TABLE 456 Contraindications to Exercise Testing

The clinical utility of ED stress testing depends upon the test result's ability to modify the pretest probability of the diagnosis and to change treatment and disposition. ED stress testing is particularly difficult to quantify because test sensitivity and specificity are greatly influenced by the population being tested. As the pretest probability of significant coronary artery disease increases, the likelihood of a false-negative test also increases. Conversely, when a population with a very low pretest probability of disease is tested, the likelihood of a false-positive result increases. Therefore, based on current data, diagnostic stress testing is recommended for patients with a low pretest probability of coronary artery disease and is unlikely to be helpful in those at either very low risk (<5 percent) or those at moderate to high risk (>30 percent).2526 The pretest probability of disease can be determined semiquantitatively based on demographic, historical, and ECG data using a number of validated decision aids. ED stress testing may be of further value when applied to a broader range of patients if the goal of testing is to predict prognosis rather than diagnosis. Stress-test performance of post-AMI patients is a valid and commonly used predictor of post-event prognosis, and several recent studies suggest that ED stress testing of selected patients can reliably predict short-term prognosis.

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