Safety of stress testing in patients with elevated cardiac biomarkers: Are all modalities created equal?

Excerpt

The safety of stress radionuclide myocardial perfusion imaging (MPI) was established more than two decades ago.1-3 This supposition has been a solid foundation in our practice such that we often resort to exercise and pharmacologic stress studies as the preferred risk stratification tools and as means to mitigate risk associated with invasive procedures. Before invasive coronary angiography was widely implemented in the evaluation of patients recovering from uncomplicated myocardial infarction (MI), pre-discharge low-level exercise stress test, using the modified Bruce protocol, was established as a safe and effective risk stratification tool. Seminal work by leaders in the field of nuclear cardiology capitalized on the added prognostic value of MPI to enhance the risk assessment of patients recovering from uncomplicated MI. Heller et al and Brown et al demonstrated that dipyridamole MPI performed 2-4 days following uncomplicated MI is not only safe but also superior to submaximal exercise stress MPI in identifying patients at risk.4,5 On the other hand, Mahmarian et al demonstrated the added prognostic value of adenosine stress MPI to invasive coronary angiography in patients with uncomplicated MI.6 Such studies paved the way for the INSPIRE trial which prospectively demonstrated that adenosine stress radionuclide MPI, performed within 10 days of uncomplicated MI, not only defines risk but can also guide patient management.7 …