Tests for Coronary Heart Disease

Just because you have symptoms of coronary heart disease (CHD) doesn't mean you actually have CHD.  It's important to be certain one way or the other because treatment can prolong the quality and length of your life. 

Remember that coronary heart disease is common.  A man at age 40 has a 50:50 chance of developing CHD.  One in three women at age 40 will get it in the future. 

If you have symptoms of CHD, your physician will run tests to determine the cause of the symptoms.  If it looks as if you indeed have CHD, further testing will help clarify the severity and your overall outlook.   

Let's assume you have chest pain, the most common symptom of CHD.  Most likely you will get a chest x-ray, EKG (electrocardiogram), and some blood work.  But those usually don't give a definite answer about CHD. 

Here are the common test options to clarify the presence and severity of CHD:

1. Exercise Treadmill Test.  This is one of the most commonly done tests due to its simplicity and low cost.  You exercise on a treadmill while your heart and blood pressure are monitored.  The speed and inclination of the treadmill are increased every few minutes.  If exercise isn't possible, you might be given a chemical into your vein to put some stress on your heart; this is called a pharmacological stress test.  Exercise, as compared with pharmacologic stress, generally yields more helpful information. 
2. Stress Echocardiography.  Ultrasound imaging - as used to picture babies in the womb - looks at the heart during exercise or pharmacologic stress. 
3. Exercise Radionuclide Myocardial Perfusion Imaging.  Stress is put on your heart through exercise or pharmacologically.  This test can pick up CHD at an earlier stage than the plain exercise treadmill test without imaging. 
4. Electron-Beam (EBCT) or Multi-Detector Row Computed Tomography (MDCT) to detect Coronary Artery Calcification.  Atherosclerosis often leads to calcium build-up in arteries.  A negative score for calcium is very reassuring (i.e., evidence against serious CHD), but it's not entirely clear what to do next when calcium is found.
5. Coronary Artery Calcification score determined by CT scanning.  Again, a negative score - no calcium found - is reassuring, but the experts argue endlessly about what to do with other results.    
6. Coronary Angiography.  This is the "gold standard" to which other tests are compared.  Unfortunately, angiography is very costly, invasive, and more dangerous than the other tests above, so it's usually not the initial test done.
7. Non-invasive Computerized Tomograpy (CT) angiography is the newest test, and its role is still being clarified. 

A doctor not familiar with the details of your case cannot tell you the best test to have done.  It depends on many factors, such as local availability and expertise, the particular details of your symptoms, your underlying risk factors for CHD, your EKG, the clinical judgement of your doctor, and even the shape of your body. 

I've seen many patients that worried me so much that I recommended coronary angiography as the initial high-tech test, not wanting to waste time with the other, less definitive tests.  But those cases are the exception rather than the rule.   

-Steve Parker, M.D.