Choosing Wisely report

Imaging Stress Tests

When you need them for your heart—and when you don’t

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If you have chest pain or other symptoms of heart disease, a test that stresses your heart can be lifesaving and help guide treatment. In some cases, taking pictures of your heart while it is stressed can provide more information. The same is true if you have a history of heart disease or are at very high risk of it. But in other cases, especially in healthy people without chest pain, you should be cautious about the tests. Here’s why.

The tests aren’t always necessary.
Cardiac stress tests make the heart work hard so your doctor can see if it responds normally. Adding imaging—with sound waves (ultrasound or echocardiography) or a small dose of a radioactive substance (nuclear cardiology)—can make the test more accurate and help your doctor determine the location and severity of your blockages. If you have symptoms of heart disease or are at high risk of it, imaging stress tests can help determine your risk of having a heart attack and help you and your doctor make treatment decisions. But those tests may not be useful if you are at low risk, especially if you don’t have symptoms.

They can pose risks.
Stress tests are usually very safe, and imaging stress tests can be done with little or no radiation. But the results of stress tests can at times cause confusion, anxiety, and trigger follow-up tests that do pose some risks. Those include CT scans or angiograms, which expose you to additional radiation. While the risk from any one scan is uncertain, risks from radiation are cumulative, so it’s best to avoid unnecessary exposures. Finally, inappropriate testing can also lead to overtreatment with drugs or procedures such as angioplasty and stenting, a procedure that can relieve symptoms but may not reduce the risk of heart attack or death—and causes serious complications in 1 to 2 percent of patients.

They can be expensive.
A stress imaging test costs between $500 and $2,000. Since the tests can provide more information than routine stress tests, that may be worth it. But money spent on unnecessary tests is money wasted. So they should be used only when they will help you and your doctor treat and manage your disease.

So when are the tests warranted?
An imaging stress test should often be ordered if you have symptoms of heart disease—such as chest pain, shortness of breath, irregular heart beats, or palpitations—but can’t exercise. They can also make sense if you have an electrocardiogram (ECG) with some abnormalities that prevent an accurate interpretation during an exercise stress test. In addition, they may also make sense for high risk people without symptoms, such as those with diabetes.


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Published by Consumer Reports © 2012 Consumers Union of U.S., Inc., 101 Truman Ave., Yonkers, NY 10703-1057. Used with American Society of Nuclear Cardiology for Choosing Wisely, a project of the ABIM Foundation. Portions of this report are derived from ASNC’s “Five Things Physicians and Patients Should Question” list. © 2012 American Society of Nuclear Cardiology