Nuclear Exercise Stress Test

What is a Nuclear Stress Test?

A Nuclear Exercise Stress Test, aka  Cardiolite/Myoview stress test (CEST), is designed to evaluate the condition of your coronary arteries.  These are the arteries that supply the heart itself with blood.  Using a special type of imager, a small amount of radioactive tracer is injected into your blood before and after a stress test and pictures are taken of your heart muscle.  These pictures help your cardiologist determine whether there are any major blockages in your arteries.  They can also see if there has been damage to the heart muscle after a heart attack.  It will also help them determine the best type of treatment you may need to correct any abnormal finding.  These would include use of certain drugs, angioplasty or bypass surgery.

There are different reasons why your cardiologist may want you to have a CEST and these may include:

• symptoms or signs suggestive of coronary artery disease (CAD)such as chest pain, Shortness of Breath
• significant risk factors for CAD such as smoking, high blood pressure, high cholesterol
• assessment of your condition after a cardiac procedure such as bypass surgery or coronary angioplasty
• clearance for certain surgeries that are determined to be of intermediate to high risk

Who will be performing my test?

• An imaging technologist with special training in the use of radioactive drugs (Nuclear Medicine Technologist) will be taking the images of your heart using a machine called a Gamma Camera.
• The Stress test will be supervised by a Hamilton Cardiology Nurse, Nurse Practitioner or Physician Assistant. A Cardiologist is immediately available at all times in case of any medical emergency.

Is there any kind of preparations or instructions that I need to follow?

Please refer to the full instruction sheet that you were given at the time of scheduling the test

• No caffeine of any kind after 8pm the night before your test.  This includes chocolate, coffee, tea and sodas to include decaffeinated beverages since these include a small amount of caffeine.  Certain migraine medicines and cough syrups may contain caffeine so please refer to the package inserts or ask your pharmacist before taking any of these medications.
• These medications may interfere with the procedure and should be discontinued for at least 24hrs prior to testing:  TheoDur, Theo24, Theophylline, Aggrenox, Persantine, Slobid Aminophylline, Slobid, Uniphyl, Trental or Pentoxifylline.
• For our male patients: The use of the following meds must be discontinued 24 hours prior to testing: Levitra or Viagra.  Cialis must be stopped 4 days prior to testing.
• For our female patients: To ensure that the breast is in the same position on both sets of images please wear a bra the day of your test if possible. An underwire bra is permissible.
• For male patients it will be necessary to shave any area where there is hair in order to get appropriate tracings.  If you prefer, you may do this at home within at least 24 hours prior to your test.
• You may use deodorant but avoid use of oils, body lotions, moisturizing soaps or body washes for 3 days prior to testing. These products may affect the quality of your EKG tracings. Examples of these are “Oil of Olay” “Dove” “Ivory” “Caress” or “Aveeno”. Due to equipment requirements the imaging area is kept at approximately 68 – 72 degrees (F).  Please bring a sweatshirt or blanket if you are uncomfortable in a slightly cold environment.

What can I expect?

Check In: Prep and Resting Imaging  

Once you have checked in you will be given a consent form to read and to sign.  If you have any questions about the testing, please feel free to ask.

• You will then be taken into the prep area by one of our Nuclear Medicine Technologists.  They will verify information from your record and explain the procedure to you.
• An intravenous line (IV Line) will also need to be placed into a vein in your arm or hand.  This is used to administer the radioactive drug used for imaging.  It is required for this procedure or we will not be able to take the pictures of your heart. Prior to testing, electrodes (sticky gel pads) will be placed on your chest so you can be connected to an EKG machine for monitoring during your test. The EKG patches need to be placed on bare skin. The areas where the patches are placed will require cleansing with an alcohol pad and a light abrasive pad.
• For male patients it will be necessary to shave any area where there is hair in order to get appropriate tracings. If you prefer, you may do this at home within at least 24 hours prior to your test. The below picture demonstrates the placement of the electrodes. You may use this as a guide if you opt to shave at home before coming in. Otherwise, one of our techs will be required to shave the appropriate areas while placing the EKG patches.

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  Additional Male Prep: Shave at Lead Locations

• These electrodes will be attached to cables which link to an ECG machine. This will be looped around your waist with a belt during the test. A blood pressure cuff will be placed around your arm.  These are used to constantly monitor your heart during the stress portion.
• The first dosage of the radioactive tracer (Cardiolite) will be administered.  This allows the cardiologist to see what your heart normally looks like.  This will be compared to the later images to see if any changes have occurred. The amount of radiation received from the exam is approximately the same that you would receive from a CAT scan of the abdomen and pelvis.   (approx – 10-12 mSv)
• You will be asked to have a seat back in the waiting room and to drink a 12 oz can of soda. This will be some type of non caffeinated beverage such as sprite or ginger ale in either a regular or diet, according to your preference. This aids in the imaging by helping eliminate the tracer from the tissue and organs surrounding the heart and also by filling the stomach so that areas of the bowel are better separated from the bottom surface of the heart.  The soda is a requirement for the exam unless there is some medical reason.  This is similar to having to drinking barium before an X-Ray procedure.
• To allow for the proper imaging a 45 to 60 minute wait is required before imaging can be started. You will be called back to the imaging area when it is time for your pictures.
• Imaging is accomplished using a special type of radiation detector called a gamma camera.  This detects the injected tracer in the heart muscle and transfers it to a computer.  The computer processes these images into thin slices so that the doctor can look at blood flow into your heart muscle.
• You will sit on the imaging chair and bring your arms over your head.  It is very important that at least the left arm be raised above the head. If it is by your side it may prevent some of the tracer in the heart from reaching the detector. We can attempt to do the scan with your arms at your side but this may seriously affect the ability of the cardiologist to properly evaluate your exam.
• The imager will be positioned close to your chest and will slowly rotate around your body in a half circle.  The picture takes approximately 15 minutes and it is very important that not move at all.
• Once the picture is completed you will be directed to have a seat back in the waiting room until they are ready for your stress test.

Stress Testing Procedure and Stress Imaging

• You will perform a graded EST. This means the work level will be advanced in pre-determined stages in order to increase your heart rate. The treadmill will usually begin at a very slow ‘warm-up’ pace. Every three minutes it will gradually increase in speed and incline (slope).
• Your pulse, blood pressure and ECG are monitored during and after the test. If these reach any critical level as determined by the monitoring nurse or physician’s assistant, the test will be stopped immediately.
• In order to achieve an adequate test, it is very important for you to reach a heart rate that is based on your age.  If you are unable to reach this heart rate your test may be changed to an alternate type of test using a medication called Lexiscan.
• The test will be stopped if you become very tired, short of breath, experience severe chest pain or reach a maximum predetermined heart rate based on your age.  When you reach this point of maximum exercise you will be given another dose of the radioactive tracer.
• You will be asked at times during the test if you have any symptoms such as chest or leg discomfort or shortness of breath. If you feel unwell you should inform us at once
• You may request that the test be stopped at any time.  However, the higher the level of exercise that you are able to complete, the better the results will be for your cardiologist.
• The length of time that you will be exercising will usually be 4 to 10 minutes for most patients.
• Your EKG and Blood pressure will be monitored for about 5 minutes after you finish exercising.
• When the monitoring Nurse, Physicians Assistant or Nurse Practitioner determines that you are back to normal levels you will be released back to the waiting room to wait for your final set of images.
• The EKG leads will be left in place on your chest as some of them will be used for the stress imaging portion.  Please do not remove them
• You may eat, drink or take any medications at this time.  There are no further restrictions of any kind at this point. You will be asked to drink another can of soda at this time to aid the quality of your images.
• Waiting time for the stress images is about 30 – 60 minutes after the stress test.
• The stress imaging procedure is the same as the one used for resting images except that wires will be placed on 3 of the remaining EKG leads.  The imager will use your heart rate to format the pictures.
• This picture takes about 10 – 15 minutes and it is again very important that you be as still as possible.
• Once this picture has been completed, your procedure is complete.  The length of time from beginning to end is approximately 3 – 4 hours.

What are the risks?

• In recommending this procedure your doctor has balanced the benefits and risks of the test against the benefits and risks of not proceeding. Your doctor believes there is a benefit of you having an EST.
• There is a small radiation exposure from the radioactive drug, but this is generally no more than you would receive from any other X-Ray procedure such as a CAT Scan or some  X-Ray Procedures.

The procedure is generally very safe,  however, a few risks include

• mild angina e.g. chest pain
• shortness of breath
• sore muscles or joint pain
• fainting (rare)
• An abnormal heart rhythm that continues for a long time. This may require further treatment to correct  (rare)
• heart attack (extremely rare)
• death as a result of this procedure is extremely rare,( less than 1 in 10,000 patients

The risks are higher if you already have blocked arteries in the heart (Coronary Artery Disease)