Evaluating the positive exercise stress test in the asymptomatic individual

Exercise electrocardiography to detect coronary disease yields a probability of its presence or absence rather than an absolute 'yes' or 'no' answer. Because of the high frequency of false-positive results in asymptomatic individuals, only select persons in this group should be tested. When testing is indicated, the conventional stress ECG is a readily available technique of reasonable cost in time and money and thus is an appropriate initial method. Additionally, stress ECGs can be performed for other indications and the results of all such studies must be interpreted with care. A normal treadmill result in a person with no coronary symptoms is highly reassuring of the absence of high risk coronary artery disease. A positive test must be viewed with caution. If the individual is young and without risk factors, the presence of disease is very unlikely, often obviating further evaluation in favor of long-term observation for other indications of coronary disease. Should the positive stress ECG be associated with multiple risk factors, or should it induce significant anxiety, further noninvasive testing is usually indicated, and is best implemented by exercise thallium perfusion scintigraphy. If this test is also positive, coronary angiography is a reasonable consideration. Only when personal or public safety require certainty regarding the presence or absence of coronary disease should a positive stress test in an asymptomatic individual lead directly to coronary angiography. Through application of the basic concepts concerning interpretation of the results of a stress ECG and utilization of the test in a discriminating manner relative to each patient's circumstances, maximum utility and cost-effectiveness in patient evaluation can be achieved.