Editing Cardiac stress test (section)

== Contraindications and termination conditions ==
Stress cardiac imaging is not recommended for asymptomatic, low-risk patients as part of their routine care.<ref name="ACCIfive">{{Citation |author1 = American College of Cardiology |author1-link = American College of Cardiology |title = Five Things Physicians and Patients Should Question |publisher = [[American College of Cardiology]] |work = Choosing Wisely: an initiative of the [[ABIM Foundation]] |url = http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Coll_Cardio.pdf |access-date = August 17, 2012 |archive-url = https://web.archive.org/web/20120624075440/http://choosingwisely.org/wp-content/uploads/2012/04/5things_12_factsheet_Amer_Coll_Cardio.pdf |archive-date = 2012-06-24 }}</ref> Some estimates show that such screening accounts for 45% of cardiac stress imaging, and evidence does not show that this results in better outcomes for patients.<ref name="ACCIfive"/> Unless high-risk markers are present, such as diabetes in patients aged over 40, [[peripheral arterial disease]], or a risk of [[coronary heart disease]] greater than 2 percent yearly, most health societies do not recommend the test as a routine procedure.<ref name="ACCIfive"/><ref name="2010CardiacCT">{{Cite journal | last1 = Taylor | first1 = A. J. | last2 = Cerqueira | first2 = M. | last3 = Hodgson | first3 = J. M. . | last4 = Mark | first4 = D. | last5 = Min | first5 = J. | last6 = O'Gara | first6 = P. | last7 = Rubin | first7 = G. D. | author8 = American College of Cardiology Foundation Appropriate Use Criteria Task Force | author9 = Society of Cardiovascular Computed Tomography | last10 = American College Of | first10 = R. | last11 = American Heart | first11 = A. | author12 = American Society of Echocardiography | author13 = American Society of Nuclear Cardiology | author14 = North American Society for Cardiovascular Imaging | author15 = Society for Cardiovascular Angiography Interventions | author16 = Society for Cardiovascular Magnetic Resonance | last17 = Kramer | first17 = C. M. | last18 = Berman | last19 = Brown | last20 = Chaudhry | first20 = F. A. | last21 = Cury | first21 = R. C. | last22 = Desai | first22 = M. Y. | last23 = Einstein | first23 = A. J. | last24 = Gomes | first24 = A. S. | last25 = Harrington | first25 = R. | last26 = Hoffmann | first26 = U. | last27 = Khare | first27 = R. | last28 = Lesser | last29 = McGann | last30 = Rosenberg | first30 = A. | title = ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography | doi = 10.1016/j.jacc.2010.07.005 | journal = Journal of the American College of Cardiology | volume = 56 | issue = 22 | pages = 1864–1894 | year = 2010 | pmid =  21087721| doi-access = free }}</ref><ref name="2011echocardio">{{Cite journal | doi = 10.1016/j.jacc.2010.11.002 | last1 = Douglas | first1 = P. S.| last2 = Garcia | first2 = M. J. | last3 = Haines | first3 = D. E. | last4 = Lai | first4 = W. W.| last5 = Manning | first5 = W. J. | last6 = Patel | first6 = A. R. | last7 = Picard | first7 = M. H.| last8 = Polk | first8 = D. M.| last9 = Ragosta | first9 = M.| last10 = Ward | first10 = R. P. | last11 = Douglas | first11 = R. B.  | last12 = Weiner | first12 = R. B. | author13 = Society for Cardiovascular Angiography Interventions | author14 = Society of Critical Care Medicine| author15 = American Society of Echocardiography| author16 = American Society of Nuclear Cardiology| author17 = Heart Failure Society of America| author18 = Society for Cardiovascular Magnetic Resonance| author19 = Society of Cardiovascular Computed Tomography| author20 = American Heart Association| author21 = Heart Rhythm Society| title = ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography | journal = Journal of the American College of Cardiology | volume = 57 | issue = 9 | pages = 1126–1166 | year = 2011 | pmid = 21349406 | doi-access =  }}</ref><ref name="radioimageasymp">{{Cite journal | last1 = Hendel | first1 = R. C. | last2 = Abbott | first2 = B. G. | last3 = Bateman | first3 = T. M. | last4 = Blankstein | first4 = R. | last5 = Calnon | first5 = D. A. | last6 = Leppo | first6 = J. A. | last7 = Maddahi | first7 = J. | last8 = Schumaecker | first8 = M. M. | last9 = Shaw | first9 = L. J. | last10 = Ward | doi = 10.1007/s12350-010-9320-5 | first10 = R. P. | last11 = Wolinsky | first11 = D. G. | author12 = American Society of Nuclear Cardiology | title = The role of radionuclide myocardial perfusion imaging for asymptomatic individuals | journal = Journal of Nuclear Cardiology | volume = 18 | issue = 1 | pages = 3–15 | year = 2010 | pmid = 21181519 | s2cid = 27605594 }}</ref>

Absolute contraindications to cardiac stress test include:
* [[heart attack|Acute myocardial infarction]] within 48 hours
* Unstable [[angina]] not yet stabilized with medical therapy
* Uncontrolled cardiac [[Heart arrhythmia|arrhythmia]], which may have significant hemodynamic responses (e.g. ventricular tachycardia)
* Severe symptomatic [[aortic stenosis]], [[aortic dissection]], [[pulmonary embolism]], and [[pericarditis]]
* Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction
* Decompensated or inadequately controlled [[congestive heart failure]]<ref name=Henzlova>{{cite journal|last=Henzlova|first=Milena |author2=Cerqueira, Hansen |author3=Taillefer, Yao|title=Stress Protocols and Tracers|journal=Journal of Nuclear Cardiology|volume=16 |issue=2 |page=331 |date=January 2009|doi=10.1007/s12350-009-9062-4|doi-access=free}}</ref>
* Uncontrolled [[hypertension]] (blood pressure >&nbsp;200/110&nbsp;mmHg)<ref name=Henzlova />
* Severe [[pulmonary hypertension]]<ref name=Henzlova />
* Acute aortic dissection<ref name=Henzlova />
* Acutely ill for any reason<ref name=Henzlova />

Indications for termination:
A cardiac stress test should be terminated before completion under the following circumstances:<ref name=CETest>{{cite book|editor1-last=Weisman|editor1-first=Idelle M.|editor2-last=Zeballos|editor2-first=R. Jorge|title=Clinical exercise testing|date=2002|publisher=Karger|location=Basel|isbn=978-3-8055-7298-9|page=111|url=https://books.google.com/books?id=dQ2zJxdXpWkC&pg=PA111|access-date=26 November 2014}}</ref><ref name=ACSM>{{cite book|author=American College of Sports Medicine|title=ACSM's Guidelines for Exercise Testing and Prescription|date=2013|publisher=Lippincott Williams & Wilkins|isbn=978-1-4698-2666-0|page=131|url=https://books.google.com/books?id=hhosAwAAQBAJ&pg=131|access-date=26 November 2014}}</ref>

Absolute indications for termination include:
* [[Systolic blood pressure]] decreases by more than 10&nbsp;mmHg with increase in work rate, or drops below baseline in the same position, with other evidence of [[ischemia]].
* Increase in nervous system symptoms: Dizziness, [[ataxia]] or near [[Syncope (medicine)|syncope]]
* Moderate to severe anginal pain (above 3 on standard 4-point scale<ref name=ACSM />)
* Signs of poor perfusion,<ref name=CETest /> e.g. [[cyanosis]] or pallor<ref name=ACSM />
* Request of the test subject
* Technical difficulties (e.g. difficulties in measuring blood pressure or EGC<ref name=ACSM />)
* ST Segment elevation of more than 1&nbsp;mm in aVR, V<sub>1</sub> or non-Q wave leads
* Sustained [[ventricular tachycardia]]

Relative indications for termination include:
* Systolic blood pressure decreases by more than 10&nbsp;mmHg with increase in work rate, or drops below baseline in the same position, without other evidence of ischemia.
* ST or QRS segment changes,<ref name=ACSM /> e.g. more than 2&nbsp;mm<ref name=CETest /> horizontal or downsloping<ref name=ACSM /> ST segment depression in non-Q wave leads, or marked axis shift
* Arrhythmias other than sustained ventricular tachycardia e.g. [[Premature ventricular contraction]]s, both multifocal or triplet; heart block; [[supraventricular tachycardia]] or [[bradycardia|bradyarrhythmias]]<ref name=ACSM />
* Intraventricular conduction delay or [[bundle branch block]] or that cannot be distinguished from ventricular tachycardia
* Increasing chest pain
* Fatigue, shortness of breath, wheezing, [[claudication]] or leg cramps
* Hypertensive response (systolic blood pressure >&nbsp;250&nbsp;mmHg or diastolic blood pressure >&nbsp;115&nbsp;mmHg)