Top Things to Know: Multimodality Approach to Coronary Ischemic Testing for Pediatric Patients
Published: February 26, 2026
Prepared by Barbara Entl, MD Science and Medicine Advisor, American Heart Association
- Provocative and ischemic coronary testing is used in both acquired and congenital heart disease to evaluate the physiologic significance of coronary artery abnormalities by assessing myocardial blood flow and detecting ischemia or vasospasm.
- Expert consensus and scientific statements from organizations such as the American Heart Association support the use of provocative and ischemic testing in children with or at risk for coronary abnormalities, including Kawasaki disease, MIS-C with coronary aneurysms, anomalous aortic origin of a coronary artery (AAOCA), cardiac allograft vasculopathy (CAV), and surgically repaired congenital heart disease involving coronary artery manipulation.
- This scientific statement aims to summarize current modalities used in pediatric provocative ischemic testing, clarify their appropriate clinical applications, and inform future technological development.
- Testing in children requires careful consideration of physiologic and technical factors. Age, developmental stage, and the type of stressor—whether exercise or pharmacologic—can significantly affect test feasibility and diagnostic value.
- Cardiopulmonary exercise testing (CPET) is valuable for detecting early ischemia and subclinical myocardial dysfunction. However, treadmill protocols require sufficient height, coordination, and mobility, which limits their use in younger patients. While cycle ergometry allows for better imaging, it may underestimate exercise capacity in children due to earlier quadriceps fatigue and less familiar motion patterns.
- Exercise and pharmacologic stress echocardiography are both used in pediatrics. Exercise stress echocardiography offers several advantages, including the elimination of the need for IV access, contrast, or radiation, as well as portability and low cost. For children who are unable to exercise (typically those under 6–10 years old), dobutamine stress echocardiography is an appropriate alternative.
- Cardiac magnetic resonance (CMR) is the preferred modality for myocardial perfusion imaging in children, offering high diagnostic accuracy with minimal radiation exposure. While single-photon emission computed tomography (SPECT) or positron emission tomography (PET) are available alternatives, their use is limited by radiation exposure, with approximately 3.7 mSv for PET and 12.8 mSv for SPECT.
- Stress perfusion CMR with vasodilators enables detection of perfusion defects, wall motion abnormalities, and scarring, informing risk stratification and early identification of ischemia. However, its utility depends on the choice of pharmacologic stress agents.
- Common vasodilators—such as adenosine, dipyridamole (non-selective adenosine receptor agonists), and regadenoson (a selective A2A agonist)—are effective in inducing coronary hyperemia but do not replicate exercise physiology, making them suboptimal for assessing dynamic obstruction. All require contrast administration, which may be challenging in young children, especially when sedation is avoided or venous access is limited.
- Coronary angiography provides high-resolution imaging of the coronary lumen but requires iodine-based contrast and offers limited vessel wall assessment. Intravascular ultrasound (IVUS) has been introduced in children to reduce contrast exposure and evaluate wall structure. IVUS also aids in stent planning and deployment, although its image resolution is limited.
- Understanding the diagnostic performance—including sensitivity, specificity, and implications of test results—is essential for optimal use of these modalities in pediatric care. Ongoing evaluation of their strengths, limitations, and clinical utility will support informed decision-making and innovation in coronary testing.
Citation
Olivieri LJ, Lee S, Chen MH, Dahdah N, Doan TT, Jegatheeswaran A, Krishnamurthy R, Tierney ESS, Weber EM, Rao A; on behalf of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young and the Council on Cardiovascular and Stroke Nursing. Multimodality Approach to Coronary Ischemic Testing in Pediatric Patients: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2026;15:e047790. doi: 10.1161/JAHA.125.047790