Evaluation of coronary artery disease in the patient unable to exercise: alternatives to exercise stress testing

Exercise stress testing is a well-established method for the diagnostic, prognostic, and functional assessment of patients with known or suspected CAD. A variety of alternative tests have been described in patients unable to perform leg exercise. Atrial pacing and dipyridamole imaging have been evaluated most extensively, and results compare favorably with those of exercise testing for diagnosing the presence of CAD. Both tests may be used to assess prognosis after myocardial infarction, and dipyridamole imaging may be useful in patients undergoing preoperative evaluation. The use of the cold pressor test and isometric handgrip exercise have also been described. However, the value of both tests is limited by a relatively low sensitivity for detecting the presence of CAD. Other testing modalities--arm ergometry, intravenous infusion of beta-adrenergic agonists, and transthoracic pacing--show promise but require further assessment to confirm their value.