16984 Exercise Stress Test

Overview

An exercise stress test is a heart test that shows how your heart works while your body is moving. You walk on a treadmill or pedal a stationary bike while sticky pads on your chest record your heartbeat. This is called an ECG (electrocardiogram) — a painless tracing of your heart's electrical signals. Some people call it a treadmill test or a stress ECG. Your heart has to work harder during exercise, so the test can uncover problems that do not show up when you are sitting still. The whole visit usually takes about 30 to 60 minutes, and the exercise itself is often only 6 to 12 minutes.

Yes, it is very common. Exercise stress tests are done in hospitals, heart clinics and some GP surgeries all over the world. Millions of people have one each year, and clinic staff do them every day, so they are very used to helping people feel at ease.

It can be offered to adults of any age, most often middle-aged and older adults. You might be offered one if you have chest pain or breathlessness when you exert yourself, if your heartbeat feels odd, if you feel dizzy or faint, or if you are being checked before starting a new exercise programme or having an operation. It is used less often in children, mainly by children's heart specialists for specific heart conditions.

Symptoms

Common symptoms

• Chest pain, tightness or heaviness, especially when walking uphill, climbing stairs or hurrying
• Breathlessness that feels out of proportion to how much you are doing
• A heartbeat that feels fast, fluttering, pounding or skipped (palpitations)
• Dizziness or light-headedness during activity
• Fainting or nearly fainting
• Unusual tiredness or a drop in how much exercise you can manage
• These are the kinds of symptoms that often lead a doctor to arrange a stress test — the test itself does not cause symptoms.

Symptoms in children

• Stress tests are only occasionally used in children, usually under the care of a children's heart specialist
• Reasons can include certain heart conditions present from birth, or fainting and palpitations during sport
• Children's tests are adapted to the child's age and size, and a parent or carer stays close by

Symptoms in older adults

• The test is more common in later life, and staff adjust the treadmill speed, incline or bike resistance to suit you
• You can hold the handrails for balance, and you can stop whenever you need to
• If walking is difficult, a bike test or a chemical stress test (using a medicine instead of exercise) may be offered
• Tell staff about any problems with your hips, knees, balance or vision before you start

Causes

Main causes

• This is a test, not a disease, so it does not have 'causes'. It is done to look for reasons behind symptoms such as chest pain, breathlessness or palpitations
• To check whether the arteries supplying your heart (the coronary arteries) have become narrowed, which can reduce blood flow when your heart works harder
• To look at your heart rhythm during activity, and to see whether an abnormal rhythm appears only when you exert yourself
• To measure how much exercise your heart can support, and to see how your blood pressure responds to effort
• To check how well a treatment, procedure or cardiac rehabilitation programme is working
• As part of fitness assessments before an operation, or before starting a new exercise plan if you have heart risk factors

Risk factors

• Smoking or vaping nicotine
• High blood pressure
• High cholesterol
• Diabetes
• A close family member with early heart disease
• Being physically inactive
• Carrying extra weight, particularly around the middle
• A diet high in salt and saturated fat
• Drinking a lot of alcohol
• Ongoing stress and poor sleep
• Getting older — risk rises with age, though heart disease can affect younger people too

When to see a doctor

See a doctor urgently if:

• Chest pain or tightness that is new, comes on with activity and eases with rest
• Palpitations that are new, frequent or last several minutes
• Breathlessness that is getting worse, or that wakes you at night
• Swelling in your legs or ankles
• Fainting, or nearly fainting, at any time
• These need to be checked quickly — contact your doctor or local urgent health service the same day. Severe or lasting chest pain means calling your local emergency number.

Book a routine appointment if:

• You have a family history of early heart disease and want advice on your own risk
• You are planning to start a new, more strenuous exercise programme and have risk factors such as diabetes or high blood pressure
• You feel more tired or less able to exercise than you used to, and it has been building over weeks
• You want to discuss whether a stress test is right for you before an operation or a new activity
• You have already had a stress test and want to talk through the results

Diagnosis

An exercise stress test is itself the test, so there is nothing to 'diagnose' beforehand. The doctor decides to offer it after talking with you about your symptoms, your health history and your risk factors, and after an examination. Sometimes a resting ECG (a tracing taken while you lie still) is done first. A specialist then reads your exercise results alongside your other information to work out what is going on and what help, if any, you need.

Tests that may be done

• Resting ECG — a short, painless tracing of your heartbeat while you lie still
• The exercise stress test itself — you walk on a treadmill or cycle while your heartbeat, blood pressure and breathing are watched
• Ambulatory (Holter) monitor — a small portable recorder you wear for 24 hours or longer to catch an irregular heartbeat
• Echocardiogram — an ultrasound scan that shows your heart's shape and how well it is pumping
• Blood tests — to check things such as cholesterol, blood sugar, kidney function and heart muscle markers
• CT coronary angiogram or a dye test (coronary angiogram) — more detailed pictures of the heart's arteries, if needed
• Sometimes a stress test using a medicine instead of exercise, or a stress MRI or stress echo scan, if you cannot exercise

What to expect at your appointment

You will be asked to wear loose, comfortable clothes and trainers. Sticky pads are placed on your chest and connected to a monitor, and a blood pressure cuff is put on your arm. You start walking or pedalling slowly, and the pace or resistance goes up in small steps every few minutes. Staff will ask how you feel and watch your tracing. Tell them straight away about chest pain, breathlessness, dizziness or anything else uncomfortable — you are never expected to push through symptoms. The test stops when you have done enough, or sooner if there is any concern. Afterwards you rest and are checked for a few minutes. You can usually go home and eat and drink normally, and drive if you feel well. Some clinics ask you not to drive yourself home, so check when you book.

Treatment

The stress test is not a treatment — it is a way of finding out what is happening so that the right care can be offered. The results guide your doctor. For many people the result is normal or shows only mild changes, and the advice is about healthy living and keeping an eye on things. If the test shows a problem, your doctor will explain what it means and discuss options with you, from lifestyle changes and medicines to further tests.

Self-care at home

• Prepare well: eat only a light meal in the 2 hours before, and avoid caffeine on the day if your clinic asks you to
• Wear comfortable clothing and supportive trainers, and bring your glasses if you need them
• Ask your clinic whether to take your usual medicines on the day — do not stop anything on your own
• Bring a list of your medicines, including inhalers, and mention any implants such as a pacemaker
• Tell staff about pregnancy, recent illness, or problems with your joints or balance
• Arrange for someone to come with you or collect you if your clinic advises it
• Afterwards, take it easy for the rest of the day if you feel tired, and ask when you can drive, shower or return to exercise

Medical treatments

There is no medicine to 'treat' the test itself. Any treatment afterwards depends entirely on what is found. If narrowed heart arteries or high blood pressure are found, doctors commonly talk about a combination of healthy lifestyle changes and medicines that help protect the heart — such as medicines that lower blood pressure or cholesterol, or help control the heart's rhythm. Your doctor will explain which, if any, are suitable for you, along with the benefits and possible side effects. If your heart rhythm is the issue, treatments may include medicines, a small procedure to correct the rhythm, or a device fitted under the skin. If you are found to have heart disease, a cardiac rehabilitation programme — a supervised exercise and education course — is often very helpful.

When is surgery considered?

Most people having a stress test never need surgery. If the test suggests seriously narrowed heart arteries, your heart team may discuss procedures such as a stent (a small tube that holds an artery open) or a bypass operation. These are only suggested when the likely benefit clearly outweighs the risks, and the decision is always yours to make with your team.

Living with this condition

While you wait for your test or your results, carry on with life as normal, but be sensible: pace yourself, rest when symptoms come on, and avoid pushing through chest pain. Keep taking your usual medicines. Write down any questions or symptoms as they happen so you can describe them clearly at your appointment. Most people find that having the test actually reduces worry, because clear information is easier to live with than guesswork.

Lifestyle tips

• Build regular movement into your week — walking, swimming, cycling or whatever you enjoy, starting gently and increasing slowly
• If you smoke, stopping is the single biggest thing you can do for your heart — ask your doctor or pharmacist for support
• Keep alcohol within the recommended limits, and cut back if you drink most days
• Aim for a steady sleep routine; poor sleep and stress both strain the heart over time
• Know your own numbers — blood pressure, cholesterol and blood sugar — and have them checked when advised
• Join a local walking group, or a cardiac rehabilitation programme if it is offered to you

Diet and exercise

A heart-friendly way of eating is simple and filling: plenty of vegetables, fruit, beans, lentils and whole grains, some fish, nuts and healthy oils, and less salt, processed meat, sugary drinks and fried food. Aim for about 150 minutes of moderate activity a week — enough to make you breathe a little faster but still able to talk. Spread it over the week in short bursts if that is easier, and build up gradually. If you have symptoms when you exercise, get them checked before pushing harder.

Mental health and emotional wellbeing

It is very normal to feel anxious before a heart test, and to feel worried while you wait for results. Some people feel low or frightened, especially if heart problems run in the family. Tell your doctor if worry is affecting your sleep, work or mood. Talking therapies, relaxation and support groups all help, and there is no need to cope alone. If you ever have thoughts of harming yourself, contact your local emergency number or a crisis line straight away — you deserve help right then.

Prevention

You cannot avoid ever needing a heart test, but you can lower your chance of heart problems — which is what these tests often look for. The same steps help whether you have already had a test or not: not smoking, staying active, eating well, keeping blood pressure and cholesterol in a healthy range, limiting alcohol and getting enough sleep. Small, steady changes beat big resolutions.

Vaccines

If you have a heart condition, your doctor may advise routine vaccinations such as the yearly flu vaccine and others recommended where you live, because infections can be harder on the heart. Ask your doctor or pharmacist what is advised for you.

Screening programmes

Where you live, you may be invited for heart and circulation checks — for example, a general health check offered to adults in midlife, or checks for blood pressure and diabetes. These are free and quick in many countries. If you have not been invited and are over 40, or have a strong family history of early heart disease, ask your doctor whether a check is right for you.

Complications

If left untreated

• If your symptoms are not looked into, a narrowed heart artery could go unnoticed and cause a heart attack later
• An irregular heartbeat may continue to cause dizziness, fainting or tiredness, and sometimes needs treatment
• This refers to the underlying condition, not to the test itself. A stress test is very safe, though occasionally people feel dizzy or light-headed, develop an irregular heartbeat, or have a drop in blood pressure during the test. Serious problems are rare — about 1 in 1,000 tests or fewer — and trained staff watch for them and treat them promptly

Long-term outlook

For most people the outlook is good. An exercise stress test gives clear answers and often reassuring ones. If it does pick something up, it usually means the problem is found early, when it is easier to treat. Many people go on to lead full, active lives after a heart test — sometimes with some lifestyle changes or medicines, and often with a clearer plan and less worry.

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