Who Should Get a Cardiac Stress Test?

Not long ago, a close member of my family called to tell me that he wanted to have a cardiac stress test and “Did I think that it was a good thing to do?”

Without hesitation, I told him it was a bad idea for an exquisitely healthy 40-something year old man who can easily run five miles without any symptom. Here’s why. Cardiac stress testing is not for everyone, and may do more harm than good if inappropriately advised.

In modern-day America, there is a tremendous emphasis on preventive medicine to keep us healthy and, mostly, for very good reasons.  “An ounce of prevention is worth a pound of cure,” Ben Franklin advised many years ago.  Most of my cardiology practice now is directed at finding early signs of trouble, such as high cholesterols, hypertension and diabetes. All these issues, if treated early enough, can and will prevent trouble later in life.  But these “abnormalities” are not black and white but mostly gray and may be overdiagnosed and treated causing more harm than good.

Cardiac stress testing is a very valuable study to uncover potentially serious and sometimes fatal coronary artery disease. But should everyone over 40 have such a study?  If not, who should and who shouldn’t?

There are three subsets of individuals to consider and separate.  The first includes those who are clearly healthy and strong, not seriously overweight, exercise regularly and are without any unexplainable symptoms — a low risk group.

At the opposite pole, are those who are clearly in trouble with numerous risk factors and classical symptoms of advanced coronary disease — a high risk group.

The intermediate group is composed of those with some or multiple risk factors such as new onset of atypical chest pains or shortness of breath with minimal exertions, very high cholesterols, strong family history of premature heart disease, abnormal resting electrocardiograms and palpitations. Careful studies have shown, without a doubt, that the most benefit from stress testing is seen in this intermediate subset. It is in this group of individuals that we are most likely to uncover potentially serious disease and, with proper treatment, prevent disabling and sometimes fatal heart attacks.

In the high risk group, the stress test may be dangerous and is usually contraindicated and is not essential to help in the diagnoses and management of these patients.

As for the low risk group, because this kind of testing is not 100 percent accurate, it is not good practice to perform these studies. Even when done by highly trained cardiologists and technicians, there is a 10 to 20  percent false positive result interpreted as an abnormal study when there is no disease at all.  But now, because of these findings, cardiac catheterization and angiography is usually recommended, exposing an essential healthy individual to certain risks even those complications are rarely seen.

And, by the way, my doubting close family relative let me know that he went ahead and had the test anyway.  He passed with flying colors and, thank heavens is, still, in great shape.


  • Thanks for the advice Dr. Silverstein! You’re tips helped me make my decision to get a cardiac stress test last week, and it was a good experience. I now have much more peace of mind. Also I’d like to recommend UCSF Radiology about this field. It was really good for my examination.

  • Doctor, You are absolutely right. I have moderately elevated Total Cholesterol, TG, LDL, and good HDL. I take 25 mins to complete 3.5km, which I do 2x a week. I play basketball frequently (half-court). I watch my diet. I smoked from age 15 to 30. Now i’m 50, 5feet9inch, 170 pounds. So when I got INDIGESTION pain in my chest, I never expect it was a full-blown attack. The angiogram found 3 blocked vessels. So, i learned there’s no early detection mechanism, only preventive mechanism – maybe stricter diets, definitely no smoking, no stress and easy life. Otherwise, i dont know what to do except to live and let live…

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