Stress Testing Options 
Exercise Treadmill Stress
Test (treadmill only; ETT):
• Order if patient is low to intermediate risk for CAD, but having chest, arm, or back discomfort, or shortness of breath with exertion.
Useful to answer questions about arrhythmias and functional aerobic capacity.
• Not recommended if patient already has EKG abnormalities, such as LVH, LBBB, or ST-T changes. Not optimal
for patients with documented CAD or for those who cannot walk on the treadmill.
• Women may have false-positive EKG results and it is preferred to include some type of imaging along with the exercise testing.
Stress Echocardiogram
(treadmill exercise with echo imaging before and after exercise):
• Has improved sensitivity and specificity over an ETT and gives information about LV function, valvular function, and pulmonary artery pressures.
• Order if improved test sensitivity is required, in middle-aged women with chest pain, or those with resting EKGs that are abnormal (except LBBB or paced rhythm). Less expensive than a nuclear stress test. Also very useful in patients with established CAD.
• Not recommended if patient is unable to walk on treadmill, or those who have LBBB or paced rhythm, patients over 250 pounds, or those with severe COPD.
Dobutamine Stress Echocardiogram
(stress test using dobutamine infusion and echocardiographic imaging):
• Order for same indications as a stress echo, but patient unable to walk on treadmill. Avoid in patients with LBBB or paced rhythm.
Bruce Cardiolite (treadmill exercise testing coupled with nuclear perfusion imaging using Cardiolite before and after exercise – 4-hour test):
• LV function is evaluated with a gated blood pool scan.
• Order in patients with known CAD, abnormal EKGs, or in those without documented CAD and chest pain for the purpose of risk-stratification. Very useful for preoperative risk assessment in patients at moderate to high risk for CAD who are undergoing intermediate to high-risk surgery. Sensitivity and specificity for detection of CAD is similar to or slightly superior to stress echo.
• Not recommended if patient unable to walk on the treadmill, LBBB on EKG, paced rhythm, atrial fibrillation, or frequent PVCs.
Adenosine Cardiolite (a nuclear stress test using an adenosine infusion to achieve coronary vasodilation coupled with nuclear perfusion imaging, using Cardiolite before after infusion – 4 hour test):
• Order for same indications as Bruce Cardiolite except functional capacity.
• Designed for patients who cannot walk on the treadmill.
• Not recommended for patients with COPD or asthma, unless only mild or intermittent (severe bronchospasm may occur with adenosine).
• An ideal test for patients with LBBB or paced rhythm. Can be ordered in patients with atrial fibrillation.
Dobutamine Cardiolite (a nuclear stress test using dobutamine infusion for chronotropic and inotropic action and nuclear perfusion using Cardiolite before and after infusion – 4-hour test):
• Order in patients with significant lung disease who need a nuclear stress test and cannot walk on the treadmill.
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These are general rules to assist you in ordering tests for your patients. For more information, please see the web sites for the American College of Cardiology at www.acc.org, or the American Heart Association at
www.americanheart.org/.