Clinical Determinants of Pharmacologic Versus Exercise Stress Testing in Myocardial Perfusion Imaging: A Retrospective Single-Center Study in Saudi Arabia

PURPOSE: Myocardial perfusion imaging (MPI) is a widely utilized noninvasive imaging modality for the evaluation of coronary artery disease and cardiovascular risk stratification. The selection of stress modality during MPI is influenced by multiple demographic and clinical factors. This study aimed to assess the clinical and demographic factors associated with the selection of pharmacologic versus exercise stress testing among patients undergoing MPI at a tertiary care center in Saudi Arabia. MATERIALS AND METHODS: This retrospective single-center analytical study included adult patients who underwent MPI at a tertiary care hospital in Saudi Arabia. Patients were categorized into exercise stress testing and pharmacologic stress testing groups according to the stress modality utilized during MPI. Demographic and clinical data including age, sex, smoking history, body mass index, cardiovascular risk factors, primary diagnoses, and associated comorbidities were extracted from institutional data collection records. Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were presented as frequencies and percentages. Comparative analyses were performed using independent t-test, chi-square test, and Fisher's exact test where appropriate. Statistical significance was considered at a P-value <0.05. RESULTS: A total of 197 patients were included in the final analysis. Among them, 147 patients (74.6%) underwent pharmacologic stress testing, whereas 50 patients (25.4%) underwent exercise stress testing. The mean age of the overall study population was 58.8 ± 10.1 years. Patients undergoing pharmacologic stress testing were significantly older than those undergoing exercise stress testing (59.8 ± 10.0 years vs. 55.9 ± 10.2 years, P = 0.02). Significant differences in sex distribution were also observed between the two groups (P = 0.006), with female patients being more frequently represented in the pharmacologic stress group. Patients undergoing pharmacologic stress testing demonstrated a greater prevalence of cardiovascular risk factors, obesity, and exercise-limiting comorbidities. Ischemic heart disease represented the most frequently documented clinical diagnosis within the study population. CONCLUSIONS: Pharmacologic stress testing represented the predominant stress modality among patients undergoing MPI at the tertiary care center. Advanced age, female sex, cardiovascular disease burden, and reduced exercise tolerance were associated with increased utilization of pharmacologic stress testing. Understanding the determinants of stress modality selection may contribute to the optimization of patient-centered imaging strategies, improved workflow efficiency, and enhanced nuclear cardiology practice. These findings may serve as a foundation for the development of a standardized clinical protocol to guide stress modality selection in MPI. Implementation of evidence-based selection criteria may improve consistency in clinical decision-making, optimize patient safety, and enhance the efficiency of nuclear cardiology services.