Deborah Howell (Host): Hearing you need a cardiac stress test can be stressful, but it doesn't have to be. Helen Shores Peters, a radiologic technologist and certified nuclear medicine technologist in Pullman Regional Hospital's imaging department is with us today.

She's board certified in x ray, mammography, computed tomography, and nuclear medicine, and dually credentialed in nuclear medicine by the NMTCB. Helen's here to tackle our questions about what to expect before, during, and after a cardiac stress test. Welcome, Helen.

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: Thank you so much for having me, Deborah.

Host: Let us dive right in. Why on earth would a physician order a cardiac stress test and what does it show and or measure?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: All right, so there is about three different stress tests that we do. The first part is a treadmill only stress test. The second test is a little more involved and it's with nuclear imaging. And then we also perform stress echocardiograms. The first one that we'll talk about is the easiest.

It's the treadmill only. It is, no imaging at all, it's just a treadmill stress test. It's also called an ETT, which is called an exercise tolerance test. Primarily these tests are ordered for when a patient is experiencing some exertional chest pain or, you know, athletes that are kind of like, hey, I'm not performing to how I normally did.

It's a low risk test that we do here in the nuclear medicine department and it will show any electrical changes or blood pressure changes while the patient is exercising. So that's the first one. Again, that's the ETT exercise tolerance test or treadmill only stress test.

The second one that we do is a nuclear stress test and that's a big fancy word. We get a lot of people that are like, whoa, what are we doing? But is just nuclear imaging in addition to the treadmill stress test. We also do a chemical stress test for patients that cannot perform the treadmill for this portion.

That test is a little more involved and shows a little bit more than the treadmill only because we're actually able to, with the introduction of the radioisotope, we're able to see the blood flow to the heart with our imaging. So it's a really good stress test for patients, where their physicians are wondering if some of their symptoms are due to an inadequate blood flow to their heart muscle.

 And then the third one is a stress echocardiogram, and that is with ultrasound. It involves the treadmill, just like the ETT that we talked about, but it has ultrasound imaging. And the echo primarily looks at the heart structure. So think like valves and such like that. So those are the three main stress tests that a physician will order.

Host: Okay. Now, let's dig in just a little bit deeper. What does the cardiac stress test process look like?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: So the treadmill only stress test and the stress echo, the prep for that is very similar. We, prep the patient's chest. So we ask patients to come in with no perfume, no good lotions, that kind of stuff because we are going to clean the chest off. It's a little spa day for our patients.

 We exfoliate the skin so that the electrodes that we use will stay on while they're sweating and working real hard on the treadmill. And then we hook them up to a blood pressure cuff as well. On the treadmill for the stress echocardiogram and the ETT they do what's called a Bruce protocol.

Mr. Bruce is the one that came up with this and basically it's three minute increments on the treadmill. It starts out nice and slow with a little bit of incline and then every three minutes it goes a little bit higher and a little bit faster. And that's so that we can get the patients up to our minimum target, which is 85 percent of their maximum.

And for stress cycles, we like to get a little bit more heart rate. We usually go to about 95 percent to a hundred percent of maximum heart rate. And for people that are wondering, you can find that out by taking 220 minus your age and that's your maximum heart rate. And for the treadmill only, we only have to get to 85 percent of that to have a good enough test.

But like I tell my patients, who doesn't like a little extra credit? So if we can get patients a little more over that 85%, it's even better, a little extra credit for them. So. Exactly. Yep. Absolutely. And then for the nuclear stress test, it's a little more involved than the other two. We start an IV in the patient's arm.

Some people come in and they're like, wait, I thought we were having to do something straight into my heart. No, we're not doing that. It's just a regular IV in the arm. And that's how we introduce the radioactive tracer. There are no side effects to that. We get a lot of patients with quite a bit of anxiety about these tests, so anything that we can do to make the anxiety less and make it a little easier for everyone.

So, for those MPIs, we do start that IV, inject that radioactive tracer, and then we do imaging with our nuclear camera. Those images take about 15 minutes and quite honestly the biggest complaint that we get about these nuclear imaging tests is that the arms have to be kind of up by the head while you're lying down.

So shoulders get a little cranky, fingers get a little numb, but other than that, that's the biggest complaint that we get.

Host: Like you said, it's a good big stretch for your spa day, right?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: Yes, exactly. That's how we like to make it happen. So we do the imaging twice for the nuclear portion of the stress test. So they'll do the imaging after the initial IV start, then they'll go do a stress test.

And so we can do the treadmill stress test with the nuclear imaging, or we can do what's called a chemical stress test. And for the patients that have knee problems or just will not be able to get their heart rate up to that and they know that, the chemical is what takes place of that. And again, a lot of anxiety for patients, you know, what are you doing?

Are you going to make my heart just want to beat out of its chest? It is not meant to make the heart rate go up like if you were on a treadmill. It dilates the vessels, which is what your vessels do when you're working out to account for more of that workload. So that's what it does at that vessel level.

And it has, some potential side effects, very, very minimal. That's why we love to use it. A little bit of shortness of breath and chest pressure for about one to three minutes. What I tell my patients is like, look, if you were on this treadmill and you had to go to your peak exercise, you're going to be feeling like, I'm working. Wow. I'm out of breath. This is a lot.

And just pretend that that's what you're doing while you're sitting in a nice recliner. It kind of helps that mind body connection to not be so anxious when you start to feel that shortness of breath. It's like, hey, I'm working out. I'm doing things. This makes sense.

And then we go do the images again after the stress test, either chemical or treadmill. We do the images one more time, and then the patient's done. Takes about a little over an hour, sometimes up to two hours is what they give us just in case it takes a little more time, but usually a little over an hour for those.

Host: Sounds good. And what should a patient wear to their test? And do they need to bring anything?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: So, we like patients to come just like they would, you know, work out. I get patients that are like, I'm in my sweatpants, I feel so weird. We're like, no, we love comfortable clothing, like sweatpants, a short sleeve shirt, something that's easily kind of moved around so we can get those stickers on, easy to work out in, move around easily in.

And really the only thing that I would say to bring is maybe a list of medications. You don't have to bring the physical medications in, but just in case our records aren't current with what your doctor has changed and stuff, a list of active medications can be really helpful.

Host: I'm supposing no three cups of coffee before all this happens.

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: I know it's the worst. I'm not the same human without my morning cup of coffee. So I feel for my patients when they come in sometimes looking a little haggard because they haven't had that first cup, but there's some good reasons why we withhold caffeine. The first one being, if you are going to be having a chemical stress test, or even if you thought you were going to do the treadmill, but you can't get your heart rate up, we can convert to a chemical stress test on the spot as long as the patient has not had caffeine.

So that vaso dilator we were talking about, it's called Lexascan, by the way. Caffeine is the antidote to that medication. So it doesn't allow the vessels to dilate as they should with that medication. So that's the primary reason that we do no caffeine. But then also we all know that, caffeine can increase blood pressure, increase heart rate.

And what we're looking at is we want a solid baseline. So we don't want the heart rate to be obscured by caffeine in the system, as far as what your baseline heart rate and baseline blood pressure is.

Host: Got it. How long does it typically take to get the results after the tests are completed?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: We do have a cardiologist here at Pullman Regional Hospital. We've had one for quite a few years now, but we do have a cardiologist, it's Dr. Yano, and he's with Providence as well, but he is down here. And so he does all of our reading for cardiology exams for us, stress echoes, ETTs, the nuclear imaging, and it's usually within 24 to 48 hours that patients can expect the results from their doctor.

Host: And what are the steps following a cardiac stress test?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: There is nothing really particular that we advise our patients to do. The first thing I tell patients is get that cup of coffee. The cafeteria here has pretty decent caffeine. And so that's what I tell my patients. Like you can have it as soon as you get out of here, but really they can resume everything as normal, normal diet, caffeine, and then just following up with their physician or cardiologist, whatever they have going on following the test.

Host: Sounds good. Well you wrapped that up with a bow. Is there anything else you'd like to add?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: I think the only thing I'd really like to get across in this podcast is like I was kind of saying, we have a lot of patients that come in that have lost sleep, that have a lot of high anxiety over this nuclear stress test or this cardiac stress test. It sounds big and scary, but a lot of times after we're done, we get patients that are thinking, wow, I wish I would have known that it was this easy.

So I could have slept last night or the last couple of days. And so I just want to encourage anyone that's maybe thinking about having this test or has had it ordered and just hasn't gotten a lot around to doing it. It is a pretty easy test. We do these all the time. And if anybody has any questions or any anxiety and stuff, we have no problem talking to them beforehand.

We don't want people to lose sleep over this and be stressed out and not get the tests that they need because they're so anxious about it.

Host: And information is power, right?

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: Absolutely,

Host: Well, Helen, thank you so much for being with us today to enlighten us about cardiac stress tests. It's been real pleasure to have you on the podcast.

Helen Shores Peters, RT(R)(M)(CT)(N), CNMT: Thank you guys so much. I really appreciate you guys taking time to put this out there and, just help patients to understand a little bit more of what we do here at Pullman Regional Hospital.

Host: Our pleasure, and for more info about cardiac stress tests and other imaging services offered by Pullman Regional Hospital, please visit PullmanRegional.org/imaging. This has been the Health Podcast from Pullman Regional. I'm your host, Deborah Howell. Thanks for listening and have yourself a terrific day.