Exercise Stress Testing: Indications and Mutual Questions

KATHRYN One thousand. GARNER, Doc, National Capital letter Consortium Family Medicine Residency, Fort Belvoir, Virginia

JAMES J. ARNOLD, Practice, National Uppercase Consortium Family unit Medicine Residency, Fort Belvoir, Virginia

Am Fam Dr.. 2017 Sep 1;96(5):293-299A.

This clinical content conforms to AAFP criteria for continuing medical education (CME). Meet the CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Article Sections

  • Abstract
  • What Are the Indications for Exercise Stress Testing?
  • Testify SUMMARY
  • When Should Exercise Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Exercise Stress Testing with and Without Imaging for CAD?
  • Which Patients May Exist Safely Risk Stratified with Exercise Stress Testing Lone?
  • What Findings on Exercise Stress Testing Warrant Termination and Further Evaluation?
  • References

Exercise stress testing is a validated diagnostic examination for coronary avenue disease in symptomatic patients, and is used in the evaluation of patients with known cardiac disease. Testing of asymptomatic patients is generally not indicated. It may be performed in select deconditioned adults before starting a vigorous practice program, just no studies accept compared outcomes from preexercise testing vs. encouraging light exercise with gradual increases in exertion. Preoperative exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery or who have active cardiac symptoms before undergoing nonemergent noncardiac surgery. Exercise stress testing without imaging is the preferred initial pick for risk stratification in most women. Sensitivity and specificity increase with the utilize of adjunctive imaging such as echocardiography or myocardial perfusion imaging with unmarried-photon emission computed tomography. Exercise stress testing is rarely an appropriate option to evaluate persons with known coronary avenue illness who accept no new symptoms less than two years after percutaneous intervention or less than five years afterwards coronary artery bypass grafting. The Knuckles treadmill score has excellent prognostic value for exercise stress testing. Imaging is not necessary if patients are able to achieve more than than 10 metabolic equivalents on exercise stress testing. Practice stress testing is not indicated earlier noncardiac surgeries in patients who tin can attain iv metabolic equivalents without symptoms.

Do stress testing is used to discover inducible cardiac ischemia in symptomatic intermediate-risk patients who can practise and who have interpretable electrocardiography results.1  Risk is adamant by American College of Cardiology Foundation/American Heart Clan (ACCF/AHA) guidelines for stable ischemic center disease or the Diamond and Forrester score to appraise pretest probability of coronary artery disease (CAD; Table i).1,ii

SORT: Central RECOMMENDATIONS FOR Practise

Clinical recommendation Evidence rating References

Preoperative exercise stress testing for risk stratification before noncardiac surgery is not indicated if the patient is able to achieve 4 or more than metabolic equivalents without symptoms.

C

1, v

Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery and in those who have active cardiac symptoms earlier undergoing nonemergent noncardiac surgery.

C

i, v

Exercise stress testing is non recommended in asymptomatic patients to screen for coronary artery disease.

C

3, 6, 7

Adjunctive imaging increases cost without improving prognostic value in patients who can reach more than 10 metabolic equivalents during practise stress testing.

B

19, 21

BEST PRACTICES IN CARDIOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY Campaign

Recommendation Sponsoring system

Exercise non perform stress cardiac imaging or avant-garde noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are nowadays.

American College of Cardiology

Do not perform cardiac imaging for patients who are at depression risk.

American Society of Nuclear Cardiology

Avoid using stress echocardiography on asymptomatic patients who come across low-adventure scoring criteria for coronary disease.

American Lodge of Echocardiography

Avoid cardiovascular stress testing for patients undergoing depression-risk surgery.

Society for Vascular Medicine

Patients who have no cardiac history and proficient functional condition exercise not require preoperative stress testing before noncardiac thoracic surgery.

Gild of Thoracic Surgeons

Practice not obtain baseline diagnostic cardiac testing or cardiac stress testing in asymptomatic stable patients with known cardiac disease (east.m., coronary artery illness, valvular affliction) undergoing low- or moderate-gamble noncardiac surgery.

American Society of Anesthesiologists

Do not perform routine annual stress testing afterward coronary artery revascularization.

Society of Nuclear Medicine and Molecular Imaging

Table i.

Diamond and Forrester Score for Pretest Probability of Coronary Artery Disease

Age (years) Sex Typical/definite angina pectoris Singular/probable angina pectoris Nonanginal chest pain

≤ 39

Male person

Intermediate

Intermediate

Depression

Female

Intermediate

Very low

Very depression

xl to 49

Male

High

Intermediate

Intermediate

Female person

Intermediate

Depression

Very low

50 to 59

Male

High

Intermediate

Intermediate

Female person

Intermediate

Intermediate

Low

≥ threescore

Male

Loftier

Intermediate

Intermediate

Female

Loftier

Intermediate

Intermediate

The standard Bruce protocol is preferred for exercise stress testing3 (eTable A). Its outcomes are well validated, and practise capacity measured in metabolic equivalents (METs) has good prognostic value. The Bruce protocol can be modified for patients with predicted poor exercise capacity by adding 2 warm-upwardly stages before the first phase. The Naughton protocol allows for a more gradual increase in exertion and uses shorter stages, increasing the likelihood of diagnostic results in older and deconditioned patients.3 This commodity reviews indications for and answers common questions well-nigh practise stress testing.

eTable A.

Mutual Treadmill Protocols for Practise Stress Testing

Protocol Miles per hour Grade (%) Metabolic equivalents

Standard Bruce protocol (3 minutes per stage)

Stage ane

1.7

10

4

Phase 2

2.5

12

7

Phase 3

iii.four

14

10

Stage 4

4.2

16

xiii

Stage v

5.0

18

xvi

Stage half dozen

5.five

xx

NA

Phase vii

6.0

22

NA

Modified Bruce protocol (3 minutes per phase)

Stage 1

ane.seven

0

ii

Phase 2

1.7

5

3

Stage three

ane.7

10

4

Stage 4

2.5

12

7

Stage 5

3.iv

xiv

10

Stage six

four.2

16

thirteen

Stage 7

5.0

18

16

Stage 8

5.5

20

NA

Stage 9

six.0

22

NA

Naughton protocol (2 minutes per stage)

Stage 1

1.0

0

one

Stage two

two.0

0

two

Phase iii

2.0

iii.5

3

Stage 4

2.0

seven

iv

Stage five

two.0

10.5

5

Stage half dozen

ii.0

fourteen

half-dozen

Stage 7

2.0

17.5

7

What Are the Indications for Exercise Stress Testing?

  • Abstract
  • What Are the Indications for Exercise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Do Stress Testing Not Exist Used?
  • What Is the Diagnostic Value of Practise Stress Testing with and Without Imaging for CAD?
  • Which Patients May Be Safely Risk Stratified with Exercise Stress Testing Alone?
  • What Findings on Exercise Stress Testing Warrant Termination and Farther Evaluation?
  • References

Practice stress testing is usually used for the detection of CAD in patients with chest hurting or dyspnea on exertion who are at intermediate risk of acute coronary syndrome. Exercise stress testing reduces costs of hospitalization without worsening outcomes in patients presenting to the emergency department with chest pain and negative cardiac enzymes. Additional indications for practice stress testing include prediction of cardiovascular events, cess of chronotropic competence, evaluation of practise-induced symptoms, evaluation of unexplained syncope in patients at intermediate to high take a chance of CAD, and assessment of response later medical or surgical interventions in patients with valve disease, arrhythmias, or other centre diseases. Consensus opinion from the ACCF/AHA is that practice stress testing can exist used for exercise prescriptions, but data on patient-oriented outcomes are lacking.

EVIDENCE SUMMARY

  • Abstract
  • What Are the Indications for Exercise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Practice Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Do Stress Testing with and Without Imaging for CAD?
  • Which Patients May Be Safely Risk Stratified with Exercise Stress Testing Alone?
  • What Findings on Do Stress Testing Warrant Termination and Farther Evaluation?
  • References

The AHA states that early do stress testing in emergency departments and breast hurting units is condom, accurate, and price-effective because of fewer hospital admissions.3 In a prospective cohort report of 3,552 patients in chest pain units who had depression Diamond and Forrester scores, none had a positive stress test.4 Some other study evaluated intermediate-take chances patients presenting to the emergency department who had no known CAD and in whom acute coronary syndrome was excluded with two negative cardiac enzyme tests performed six hours apart.two Exercise stress testing stratified intermediate-risk patients to a nigh zero short-term chance of acute coronary syndrome. A retrospective analysis of 3,987 patients younger than forty years who were at intermediate risk of CAD and in whom myocardial infarction (MI) had been excluded found that practise stress testing was of minimal value given the 0.4% incidence of positive findings.v

Preoperative practice stress testing is not indicated for adventure stratification earlier non-cardiac surgery in patients who are able to achieve a minimum of iv METs (e.thousand., walking up i flight of stairs) without cardiac symptoms, even if they have a history of CAD.1,five Exercise stress testing is helpful for risk stratification in patients undergoing vascular surgery and in those who accept active cardiac symptoms before undergoing nonemergent noncardiac surgery.1,v Patients with poor functional capacity (unable to achieve 4 METs) should undergo stress echocardiography or exercise unmarried-photon emission computed tomography (SPECT) before undergoing vascular surgery or a kidney or liver transplant.i

Activities greater than six METs are associated with an increased risk of acute coronary syndrome. Experts recommend that deconditioned patients with diabetes mellitus, men older than 45 years or women older than 55 years, and those with two or more risk factors for CAD undergo practise stress testing before starting a vigorous exercise plan. However, no studies take compared outcomes from preexercise stress testing vs. encouraging light practise with gradual increases in exertion.3

When Should Exercise Stress Testing Non Be Used?

  • Abstract
  • What Are the Indications for Practise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Exercise Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Exercise Stress Testing with and Without Imaging for CAD?
  • Which Patients May Be Safely Adventure Stratified with Exercise Stress Testing Alone?
  • What Findings on Do Stress Testing Warrant Termination and Further Evaluation?
  • References

Exercise stress testing is generally inappropriate for detection of ischemia in asymptomatic patients with no history of revascularization. Absolute contraindications include MI in the previous two days, ongoing unstable angina, uncontrolled cardiac arrhythmia with hemodynamic compromise, and symptomatic severe aortic stenosis (Table two). 1,three One in x,000 exercise stress tests results in sudden cardiac death or hospitalization.

Table 2.

Contraindications to Practice Stress Testing

Accented contraindications

Agile endocarditis

Acute aortic dissection

Acute myocarditis/pericarditis

Decompensated heart failure

Disability to practice

Myocardial infarction in previous two days

Ongoing unstable angina

Symptomatic severe aortic stenosis

Uncontrolled cardiac arrhythmia with hemodynamic compromise

Relative contraindications

Acquired complete heart cake (left bundle branch block)

Hypertrophic obstructive cardiomyopathy with severe resting gradient

Known left main coronary artery disease

Recent stroke or transient ischemic attack

Resting systolic claret pressure level > 200 mm Hg or diastolic claret pressure level > 110 mm Hg

Tachyarrhythmia with uncontrolled ventricular charge per unit

Bear witness SUMMARY

Testing asymptomatic patients without a history of revascularization is not recommended.1,3 The U.Due south. Preventive Services Job Forcefulness recommends against testing low-risk patients and institute bereft show for those at intermediate and high risk.half-dozen The American Academy of Family unit Physicians supports this recommendation.7 A randomized controlled trial of asymptomatic patients 50 to 75 years of age who had blazon 2 diabetes and no known CAD found that screening with adenosine-stress radionuclide myocardial perfusion imaging did not reduce nonfatal MIs or cardiac deaths over 5 years compared with no screening.8 Testing patients with no new symptoms less than two years subsequently percutaneous coronary intervention or less than five years after coronary avenue bypass grafting is rarely advisable.1

What Is the Diagnostic Value of Exercise Stress Testing with and Without Imaging for CAD?

  • Abstract
  • What Are the Indications for Exercise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Exercise Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Practise Stress Testing with and Without Imaging for CAD?
  • Which Patients May Be Safely Risk Stratified with Do Stress Testing Lonely?
  • What Findings on Exercise Stress Testing Warrant Termination and Farther Evaluation?
  • References

Exercise stress testing is often better at excluding CAD than confirming information technology. Testing without imaging is the principal initial choice for risk stratification for about women and men. Imaging is best used when there is a baseline aberration in resting electrocardiography that would make interpretation of results difficult, if the patient has symptoms at rest, if anatomic cardiac features require evaluation, or if it is likely that the examination results would be nondiagnostic (east.g., in patients with poor exercise tolerance due to severe osteoarthritis) and that further testing would exist required. Adjunctive imaging is required in patients taking digitalis because of the loftier false-positive charge per unit of practise stress testing solitary in these patients.

Testify SUMMARY

Stress echocardiography and exercise SPECT are appropriate in symptomatic patients at intermediate or high adventure of CAD and in those with hard-to-interpret electrocardiography results.i Symptomatic patients with a history of percutaneous coronary intervention or coronary avenue bypass grafting should undergo practice SPECT, stress echocardiography, or coronary angiography as clinically indicated.1

A 2012 systematic review of 34 prospective studies constitute that practice stress testing and stress echocardiography were better at excluding CAD than confirming it (likelihood ratio [LR] of ruling out CAD via practice stress testing = −0.34; 95% confidence interval [CI], 0.28 to 0.41; LR for stress echocardiography = −0.24; 95% CI, 0.17 to 0.32).ix Of the 2 testing modalities, stress echocardiography was better at ruling in CAD (LR = 7.94 vs. iii.57 for exercise stress testing).9  Sensitivity and specificity for CAD detection increase when imaging is performed with practice stress testing (Table 3).10–14 The prevalence of severe CAD is higher in older patients; exercise stress testing has a sensitivity of 84% in this population merely a decreased specificity of 70%.3 SPECT is no improve at detecting severe CAD than practise stress testing, only information technology stratifies more than intermediate-risk patients every bit low adventure.15 SPECT is superior to echocardiography for attaining images diagnostic for CAD in obese patients and in those with chronic obstructive pulmonary disease.16

Table iii.

Summary of Tests for Detection of Coronary Artery Disease

Test Sensitivity (%) Specificity (%) Limitations Advantages

Cardiac catheterization

98

82

Invasive, requires radiation

Preferred test, allows for detection and intervention

Exercise unmarried-photon emission computed tomography

85

85

Cannot appraise myocardium or valves, center rhythm irregularities may affect results, soft tissue attenuation artifacts, requires radiation

Assesses myocardial perfusion and regional/global function at rest and during stress, good prognostic data and negative predictive value

Exercise stress testing

68

77

Requires normal baseline electrocardiography, not recommended for patients with history of percutaneous coronary intervention or coronary avenue featherbed grafting

Less expensive, express equipment required, good prognostic data and negative predictive value

Stress echocardiography

79

87

Image quality affected by torso habitus and dependent on operator, express fourth dimension for imaging postexercise

Assesses cardiac structure, global and segment function at balance and during stress, relatively inexpensive, does not require radiation, skillful prognostic data and negative predictive value

A randomized controlled trial of symptomatic women at intermediate risk of CAD showed no difference in upshot-gratis survival over two years of follow-upwardly between those undergoing exercise stress testing vs. practise SPECT.17 Yet, practice stress testing costs less. Systematic reviews show that because the median prevalence of CAD in women is less than that in men, a positive result on practice stress testing indicates a lower probability of CAD (69% vs. 89%); however, negative results in women accept improve negative predictive value.9 Practise stress testing without imaging is the preferred initial pick for risk stratification in women.

In a 2014 randomized controlled trial comparing exercise stress testing alone and exercise stress testing with myocardial perfusion imaging, 965 patients younger than 65 years who had no known CAD, normal resting electrocardiography, and symptoms of CAD underwent practice stress testing for chance stratification. Per the provisional practise stress testing protocol, if they achieved maximal predicted center charge per unit or greater than 10 METs of exercise with a clinically and electrically negative exercise stress test issue, no imaging was performed.18 All-cause mortality was similar between those who underwent imaging and those who did not. No cardiac deaths occurred in those who underwent practice stress testing alone.

Which Patients May Exist Safely Risk Stratified with Do Stress Testing Alone?

  • Abstruse
  • What Are the Indications for Exercise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Exercise Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Do Stress Testing with and Without Imaging for CAD?
  • Which Patients May Be Safely Risk Stratified with Exercise Stress Testing Alone?
  • What Findings on Exercise Stress Testing Warrant Termination and Further Evaluation?
  • References

Persons who attain greater than ten METs on practice stress testing have an first-class prognosis, with a depression prevalence of significant ischemia or CAD mortality. Farther imaging in these patients increases cost without increasing prognostic do good.

EVIDENCE SUMMARY

Patients with Knuckles exercise treadmill scores greater than 7 take a v-year survival rate of 93% compared with 67% for those with scores less than −11.19 METs are the just treadmill-associated variable significantly related to all-cause bloodshed.xx Decreased practise chapters is associated with increased take a chance of MI, unstable angina, and coronary revascularization.21 A one-MET increase in summit period treadmill workload was associated with an 18% reduction in cardiac events in patients older than 65 years and a 14% reduction in younger patients.22 Achievement of more than 10 METs on practise stress testing equates to a low risk of decease, regardless of imaging results.22 A prospective study of vii,236 patients without known dilated cardiomyopathy or moderate valvular affliction who achieved more than ten METs on stress echocardiography found less than 1% CAD mortality per person-year of follow-up, regardless of the presence of wall motion abnormalities on exertion.23 Similarly, patients who achieved at least x METs on exercise SPECT had an annualized cardiac bloodshed rate of 0.one% and combined cardiac death and nonfatal MI rate of 0.4%.20 This suggests that when at least x METs are accomplished, farther imaging increases cost without increasing prognostic benefit.20,23

What Findings on Exercise Stress Testing Warrant Termination and Further Evaluation?

  • Abstract
  • What Are the Indications for Exercise Stress Testing?
  • EVIDENCE SUMMARY
  • When Should Exercise Stress Testing Not Be Used?
  • What Is the Diagnostic Value of Do Stress Testing with and Without Imaging for CAD?
  • Which Patients May Exist Safely Run a risk Stratified with Do Stress Testing Lonely?
  • What Findings on Practise Stress Testing Warrant Termination and Further Evaluation?
  • References

ST-segment elevation of more than one mm without preexisting Q waves is an absolute indication for termination of practice stress testing, whereas a horizontal or downsloping depression of more than ii mm measured 60 to 80 milliseconds afterwards the J-point is a relative indication (Table 4).iii Bear witness of chronotropic incompetence by the inability of a patient's systolic blood pressure level (BP) to ascension above or drib below the resting systolic BP increases the risk of cardiovascular events.24 A subtract in systolic BP of more than x mm Hg with other evidence of ischemia is an absolute indication to end testing. An isolated decrease in systolic BP is a relative indication.

Table 4.

Indications for Termination of Do Stress Testing

Absolute indications

Central nervous organization symptoms (east.g., ataxia, dizziness, most syncope)

Decrease in systolic blood pressure greater than 10 mm Hg despite an increase in workload and accompanied by other prove of ischemia

Moderate to severe angina

Signs of poor perfusion (east.one thousand., cyanosis, pallor) ST-segment height (> 1.0 mm) in leads without preexisting Q waves because of prior myocardial infarction (other than aVR, aVL, and V1)

Sustained ventricular tachycardia or other arrhythmia (including second- or third-degree atrioventricular block) that interferes with normal maintenance of cardiac output during do

Technical difficulties in monitoring electrocardiography or systolic blood force per unit area

The patient asks to stop

Relative indications

Arrhythmias other than sustained ventricular tachycardia, including multifocal ectopy, ventricular triplets, supraventricular tachycardia, and bradyarrhythmias that have the potential to become more circuitous or to interfere with hemodynamic stability

Bundle branch block that cannot immediately exist distinguished from ventricular tachycardia

Claudication, fatigue, leg cramps, shortness of breath, or wheezing

Decrease in systolic blood pressure greater than x mm Hg (persistently below baseline) despite an increase in workload and without other evidence of ischemia

Exaggerated hypertensive response (systolic blood pressure level > 250 mm Hg or diastolic blood pressure > 115 mm Hg)

Heart rate > 85% of age-predicted maximum

Increasing chest pain

Marked ST-segment deportation (horizontal or downsloping> 2 mm, measured lx to 80 milliseconds after the J-point) in a patient with suspected ischemia

Bear witness SUMMARY

ST-segment elevation of more than 1 mm during stress identifies areas of ischemia in proximal coronary vasculature.25 ST-segment depression of more 2 mm does non localize anatomic ischemia, but when combined with clinical symptoms of ischemia suggests CAD (Figure one).3 The sooner ST-segment depression develops during testing and the longer information technology persists into recovery, the more severe the CAD.26 Every bit practise increases cardiac output, systolic BP should increase. Disability to increase systolic BP suggests left ventricular systolic dysfunction or CAD. A prospective study (n = 44,000) of men and women, including blacks, with a mean historic period of 53 years showed a strong clan betwixt decreasing exercise systolic BP response, all-cause death, and MI.27 The lower the patient's rise in systolic BP in response to exercise, the college the incidence rate of MI per 1,000 person-years (increase of more than than 20 mm Hg above baseline = 3.ix incidence rate [95% CI, iii.vi to 4.i], one to 20 mm Hg in a higher place baseline = viii.0 [95% CI, vii.0 to 9.one], and decrease from baseline = 12.five [95% CI, 10.2 to 15.4]).27 Therefore, it is recommended that exercise stress testing be discontinued if systolic BP decreases by more than 10 mm Hg.

Figure 1. ST-segment depression during exercise. Downsloping of more than ii mm is a relative indication for termination. (ECG = electrocardiography.)

Adapted with permission from Fletcher GF, Ades PA, Kligfield P, et al.; American Eye Association Exercise, Cardiac Rehabilitation, and Prevention Commission of the Quango on Clinical Cardiology, Council on Diet, Concrete Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific argument from the American Center Clan. Circulation. 2013;128(8):885.

Conversely, a hypertensive response to moderate-intensity exercise (systolic BP greater than 210 mm Hg in men or greater than 190 mm Hg in women) indicates a 1.36-fold greater rate of cardiovascular events and mortality (95% CI, 1.02 to 1.83; P = .039).28 The AHA recommends termination of testing when systolic BP exceeds 250 mm Hg or when diastolic BP exceeds 115 mm Hg.three Reaching 85% of the maximal predicted heart rate (220 minus age) is a measure of acceptable diagnostic exercise stress testing, but the AHA recommends that it not be used in isolation to terminate testing.3 During do, the centre rate should increase by 10 beats per minute per 1 MET. Failure of the heart charge per unit to increment and prolonged filibuster in returning to resting levels may affect prognosis and indicate CAD.

This commodity updates previous manufactures on this topic by Fletcher, et al.,29 and by Darrow.thirty

The opinions and assertions independent herein are the personal views of the authors and are not to be construed as official or as reflecting the views of the U.S. Armed Services or their medical departments.

Data Sources: A PubMed search was completed using the MeSH office with the fundamental phrase practice stress test combined with at to the lowest degree one of the following terms: coronary artery affliction detection or prognosis, stress echocardiogram, myocardial perfusion imaging, and SPECT. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were Essential Evidence Plus, the Cochrane Database of Systematic Reviews, and the websites of the U.S. Preventive Services Task Force and the American Heart Association. Search dates: Apr 2016 and May 2017.

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The Authors

prove all author info

KATHRYN K. GARNER, Doctor, is a faculty fellow member at the National Capital Consortium Family Medicine Residency in Fort Belvoir, Va., and an assistant professor of family unit medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

WILLIAM POMEROY, MD, is a staff cardiologist at Keesler Medical Heart, Biloxi, Miss.

JAMES J. ARNOLD, DO, FACOFP, FAAFP, is the senior associate program director at the National Capital Consortium Family unit Medicine Residency and an assistant professor of family unit medicine at the Uniformed Services University of the Wellness Sciences.

Address correspondence to Kathryn K. Garner, MD, 2501 Capehart Rd., Offutt Air Forcefulness Base, NE 68113 (e-mail: kathryn.1000.garner2.mil@postal service.mil). Reprints are not bachelor from the authors.

Author disclosure: No relevant financial affiliations.

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