Assessment of stable ischemic heart disease. Which tests are best for which patients?

Exercise testing in special populations: athletes, women, and the elderly

Exercise testing in special populations such as athletes, women, and the elderly requires additional considerations from the clinician. Different protocols, as well as special accommodations, may be necessary for performing the test. Symptomatic athletes may have a number of cardiac conditions that lead to ischemic changes on the exercise test. Asymptomatic athletes often use serial exercise testing to evaluate the efficacy of training programs. For women and the elderly, assessment of risk factors and evaluation of symptoms are important considerations before performing the exercise test. Negative exercise test findings suggest a low risk for future cardiovascular events. Positive exercise test findings must be interpreted in light of the individual's pre-test probability. Assessment of the needs of these patients allows the clinician to tailor the exercise test to produce useful information.

Chronic stable angina pectoris. Risk stratification and treatment

Workup of stable angina patients begins with careful history taking and evaluation of various risk factors, physical examination, and a resting electrocardiogram (ECG). A noninvasive exercise stress test is valuable for risk stratification. Abnormalities on a resting ECG or equivocal results on a stress test warrant an exercise test combined with thallium scintigraphy, which is more sensitive and specific. Cardiac catheterization is advisable for patients with chest discomfort and multiple risk factors, even if results of thallium testing are negative. Patients with severe or progressive angina or congestive heart failure should also have cardiac catheterization. Nitrates, beta-adrenergic blockers, and calcium channel blockers are cornerstones of medical therapy. Revascularization with coronary artery bypass graft is recommended for patients with left main coronary artery disease, left ventricular dysfunction, or severe proximal three-vessel coronary artery disease. Percutaneous transluminal coronary angioplasty (PTCA) is a good alternative for one- or two-vessel disease. Three-vessel PTCA can be accomplished, but its real role still remains to be established.