Michael Smith, MD (Host): This is Meaningful Medicine. I'm Dr. Mike, and joining me today is Dr. Aaron Ford from Novant Health. Today we explore what happens after your doctor orders a stress test and how it fits into your healthcare journey. Dr. Ford, welcome to the show.

Dr. Aaron Ford: Thank you for having me. Very much appreciate it.

Host: What exactly is a stress test and why would my doctor order one?

Dr. Aaron Ford: So couple things. Stress test is a lot of times medical procedures, the test and the name are exactly what it is. So a stress test is literally just that. We're going to put the heart under stress. Typically, that's some type of exercise, almost universally that'll be walking on a treadmill. And then we'll do some type of imaging of the heart.

A lot of times we'll do an EKG, but you can also take pictures of the heart with echo, you can do it with nuclear imaging. There's a few reasons your doctor might order a stress test. The most common reason would be you're not feeling well, somebody's having chest pain, and we're trying to get to the bottom of that to see if there's a heart related reason that might be happening.

Shortness of breath that might be related to your heart, looking at your heart function. A couple of reasons to do that, but those would be the most common, but for most people, a very straightforward test, stressing the heart and seeing how it's going to do.

Host: What if somebody's not able to walk or it's just really tough for them with, you know, maybe arthritis or something. Can they still have this test done?

Dr. Aaron Ford: There's a couple of ways you can do that actually. So there are some stress protocols where we will have someone walk slowly. A treadmill's not the only way we can do a stress on the heart. There are some bicycle stress tests where we can put you on some type of recumbent bike and do it usually on a table.

Obviously if somebody's in a wheelchair or heaven forbid has a broken leg and we need to check their heart and make sure things are okay; there's a couple of types of medications we can use to stress the heart. Ideally, if we can, physical stress is almost always the best. The only other reasons to do a non-physical stress test or a chemical stress test, there's a couple of things with an EKG or some people with special pacemakers that sometimes do better with chemical stress tests, but that would be something for your doctor to kind of figure out.

Host: So regardless of whether they're walking, riding a bike or it's a medicine, the whole point is we're putting stress on the heart. We want that heart rate to come up. We want the pressure to come up and we want to see what kind of rhythm stuff is going on. Is that correct?

Dr. Aaron Ford: We almost always want to do some stress on the heart, although some of the chemical stress test actually doesn't necessarily make the heart rate go up. Some of them work as what's called a vasodilator, so they dilate the vessels. So a couple of the chemical stress tests don't actually make the heart rate go up.

We put stress on the heart in a little bit of a different way, but the concept is all the same. Seeing how the heart does and how the blood flow to the heart's doing.

Host: How should a patient prepare for this and what can they expect when they like walk in for this procedure?

Dr. Aaron Ford: So I would say almost all offices who do stress tests, the procedure is really fairly simple. If it's going to be just a stress test on a treadmill, most of the time the only thing you need to bring is yourself and a comfortable pair of shoes. Flip flops might not be the best option, or high heels if somebody's wearing something like that might not be the best option.

 All stress tests will have you hooked up to an EKG and an EKG is just a procedure where we put little electrodes on the chest, look at the electrical rhythm, and then we get people on a treadmill. The most common protocol used for stress test is something called the Bruce Protocol, and what it does is it goes in three minute increments and every three minutes you go a little higher and faster.

The first stage starts at 1.7 miles an hour, which for most people it's a pretty leisurely walk. The big place where the stress test gets people is the elevation. There's always a little bit of an elevation on it. So a, the normal standard protocol starts at 10% incline, which if anyone at home's ever been on a treadmill and they hit up the elevation, 10 percent's actually quite a bit.

And then each three minutes it goes higher and faster until we get your heart rate up.

Host: Now, how long does it usually last?

Dr. Aaron Ford: So it kind of depends on the person. Most people we're trying to get their heart rate up. I'll always tell patients the, there's a couple of advantages of getting older. As we get older, we don't have to get your heart rate as high. So if we do stress tests on 20 year olds, we have to get their heart rates up really high.

They're going to have to go a long ways on a treadmill. If somebody's 80 years old, we might only have to go three or four minutes to get their heart rate up. Now the longer someone goes, they're better in better shape. So if you're in really, really good shape, it might take you a little bit while longer to get that heart rate up.

But people always ask, how long do you have to go and always say, it kind of depends on you on how long it takes you heart rate to get up. There are some medicines that can lower the heart rate artificially. A lot of those we'll stop before we do the stress test or maybe stop them the night before type of thing.

Host: Yeah, that was going to be another question. What about medication? So normally they stop the night before and then they should dress like they're going to exercise a little bit.

Dr. Aaron Ford: Yeah, usually I tell people wear some type of comfortable, you know, gym shorts or leggings or whatever somebody would be comfortable walking in. Most people won't have to run on it, but you want to be comfortable. And it's just going on that walk. And like I said, no uncomfortable shoes.

I do see people in flip flops do them occasionally, and that does work, but it's not always the best, just living down here in the low country by the beach.

Host: Is this done in your office or in a hospital setting?

Dr. Aaron Ford: So most of the time, most stress tests are done in the, in the office. We'll have the treadmill there, and then we'll do the treadmill and then any pictures we have to take. Even most cardiology offices have the ability to use the medications. You can also do them in the hospital. So heaven forbid if someone's in the hospital and they don't feel like they're safe to go home because they're having a lot of chest pain, there are, we can do stress tests in the hospital as well, but, I would say the vast majority of stress tests are done in the office nowadays. With some exceptions to that. They can be done in the hospital as well, if somebody's in the hospital and needs it done before they can leave.

Host: Everybody wants to know when they're going to have anything done whether it's a stress test, blood draw, whatever. It doesn't matter. Does it hurt?

Dr. Aaron Ford: For the vast majority is stress test, if it's a treadmill stress test, the only part that hurts is walking on the treadmill. Otherwise we put some little electrodes on the chest. I suppose if you're a guy or somebody who has a hairy chest or some sensitivity to the electrodes, that might hurt a little bit, but the vast majority of them, they shouldn't be uncomfortable other than at the end it should feel like you worked out.

It is a stress test, so at the end, you know, someone should feel like they were breathing hard and they, that they were maybe pushing it a little bit at the end. But other than that, the goal is not to make someone hurt. If someone has a bad knee, we will have them stop. We don't want them to hurt.

There are for some of the chemical stress tests, the exception to that is those do require an IV. So if we are going to do a medicated stress test, you do have to have an IV in, but that's just the pain of an IV, which is not nothing, but not a huge inconvenience for most people.

Host: When they just go home right away? Do they have wait a little bit in the office to kind calm down a little bit?

Dr. Aaron Ford: Absolutely great questions. So depending on which one we do, if it's a stress treadmill and it's just a stress test without chemical or without kind of special nuclear pictures, probably about half of them that I do, I'm actually in the room with them and they'll finish it up. If it takes them six minutes to do the stress test, they'll finish up.

They'll kind of sit down and let their heart rate come down and recover. And I'll actually look at their EKG and if they happen to have an echocardiogram or an ultrasound of the heart with it, I'll look at those pictures too and tell them at the, at that time what things look like and if everything looks okay, they'll go home 10 minutes right after 10 minutes and be done. They might be a little bit sweaty, but that's it.

If it is a chemical stress test, especially if it's one where we're taking nuclear pictures of the heart, those do take a little while longer. So some of the other stress tests with some of the medicines can take two or three hours. And then afterwards you go home and usually we don't have results for them right away, but we usually have them within a day or two.

Host: What kinds of heart issues can a stress test detect or rule out?

Dr. Aaron Ford: There's two or three that are mainly used. The most common one is looking for blocked arteries. Now, I will tell people stress tests don't necessarily look at blocked arteries, but they're pretty good at finding fairly severe blockage. So if someone has a minor blockage, a stress test won't really show that.

There are some other tests that it can be done to kind of look for that. But a stress test is a very good test to figure out number one, the likelihood of someone having a severe blockage. Number two, the likelihood of them benefiting from fixing it. The other things we can use them for, there's several other things we can use them for.

We'll sometimes use them in people who have some type of heart valve problems, some calcified valves to figure out if the valve is severe based on what a stress test looks like. The other thing that we'll occasionally use them for is to help us determine if someone needs a pacer. One of the things we're supposed to look at on a stress test as we all exercise that heart rate should rise up and if that heart rate can rise up naturally, someone probably doesn't need a pacer. If they have a hard time getting their heart rate up, it sometimes gives us a little bit of help figuring out if someone might benefit from a pacemaker type of thing.

Host: How essential is a stress test to a cardiologist? It sounds like it's another tool in the toolbox. How important is this tool?

Dr. Aaron Ford: It's a great tool because for most people it's non-invasive. It's very, very rare chance of complications. So the biggest thing with a lot of medical tests is you don't want to hurt somebody. So the vast majority of stress tests are non-invasive. A lot of them have no radiation, no IV, so you can get some really, really good data.

They're not no risk. There is always a chance of something happening, but when you're walking on a treadmill, it's fairly safe. So stress tests are a really good starting point for a lot of cardiologists to help figure out, do we need to do more testing? Are we okay just monitoring things? There are more types of CTs and other things we can do, but stress tests are such a nice test. They're non-invasive. They give us a lot of great data, and it's really hard to hurt someone with a vast majority of them.

Host: How do stress test results impact treatment decisions?

Dr. Aaron Ford: The big major one would be if someone is having a lot of symptoms of chest. If their chest is hurting, they're having shortness of breath and their stress test is abnormal, it gives us a lot of power to say their benefit of us going in and doing something like a stent, or heaven forbid, a bypass, becomes much larger.

That is by far the largest treatment impact for a stress test is the probability of blocked arteries, and if they're having symptoms with an abnormal stress test, helps us figure out when to fix them. So that is by far the most powerful thing for a stress test.

Host: Meaning like if they're on the stress test and they become short of breath, like beyond just breathing hard or chest pain develops, those are things where you're going to, okay, why is this happening?

Dr. Aaron Ford: Why is happening? And then if that stress test is abnormal and they're having symptoms, it makes huge impacts on their treatment decision for do we need to go? There are certainly times we can treat that with medications, but it also helps us figure out when to do more invasive therapy and to think about going in and does somebody need a stent? Do they need more type of surgical approach to fixing things?

Host: So patients should not be afraid of a cardiac stress test.

Dr. Aaron Ford: It's one of the easiest tests you can do. For the vast majority of people, it's no big deal. It's doing stuff we should all be doing every day anyway. It's exercising. So it's really just an exercise. Look and see how your heart does under exercise. For the vast majority of us, it's no big deal.

Everyone understandably has some anxiety whenever they go to the doctor. I do too, because I'm always nervous they're going to find something wrong. But there's always these stress tests for a vast majority of people. No big deal. Give us some pretty good data and don't have a lot of side effects.

Host: Dr. Ford, any last word for the listening audience?

Dr. Aaron Ford: No, thank you so much for having me on. It's very much appreciated.

Host: This is great information. I think what you just did is you're going to help a lot of patients feel better about getting a cardiac stress test, so thanks for coming on. That was Dr. Aaron Ford. For more information, you can visit novanthealth.org. If you liked this podcast, please share it on your social channels and explore our podcast library for more topics of interest to you, this is Meaningful Medicine. Thanks for listening.