Stress testing: Problems and appropriate use in acute coronary syndromes.

In the early days of stress testing, there was a consensus that exercise was contraindicated in patients who had unstable angina and an acute myocardial infarction. Most patients were hospitalized for 2 or 3 weeks, and at some interval after the event, they exercised on a limited workload to determine just how vigorous their rehabilitation should be. In 1977, my colleagues and I surveyed 1,375 centers to determine the risk of exercise testing, which included a population of 448,396 tests. 1 Few large surveys have been published since that time, but the indications for exercise testing have progressively relaxed. In 1984, Butman et al 2 reported on a series in which submaximal exercise testing was accomplished safely in patients who had unstable angina after 3 days of observation; this was followed by several other studies that confirmed that, under some circumstances, exercise testing was not only safe but clinically useful in patients who had this syndrome. This was followed by reports in which exercise testing was used in the emergency department on patients who were being triaged for chest pain, 3,4 a group that would contain a significant number of patients who had unstable angina and probably a few who had non‐ST-segment elevation myocardial infarction. This issue of the American Journal of Cardiology contains a report with a conclusion that exercise testing is safe in patients who have unstable angina and non‐ST-segment elevation myocardial infarction. 5 I will leave it to the readers to determine how safe a test is that results in 1 death and 2 myocardial infarctions among 494 patients. This editorial presents evidence that I hope will create a certain degree of caution in this situation. During the 20 years since the report by Butman et al, 2 there has been no organization or agency that has the capacity to track untoward events in most exercise laboratories and there is little incentive for self-reporting. Because of my prolonged interest in exercise testing, I am frequently contacted by attorneys defending or prosecuting physicians or hospitals after an accident or death in the exercise laboratory. I present one case that I believe illustrates some of the problems when using exercise testing in this setting and then propose some issues that I believe are worth considering. CASE HISTORY A 66-year-old man who had a 26-year history of smoking had recent onset of chest pain, sometimes at rest. He had a significant family history, and his son recently died of a myocardial infarction. In 1996, he had a consultation before planned foot surgery; an electrocardiogram showed high voltage and evidence of an inferior wall myocardial infarction and an echocardiogram showed inferior wall hypokinesia. Ten days before his exercise test, he had an examination and an electrocardiogram (Figure 1). He then reported to a hospital laboratory for an exercise test and reported only to the monitoring physician that he had exercise-induced angina. There was no previous review of the electrocardiogram seen by the cardiologist 10 days before, and there was no direct communication. He collapsed during the fourth minute of the exercise test after having an onset of chest pain 1 minute previously (Figures 2 and 3). CRITIQUE This case history illustrates some problems that lead to serious complications associated with stress testing. (1) The physician did not have the information