 1 nuke stress test).  As a result, I have some confidence in the nuke stress test, as it has "at times" been able to find ischemia; however, I have passed this test as well with blockage of 90% or more found in a following heart cath.  I put no stock in the regular stress test.  I think it is probably a good idea to have one as it is non-invasive and can find problems in some people.  However, if I was having chest discomfort and the stress test came up negative, I would not feel comfortable accepting those results as the ground truth.  By the way, EKGs aren't a reliable test for me either.  I only value them in determining that I haven't had a heart attack.  But I wouldn't trust one to help prevent a heart attack.  I don't think they can accurately determine if you have building placque that can lead to a future heart attack. And I am a huge proponent of preventing heart attacks rather than focusing on treating them after they occur.  God Bless!
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97628_tn?1204465633
My mom, she's in her 70's, had an ekg a few months ago that indicated a possible MI. I then took her for a thallium stress test which came back negative.  She says she has no symptoms. She is on Toprol for her BP and has always been very anxious.  Her cholesterol seems to be okay though. Now you've got me thinking we still know nothing...
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63984_tn?1385441539
I've had six stress tests, each indicated problems and were right on the target.  Suggesting they are simply a money-making procedure seems a reckless and careless remark to someone with sincere questions.  I recently had a stress test that indicated blockages in the Right Coronary Artery, and guess what, I have three more stents. I'm able to breathe again during exercise, and I'm thrilled.  A stress test obviously isn't a perfect test, but read the doctor's comments, they make a huge amount of sense.
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61536_tn?1340701763
I don't trust stress tests.  My dad had one that was perfect and he had a triple bypass (80, 90 and 90 blocked) two weeks later.  He'd been going to the ER for FIVE YEARS with cardiac pain and they kept sending him home with Maalox.  The Maalox never worked.  Nitro did the trick.  When it did, they did the catherization and found the problem.

Similarly his two brothers passed stress tests.  One had four bypasses and the other had SIX!!!  They did the catherizations on them because of a family history of early onset CAD.  My dad has since been back (at 7 years post-op) for three more stents, though his original graft sites remain clear.

I suppose stress testing can show the really really bad cases, but my dad and his brothers were/are very active guys.  That puny treadmill was nothing compared to a day's work for them, and I think that the heart adapts to need and fitness level.  But that's speculation.

All that said, I am glad the problem was found and stented.  Hopefully that will cure the symptoms.
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88793_tn?1290230777
Have anyone compare the stress test with holter monitor?  Some said ECG will show ST segment!  Is that true?
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129317_tn?1189759421
I don't agree that Al Dente's negative comments about stress testing are reckless and careless - quite the opposite.  I'm very glad that the test was helpful to you, but as you can see from other postings, it is simply not an accurate diagnostic tool from some and shouldn't be considered as such.  I agree that the docs comments were good (as usual), but Al Dente's original posting wasn't in response to the docs, but was actually placed before the doc made his post.  Anyway, I can understand your confidence in the stress test since it has been helpful to you, but as I said earlier, from my experience if I am having true cardiac symptoms (chest discomfort/pressure) I will not stop seeking medical care simply because I pass a stress test.  For me, it has proven to be an inaccurate test.  I think it is a okay to be used as an initial diagnostic tool since it is non-invasive, but I think dismissing classic chest pain symptoms as non-cardiac related by only doing a stress test is reckless and careless.  Thank goodness it found your problems though, and I hope you are doing better now.  Take care!
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Avatar_n_tn
Hi there,

I read your comments with interest. It sounds to me like your dad/uncles we're able to do strenuous activity without any pain?

Is it really that common to have a blockage and not suffer from chest pain?  I ask because my husband has symptoms other than chest pain and a rotten family history, and feels until he gets the pain, he is fine. I have been begging, cajoling you name it to get him to a Dr. He is short of breath with basic activities but has a job where he is lifting all day and seems to be fine with this. I'm not convinced...

And now, after reading this thread, maybe it ISNT uncommon to not experience a lot of pain.

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Avatar_n_tn
I am a 54 old male and had a heart attack 9 months ago. I had no chest pain nor did I have shortness of breath. I had some discomfort between my shoulder blades. (I remember going up and down stairs serval times with no pain.) I went to the ER for muscle relaxants because I thought I had pulled a muscle or pinched a nerve. The Drs ran a EKG on me because I was over 50 and wanted to rule heart problems. Instead, they found I was suffering a heart attack.

While the most common symptons for men are chest pain, arm pain, jaw pain, shortness of breath, it is indeed possible to have a heart attack w/o alot of pain.  Women can also present with symptons than men.

It can be difficult to diagnose a heart attack...
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Avatar_n_tn
You were suffering a heart attack?????? Oh my. Good thing you got yourself to the ER.  How are you feeling now??

So you say you didnt have chest pain before? I'm just not liking the sound of this...It seems to me symptoms other than classic angina are more common than your average joe realizes. That would include my hard headed husband who is 43, dad had quad bi-pass at 45 and died at 58. I have noticed the shortness of breath, he of course insists its all in my head.

Thanks for responding to my query. I truly do hope you're alright for a very very long time! 54 is just too young!

Scary really when you think about it....aceing a stress test with blocked arteries. Heart attacks in progress with no chest pain....

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61536_tn?1340701763
When it came right down to there being a major life-threatening problem, there was pain.  My dad described it as a truck parked on his chest with a big metal spike through the middle of it.  Incredible pressure and a pain like something had gone through his chest.  Prior to that, his symptoms were identical to reflux, which he also has.  He experienced five years worth of increasing "heartburn" episodes before finally having a heart episode.  He did not actually have a heart-damaging heart attack, but if he hadn't gone immediately to the ER, he'd have been in big trouble.

My brother in law, who suffered a massive, near-fatal heart attack at 40, said he just felt "lousy" for a few months.  Tired, generally crappy.  When his hit, he was sweating profusely and nothing would help.  Then came the pain and he called the ambulance.  He flat-lined four times during the trip to the hospital, then again once there.  Unfortunately, he suffered some heart damage, but he is alive and better since his stents were placed.

My grandfather, who finally suffered a fatal heart attack, had been having serious symptoms for days (severe pain, shortness of breath).  Stubborn, he didn't want to wait at one hospital, so he went home and finally checked into another several days later.  By then, the damage was done and he died shortly after refusing cardiac catherization.

My grandmother's symptoms were like heartburn, but she also could not catch her breath and knew something was very wrong.  The pain came in waves, but was quite nasty.

My uncle, the one who needed six bypasses, is quite overweight (340 pounds).  His breathlessness, he figured, was probably his weight.  It wasn't.  One day while he was working on a job with my father, he couldn't finish screwing in a fuse because holding his arms up made them go numb and weak and he began to sweat each time he tried.  My dad took him immediately to the ER.  Good thing.  He was the only one who didn't have pain, but he also was not having a heart attack at that point either.

From what I have seen, pain, shortness of breath, weakness and sweating seem pretty much universal.  At that point though, getting to an ER - FAST - is important.

Pain prior to the actual event though, it seems easy to dismiss as something else (muscle pain, heartburn, etc.)  This is why it's important to keep an eye on other things, like shortness of breath or weakness...or unusual fatigue.  Everyone I know who had ischemic chest pain had unusual fatigue long before the actual heart episode, usually along with the pain.  Unfortunately fatigue is vague too.

Certainly my family doesn't paint a universal picture of what every heart patient will feel, but maybe it gives an idea.  Yes, they could perform activities without pain.  Sometimes they would get pain and sometimes not.  Cardiac pain can start and stop over time, with many factors playing a role in whether it pops up or not.
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Avatar_n_tn
Things are going well (knock on wood).  They put a stent in to take care of the blockage.  I stopped pipe smoking, changed my diet, exercise more, and take my meds.  My total cholesterol dropped from 200 to 95, bad LDL from 139 to 46. My HDL is still a little low (33). The cardiologist has me on Niaspan in an effort to raise it.

I exercise every day. I walk 5 miles at a 6.5% incline on a treadmill 4 times a week and still go to rehab the remaining days.

I feel pretty good.

Good luck with your husband! I think you are doing the right thing in trying to get him to go to the Dr.  It is amazing how pigheaded some men can be in some matters.  I wish you the best of luck!
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88793_tn?1290230777
If Stress Test is so inaccurate, why they want our heart in that torture place for?  It costs AUD$958.30 which is very expensive!
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Avatar_n_tn
I myself am a little confused about stress tests, 2 years ago I was diagnosed with mild left mitro regurtitation. Have had EKG's, stress tests, echo's and passed except the prolapsse. My chest pain continued, wore a halter it found possible ischemia. Had a 2 day stress test with the dye and DR said ......something is wrong wrong with your right atrium.....stress test just happened yesterday don't have another appointment until next week to find out results. But now I am a little worried. I passed the stress test with 99% in over 7 min. I have been trying to find out more about the right atrium does anyone have any websites that could explain more in detail about the right atrium? Thanks in advance.
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88793_tn?1290230777
I don't know am I passed or not?  My duration is 1.5 mins and terminated by the Dr there.  

I'm interesting and wish to compare my holter with you.  Is that Ok?  Which numbers or sections showed possible ischemia?  Do you have a report in your hand?  

Take care.
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Avatar_n_tn
i don't have the actual test all it stated was "tracing revealed sinus rythem with an episode of tachycardia (up tp 117 mpb) with questionalble ST segment depression. Impression: possible myocardinal ischemas" doc ordered another stress test since my last two within the last 2 years all have came back clear. had stress test 2 days ago, doc didn't seem overly concerned, asked me if i ever has clots in leg or lungs.answer was no. stated that there was something wrong with my right atrium however my heart did fine during the stress test. he further stated he believes pulmonary problems need to be ruled out as well.so right now i am just waiting to see him next thursday for the results. don't know what else to do. i don't know if this was any help to you what did your summary of the report state? take care
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Avatar_n_tn
I had severe bouts of angina for 7-8 years and not TWO Stress Thalliums nor a Dobutermine Echo nor a Nuclear Adenosine Cardiolite showed anything.....I had to have a heart attack before something finally showed up.  )-:  Now, I have scarring.

With symptoms and strong family history of HD and negative tests, patients are entitled to a Heart Cath for peace of mind....
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88793_tn?1290230777
I got no doctor read on my holter report!  I paid for and he handed it to me.  Opened the door and walked out.  My GP and Cardio said, I wasn't need one.  All in my head!  Here is my holter report.  If anyone knows, please comment!

ST SEGMENT ANALYSIS
Total ST Minutes CH1 : 0
Total ST Minutes CH2 : 17
Total ST Minutes CH3 : 0
Max Delta ST Depression : -1.6 at 21:19 @ CH2
Max Delta ST Elevation : +1.9 at 6:14 @ CH2
Max ST Episode : 5 Minutes at 9:28
Max HR In ST Episode : 96

BRADYCARDIA
Pauses in Excess of 2.5 sec : 1
Max Pause : 3.2 sec at 14:14

I've a pacemaker.  I'm a wpw and the people in the web said wpw with ST segment is normal!  Stress Test said "The changes seen could be due to attenuation artefact, but ischaemia cannot be excluded."  My cardio not a concern either!
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Avatar_n_tn
I am out of my league on your scores. I am sorry I couldn't help. Have you thought about going to your regular PC or cardiologist and have him explain the readings to you? Or go back to the doctor you paid and have him explain it, (afterall you did pay for the service). If all else fails post a question in this forum and see what the doc says? Sorry I wish I could help, I never did get to see my report just a summary. Good luck keep me posted. Tanja
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88793_tn?1290230777
I saw my cardio this morning. He explains my stress test
report as follow:

Report said : 24 hour thallium study shows at most a very small
amount of reversible ischamia in the posterior wall. No major
reversibility is seen.
Cardio explained : It is due to the pacemaker pacing. They don't
know I have a pacemaker.

Report said : Clinical Indication: Multiple risk factors with
pacemaker in-situ and atypical PIC.
My explained : Proved that he didn't read my full report!

Report said : The changes seen could be due to attenuation artefact,
Cardio explained : It wasn't any ischaemia there, not real one.

Report said : but ischaemia cannot be excluded.
Cardio explained : standard print, everyone's report printed like that!

I showed/gave him a copy of my holter monitor report. He looked at that for a while. He said, "it didn't make sense!" He told me my pacemaker has a built in holter. After he checked my pacemaker, he said, "the pacemaker said only a few skip beats, that's all! If you want can take some medicine but it wouldn't help at all." See you six months time, around next year April.

I walked out with a crying and broken heart..........  Didn't get fix!
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Avatar_n_tn
Hi there, How does your cardio know medication ''wont help at all'' he is obviously blessed with psychic powers. I have had this kind of treatment from an arrogant cardio and my advice to you is, if you feel unwell and unhappy with what he had to say, get a copy of your results and go find another cardio who is less arrogant. Like you I have come out of cardio office crying inside at least. Gather your 'spirt' and get the help you need this is your life not his. Best Wishes :)
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88793_tn?1290230777
I want to request a copy of my pacemaker check report. It tells the setting and built in holter record... etc.  What is this report called?

He said won't help at all, so why I wasted my money and left the unwanted chemical flow in my body?  He didn't write the script and didn't tell me what med are they?

Pika
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A related discussion, Stress Test vs. Angiography was started.
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A related discussion, cardiac cath was started.
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