Choosing Wisely is an initiative by the ABIM Foundation to identify commonly-used tests or procedures whose necessity should be questioned and discussed. This information was developed by Consumer Reports in cooperation with the American Society of Nuclear Cardiology.

If you have chest pain or other symptoms of heart disease, a test that stresses your heart can be lifesaving and help guide treatment. In some cases, taking pictures of your heart while it is stressed can provide more information. The same is true if you have a history of heart disease or are at very high risk of it. But in other cases, especially in healthy people without chest pain, you should be cautious about the tests. Here’s why.

The tests aren’t always necessary.

Cardiac stress tests make the heart work hard so your doctor can see if it responds normally. Adding imaging — with sound waves (ultrasound or echocardiography) or a small dose of a radioactive substance (nuclear cardiology) — can make the test more accurate and help your doctor determine the location and severity of your blockages. If you have symptoms of heart disease or are at high risk of it, imaging stress tests can help determine your risk of having a heart attack and help you and your doctor make treatment decisions. But those tests may not be useful if you are at low risk, especially if you don’t have symptoms.

They can pose risks.

Stress tests are usually very safe, and imaging stress tests can be done with little or no radiation. But the results of stress tests can at times cause confusion, anxiety, and trigger followup tests that do pose some risks. Those include CT scans or angiograms, which expose you to additional radiation. While the risk from any one scan is uncertain, risks from radiation are cumulative, so it’s best to avoid unnecessary exposures. Finally, inappropriate testing can also lead to overtreatment with drugs or procedures such as angioplasty and stenting, a procedure that can relieve symptoms but may not reduce the risk of heart attack or death — and causes serious complications in 1 to 2 percent of patients.

They can be expensive.

A stress imaging test costs between $500 and $2,000. Since the tests can provide more information than routine stress tests, that may be worth it. But money spent on unnecessary tests is money wasted. So they should be used only when they will help you and your doctor treat and manage your disease.

So when are the tests warranted?

An imaging stress test should often be ordered if you have symptoms of heart disease — such as chest pain, shortness of breath, irregular heart
beats, or palpitations — but can’t exercise. They can also make sense if you have an electrocardiogram (ECG) with some abnormalities that prevent an accurate interpretation during an exercise stress test. In addition, they may also make sense for high risk people without symptoms, such as those with diabetes.

Consumer Reports’ Advice

How should you assess your risk of heart disease?

People without symptoms of heart disease should take the following steps:

• Know your risk. Factors such as your age, gender, cholesterol and blood pressure levels, and whether you smoke or have diabetes can help determine which screening tests are right for you and whether treatment is necessary. (To determine your risk, use our heart-attack risk calculator available for free at www.ConsumerReports.org/heartrisk.)

• Protect your heart. Stop smoking, lose excess weight, engage in regular exercise such as brisk walking, avoid foods high in saturated fat, trans fats or cholesterol, limit sodium intake, manage stress, and talk with your doctor about possibly taking low-dose aspirin.

• Consider these tests. Everyone should have a doctor measure their upper and lower blood pressure numbers at least once a year. Men 35 and older and women 45 and older who have risk factors for heart disease should have a blood test at least every 5 years to measure their lDl (bad) and HDl (good) cholesterol levels, as well as their triglycerides, an arteryclogging fat. And people at risk for diabetes should have a blood glucose test at least every 3 to 5 years.