The Value of Exercise Stress Testing for Renal-Cardiac Risk Assessment in Military Personnel: Exploring the Hidden Half!

For decades, the exercise stress test (EST) has been known as a well-established non-invasive diagnostic test in patients with suspected or known cardiovascular disease (CVD). However, EST is also used for several other purposes in the armed forces including fitness assessment and adjustment training in simulated non-conventional environments such as altitude chambers. While exercise stress test is a part of periodic health check-up in specific groups of the military forces such as aviators, divers, and commanders, its diagnostic value for cardiovascular disease (CVD) detection is unclear in asymptomatic healthy subjects with low and intermediate cardiovascular risk according to the current clinical practice guidelines. Furthermore, it is demonstrated that it has a modest sensitivity and specificity for the diagnosis of coronary artery disease (67-72% and 69-90% respectively) in symptomatic patients. Hence, the hidden half of the test including non-electrical variations such as hemodynamic changes would be taken into the account or results of other tests such as arterial evaluations would be combined to provide a diagnostic battery. Meanwhile, its performance is also related to the CVD pre-test probability and the prevalence of the disease in the target population. On the other hand, not only the heart, but also vessels and kidneys can be evaluated by EST. Current evidence demonstrates that the hemodynamic response to exercise and exercise-induced micro-albuminuria are associated with cardiac, renal, and arterial functional status. In addition, impaired hemodynamic response to exercise predicts the development of renal dysfunction in the future. In conclusion, EST would be particularly important in the early detection of cardiac, vascular, and renal diseases in military personnel; however, justification and arrangements for the testing must be individually assessed, and this process can be facilitated by decision analysis methods.