Snapshot A 62-year-old man presents to his primary care physician a few days after developing chest pain. This is the first time he has ever had chest pain and it occured while he was shoveling snow. Past medical history is unremarkable. He denies to ever drinking alcohol but has smoked half a pack of cigarettes per day for 30 years. He went to the emergency department and was found to have a normal electrocardiogram and CK-MB. The patient denies having another episode of chest pain since. Arrangements are made for cardiac stress testing. Introduction Cardiac stress testing can allow for the diagnosis of cardiac disease and is a prognostic tool the type of cardiac stress testing depends on the type of stress such as exercise pharmacologic the type of assessment electrocardiogram (ECG) echocardiography (echo) radionuclide imaging (nuclear stress test) Factors to take into considerationg when performing cardiac stress testing are many, and include the patient's ability to exercise their resting ECG a history of prior revascularization Cardiac Stress Testing Cardiac Stress Testing Modalities Modality Comment Exercise treadmill testing Preferred in patients who are able to exercise with limited symptoms and interpretable ECG Contraindications include acute myocardial infarction unstable angina symptomatic severe aortic stenosis acute pulmonary embolism, endocarditis, myocarditis, pericarditis, and dissection Pharmacologic stress testing Typically performed in patients who cannot exercise or in patients with uninterpretable baseline ECG (e.g., bundle branch block) pacemaker Pharmacologic agents vasodilators are preferred in radionuclide myocardial perfusion imaging and include adenosine dipyridamole regadenoson should not be performed in patients with bronchospastic airway disease inotropes and/or chronotrope drugs include dobutamine (preferred for stress echo) atropine