Did you know a patient can have significant heart disease despite a normal stress test?

Comedian Brad Upton recently posted on Facebook that he suffered a "significant" heart attack on Memorial Day after a normal cardiac stress test approximately eight months ago.

"Last September when my esophagus was giving me chest pains, I took the treadmill stress test. They told me I had the heart of a 20-year-old college soccer player," Upton, who is 66, wrote on his Facebook page.

"Monday [on May 30] my right coronary artery was 100% blocked and required three stents to open it back up," the comedian added, whose routine went viral on Dry Bar Comedy and now has amassed over a combined 170 million views on the site.

He was in "disbelief" because he always took care to maintain a good fitness level, noting from April 1, 2020, to April 2, 2021, he walked over 2700 miles, which was at least 7 miles a day for 365 days.

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"Heart attacks can originate from severe heart artery blockages. But importantly, they can also originate from initially moderate degrees of blockage – the sort that stress tests are not designed to pick up," said Dr. Deepak L. Bhatt, professor of medicine at Harvard Medical School and executive director of interventional cardiovascular programs at Brigham and Women’s Hospital Heart & Vascular Center in Massachusetts.

An acute coronary syndrome (ACS) is defined by a sudden restriction of blood flow to the heart often due to cholesterol-filled deposits called plaques, according to a recent Journal of the American Medical Association review on the diagnosis and treatment of ACS.

When a plaque breaks and a blood clot forms to block a blood vessel, a heart attack occurs, the review added.

"Therefore, a normal stress test is reassuring with respect to overall good cardiac health, but it does not mean that a heart attack is still not possible – even a few days after a normal stress test," Bhatt told Fox News.

"That is a key observation over the past couple of decades – that it isn’t just initially severe heart artery narrowing but even moderate ones that can lead to a heart attack."

Bhatt, who is not familiar with Upton’s case, said the most common stress test is an exercise treadmill test, where the patient runs on a treadmill while the blood pressure, heart rate and rhythm as well as the electrocardiogram (EKG) are being monitored.

Patients may get an abnormal result if there are certain changes on the EKG that signify problems with the coronary arteries of the heart.

Stress tests often examine a heart at rest and also want to "push" the heart to see if there are any issues on exertion, but the type or combination of tests are individualized to the patient, according to Cleveland Clinic.

Upton told Fox News that he had a stress test called a myocardial perfusion scan, otherwise known as a nuclear stress test, that also included a treadmill test component to "stress" his heart.

A myocardial perfusion scan utilizes a small amount of radioactive tracer that travels through the bloodstream where the healthy heart muscle eventually absorbs it, while unhealthy parts don’t, according to Johns Hopkins Medicine.

For those who can’t run on treadmills, for example because of arthritis, a chemical stress test might be performed instead, Bhatt added.

"In the case of chemical stress tests (the medical term being pharmacological stress testing), a person doesn’t actually exercise, but a chemical is injected to make the heart think it is exercising," Bhatt explained.

But the cardiologist told Fox News when a stress test is normal even when there is significant heart disease, this is called a "false negative" test.

Patients run on a treadmill test to "stress" their heart, but sometimes the degree of exercise in the test isn’t enough to make the heart work hard enough for any blood flow limitation to become apparent, Bhatt explained.

In Upton’s case, "I reached stage 4 on the treadmill test; the nurse told me they hadn’t seen a stage 4 in several months. I was really fit."

"In [a chemical] stress test, since blood flow in one part of the heart is compared with images in another part of the heart, if all the arteries are severely narrowed, the test may seem to be normal, because the blood flow is similarly reduced in the three regions being compared," Bhatt said.

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And another reason for a normal stress test in someone with significant coronary artery disease is that heart arteries form a "natural bypass" around the blocked artery or the blocked artery is just too small to be picked up on a stress test, Bhatt added.

"In patients with a normal baseline EKG, many professional society guidelines say to start with an EKG treadmill stress test, but if a physician has a very high suspicion of coronary artery disease or if the baseline EKG is abnormal, then the imaging part may be added," Bhatt said.

"There isn’t really any established ‘warranty period’ for a normal stress test, but in general, we like to think it can rule out the presence of any severe coronary artery disease for one year or so. But it is important to remember that even someone with a normal stress test can still have a heart attack. So, whenever there is severe chest discomfort, the right thing to do is to call 911."

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