If you are wondering if you should have a stress test, you’re not alone. This is one of the most common questions I get from my patients. You may be surprised that the answer has changed over the years. And what you need to know is that based on more recent research, many stress tests are unnecessary.
There are an estimated 8 million heart stress tests done each year in the US, making them among the most common heart testing procedures done in medicine. While there are a variety of reasons why a stress test is performed, the most common reason is to assess for blockage in the heart arteries, which is called coronary artery disease.
Stress tests are often done on people with no symptoms to provide reassurance the heart is ok. Annual stress tests were commonly performed in the past, but as we learn more about the limitations of opening blocked heart arteries in people who are not currently having a heart attack, the idea of “Let’s make sure everything is ok.”, doesn’t make sense.
Should you have a stress test?
The decision to have any procedure in medicine needs to weigh the risks against the benefits, and stress testing is no different.
While generally safe, stress tests do have risks. For one, frequent or regular nuclear stress tests expose individuals to a large amount of radiation. It is not known that this radiation exposure leads to subsequent problems like an increased risk of cancer, but it also hasn’t been shown to be safe either. Given this uncertainty, a thoughtful approach to nuclear stress testing, particularly in young people is warranted, and there is likely no role for annual nuclear stress testing.
Another risk of stress testing is an increased likelihood of having an invasive procedure that can have complications. Stress tests are not perfect. There is a chance for false positive and false negative results, which doctors call the sensitivity and specificity of the test. When imperfect tests are applied to a low probability group (such as those who are asymptomatic without significant risk factors for heart disease), there can be even more false positives than true positives. The problem with false positive stress tests is they often lead to invasive procedures like heart catheterization, which may put the person at unnecessary risk of complications.
The risks of stress testing are low, but not zero. It’s when we balance that risk against the benefits that stress testing in asymptomatic, low-risk individuals doesn’t make sense.
The rationale for stress testing for people without symptoms in the past was it would be beneficial to discover heart artery blockages that could be fixed with a stent or bypass surgery. However, subsequent research has NOT shown that stents or bypass surgery in most people with stable heart disease (meaning not during a heart attack), saves lives or lowers the risk of future heart attacks.
Previous studies to assess the benefits of stents and bypass surgery in stable heart artery disease did not show a decrease in death or heart attacks. However, they may improve symptoms in those who had chest pain called angina. More recently, a large study with more modern therapy confirmed these findings.
The ISCHEMIA trial of over 5,000 people with a blockage in a major heart artery were randomized to fixing the blockage and medications or just medications. The study found no differences in death, heart attack, heart failure, or hospitalization between the two groups.
A 2014 study found that over one-third of stress tests are unnecessary at the cost of over $500 million per year. These and other studies call into question the idea of doing stress tests on people with no symptoms. If there are no benefits, why would we accept any risks? Yet, stress tests for screening or as part of an executive physical remain common.
If you are considering doing a stress test, I recommend you have a thoughtful, shared decision-making discussion with your physician. I will also emphasize that stress tests in those with symptoms, such as chest pain or shortness of breath, are often indicated.
Lastly, this article is not medical advice. Stress tests and their role in managing heart artery disease is complicated. There are many factors to consider, too many to explain in a single article. The best approach is for your physician to explain the medical risks, benefits, and alternatives, and for you to balance that information with your values and goals.