Intro to Exercise Stress Testing*

Intro to Exercise Stress Testing*

Dr. Sarah Ramer 2021

Resources

• 2013 ACC/AHA guideline

• Dr. Sarah Ramer - [email protected]

mailto:[email protected]

mailto:[email protected]

63 pages to combat insomnia…..

AHA Scientific Statement

873

The 2001 version of the exercise standards statement1 has served effectively to reflect the basic fundamentals of

ECG–monitored exercise testing and training of both healthy subjects and patients with cardiovascular disease (CVD) and other disease states. These exercise standards are intended for use by physicians, nurses, exercise physiologists and special-ists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. Because of an abundance of new research in recent years, a revision of these exercise standards is appropriate. The revision deals with basic fundamentals of testing and training, with no attempt to dupli-cate or replace current clinical practice guidelines issued by the American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and other professional societies.

(Circulation. 2013;128:873-934.)© 2013 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31829b5b44

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 1, 2013. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].

The American Heart Association requests that this document be cited as follows: Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation . 2013;128:873–934.

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

Exercise Standards for Testing and TrainingA Scientific Statement From the American Heart Association

Gerald F. Fletcher, MD, FAHA, Chair; Philip A. Ades, MD, Co-Chair; Paul Kligfield, MD, FAHA, Co-Chair; Ross Arena, PhD, PT, FAHA; Gary J. Balady, MD, FAHA;

Vera A. Bittner, MD, MSPH, FAHA; Lola A. Coke, PhD, ACNS, FAHA; Jerome L. Fleg, MD; Daniel E. Forman, MD, FAHA; Thomas C. Gerber, MD, PhD, FAHA;

Martha Gulati, MD, MS, FAHA; Kushal Madan, PhD, PT; Jonathan Rhodes, MD; Paul D. Thompson, MD; Mark A. Williams, PhD; on behalf of the American Heart Association

Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke

Nursing, and Council on Epidemiology and Prevention

XXX

20

August 20,

2013

Table of ContentsExercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Purposes of Exercise Testing . . . . . . . . . . . . . . . . . . . . . 874 Physiology of Exercise Testing . . . . . . . . . . . . . . . . . . . 874 Types of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Cardiovascular Responses to Exercise

in Normal Subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Exercise Testing Procedures . . . . . . . . . . . . . . . . . . . . . 876 Clinical and Cardiopulmonary Responses

During Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 The ECG During Exercise . . . . . . . . . . . . . . . . . . . . . . . 883 Stress Imaging Modalities and Exercise Testing . . . . . . 889 Prognosis and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 890 Additional Uses of Exercise Testing . . . . . . . . . . . . . . . 893 Interpretation of the Exercise Test in

Specific Populations and Settings . . . . . . . . . . . . . . . 893 Drugs and Electrolytes in Exercise Testing . . . . . . . . . . 902 The Exercise Electrocardiographic Test Report. . . . . . . 903Exercise Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 903 Exercise and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 903 Exercise Prescription for Apparently

Healthy Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . 907 Exercise Training Techniques . . . . . . . . . . . . . . . . . . . . 908 Behavioral Aspects of Initiating and

Sustaining an Exercise Program . . . . . . . . . . . . . . . . 911

Evaluation and Exercise Prescription in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 912

Effects of Exercise Training in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914

Prognostic Benefits of Exercise in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914

Targeting Exercise Prescription to Relevant Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 915

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920

at Capital Health on May 27, 2015http://circ.ahajournals.org/Downloaded from

AHA Scientific Statement

873

The 2001 version of the exercise standards statement1 has served effectively to reflect the basic fundamentals of

ECG–monitored exercise testing and training of both healthy subjects and patients with cardiovascular disease (CVD) and other disease states. These exercise standards are intended for use by physicians, nurses, exercise physiologists and special-ists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. Because of an abundance of new research in recent years, a revision of these exercise standards is appropriate. The revision deals with basic fundamentals of testing and training, with no attempt to dupli-cate or replace current clinical practice guidelines issued by the American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and other professional societies.

(Circulation. 2013;128:873-934.)© 2013 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31829b5b44

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on February 1, 2013. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].

The American Heart Association requests that this document be cited as follows: Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA; on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation . 2013;128:873–934.

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

Exercise Standards for Testing and TrainingA Scientific Statement From the American Heart Association

Gerald F. Fletcher, MD, FAHA, Chair; Philip A. Ades, MD, Co-Chair; Paul Kligfield, MD, FAHA, Co-Chair; Ross Arena, PhD, PT, FAHA; Gary J. Balady, MD, FAHA;

Vera A. Bittner, MD, MSPH, FAHA; Lola A. Coke, PhD, ACNS, FAHA; Jerome L. Fleg, MD; Daniel E. Forman, MD, FAHA; Thomas C. Gerber, MD, PhD, FAHA;

Martha Gulati, MD, MS, FAHA; Kushal Madan, PhD, PT; Jonathan Rhodes, MD; Paul D. Thompson, MD; Mark A. Williams, PhD; on behalf of the American Heart Association

Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke

Nursing, and Council on Epidemiology and Prevention

XXX

20

August 20,

2013

Table of ContentsExercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Purposes of Exercise Testing . . . . . . . . . . . . . . . . . . . . . 874 Physiology of Exercise Testing . . . . . . . . . . . . . . . . . . . 874 Types of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Cardiovascular Responses to Exercise

in Normal Subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Exercise Testing Procedures . . . . . . . . . . . . . . . . . . . . . 876 Clinical and Cardiopulmonary Responses

During Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882 The ECG During Exercise . . . . . . . . . . . . . . . . . . . . . . . 883 Stress Imaging Modalities and Exercise Testing . . . . . . 889 Prognosis and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 890 Additional Uses of Exercise Testing . . . . . . . . . . . . . . . 893 Interpretation of the Exercise Test in

Specific Populations and Settings . . . . . . . . . . . . . . . 893 Drugs and Electrolytes in Exercise Testing . . . . . . . . . . 902 The Exercise Electrocardiographic Test Report. . . . . . . 903Exercise Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 903 Exercise and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 903 Exercise Prescription for Apparently

Healthy Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . 907 Exercise Training Techniques . . . . . . . . . . . . . . . . . . . . 908 Behavioral Aspects of Initiating and

Sustaining an Exercise Program . . . . . . . . . . . . . . . . 911

Evaluation and Exercise Prescription in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 912

Effects of Exercise Training in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914

Prognostic Benefits of Exercise in Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914

Targeting Exercise Prescription to Relevant Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 915

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920


What is this?

Look familiar?

On the exam - Paper 1• List absolute and relative contraindications to stress testing

• Complications of Exercise Testing

• Absolute and Relative Indications for Terminating EST

• Definition of positive, negative or equivocal ECG changes during exercise

• Definitions of abnormal BP response

• Prognostic value of exercise stress testing - DUKE Score

• Exercise prescription

• Sens/Specificity, pre-test and post-test probabilities

On the exam - Paper 2

• Report a stress test (graphics provided)

• Could be normal or abnormal

• Clinical stem, stress test given - how to manage?

• Calculate a Duke score and estimate risk

On the Exam - Oral• Clinical scenario where a stress test is ordered.

Interpret the stress test in front of the examiner and develop an appropriate management strategy.

• Evaluation of chest pain

• Assessment of prognosis

• Indication for valve surgery based on symptom assessment

• Assessment of arrhythmia, long QT, WPW etc.

Case• A 44 year old woman is referred for exercise

stress testing. She reports chest pain, sharp stabbing retrosternal lasting a few seconds several times per day. No relationship to physical activity. She is concerned because of a positive family history. She has no other cardiac risk factors.

Stress test

QE II Health Sciences Centre Ward1798 Summer Street Telephone: Halifax, Nova Scotia

EXERCISE STRESS TEST REPORTPatient Name: LEPINE, PAUL DOB: 09-Jun-1961Patient ID: 0011176781 Age: 55 yrHeight: in Gender: MaleWeight: lb Race: --

Study Date: 20-Apr-2017 Referring Physician: DOUGLAS HAYAMITest Type: Treadmill Stress Attending Physician: MACDONALD, M.D., NancyProtocol: BRUCE Technician: SARAH MCLEAN

Medications: Tamsulosin , rosuvastatin

Medical History:

Reason for Exercise Test:Ischemia Evaluation, R/O Arrhyth

Exercise Test Summary

Phase Stage Time Speed Grade HR BP Comment Name Name in Stage (mph) (%) (bpm) (mmHg)

PRETEST STANDING 01:08 1.0 0.0 71 120/80Exercise STAGE 1 03:00 1.7 10.0 84 114/80 STAGE 2 03:00 2.5 12.0 98 126/76 STAGE 3 03:00 3.4 14.0 127 140/76 STAGE 4 01:11 4.2 16.0 144 Recovery 1 Minute 01:00 0.0 0.0 171 142/76 00:00 Target heart rate

achieved 2 Minute 01:00 0.0 0.0 84 150/76 3 minute 01:00 0.0 0.0 71 4 minute 01:00 0.0 0.0 75 130/70 5 MINUTE 00:52 0.0 0.0 72 120/70 The patient exercised according to the BRUCE for 10:11 min:s, achieving a work level of Max. METS: 12.0. The resting heart rate of 73 bpm rose to a maximal heart rate of 171 bpm. This value represents 103 % of the maximal, age-predicted heart rate. The resting blood pressure of 120/80 mmHg , rose to a maximum blood pressure of 150/76 mmHg. The exercise test was stopped due to Target Heart Rate, Dyspnea.

Interpretation

Summary: Resting ECG: Early repolarization abnormality.Functional Capacity: Class I.HR Response to Exercise: appropriate.BP Response to Exercise: normal resting BP - appropriate response.Chest Pain: none.Arrhythmias: see comments.ST Changes: Depression upsloping see comments.

Rest12-Lead ReportLEPINE, PAUL

Patient ID: 00111767812017/04/20 9:25:46

GECASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(II,V5)

PRETESTSTANDING00:08

BRUCE 0.0 mph 0.0 %

73 bpm 120/80 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Peak12-Lead Report (PEAK EXERCISE)LEPINE, PAULPatient ID: 00111767812017/04/20 9:36:57


EXERCISESTAGE 410:11

BRUCE 4.2 mph 16.0 %

144 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Recovery 00:1512-Lead ReportLEPINE, PAUL

Patient ID: 00111767812017/04/20 9:37:12


RECOVERY1 Minute00:15

BRUCE 1.5 mph 3.1 %

141 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Recovery 2:0012-Lead ReportLEPINE, PAULPatient ID: 00111767812017/04/20 9:38:57



BRUCE 0.0 mph 0.0 %

84 bpm 150/76 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Medians SummaryLEPINE, PAUL ID:0011176781 20-APR-2017 09:25:38 NSES

GRADED EXERCISE SUMMARYBRUCE Total Exercise Time:10:11

25mm/s10mm/mV150Hz

Max HR: 171 bpm 103% of Max Predicted 165 bpmMax BP: 150/76 Maximum Workload: 12.0

cc: Dr. Maged GergesEndpoint was THR and dyspneaFunctional Class I ( 12 METs)No chest painResting EKG shows early repolarization abnormailty. At peak exercsie developed> 1.5 mm ( beyond baseline) upsloping ST depressionIn recovery had 18 second run of SVT at 160 bpm, withusual symptomsBorderline positives test by EKG with SVT in recovery

Confirmed by MACDONALD, M.D., NANCY (9504) on 4/20/2017 11:33:05 AM

09-JUN-1961 (55 yr) MaleWt: Ht:Med: Tamsulosin, rosuvastatin

Referred by: DOUGLAS HAYAMITechnician:SARAH MCLEANTest ind: Ischemia Evaluation, R/O ArrhythTest type: Treadmill Stress

Confirmed By: NANCY MACDONALD, M.D. Date:20-APR-2017

BASELINE

EXERCISE STAGE 1 71 bpm ST @ 10mm/mVLeadSTSlope00:00 1.3 60ms postJ

I0.4 mm

-0.3 mV/s

II0.80.3

III0.30.3

aVR-0.6-1.5

aVL0.1

-0.5

aVF0.50.3

V10.70.3

V21.71.5

V31.41.4

V40.90.8

V50.70.5

V60.40.1

MAX ST


I-0.10.1

II-1.61.7

III-1.51.1

aVR0.8

-1.3

aVL0.7

-0.8

aVF-1.51.5

V11.10.5

V20.82.2

V30.32.4

V4-0.82.4

V5-1.31.5

V6-0.90.8

8.0.1 SID: 0001644160 EID:9504 EDT: 11:33 20-APR-2017 ORDER: ACCOUNT: 28714882CASE V6.73-0.0

With respect to this stress test:

• A) It’s normal - Negative

• B) It’s abnormal - Positive

• C) It’s equivocal - Non-diagnostic

• D) Holy crap why did I order this stress test?

ECG changes with exerciseFletcher et al Exercise Standards for Testing and Training 885

HR Adjustment of ST-Segment Depression. Peak HR and the change in HR during exercise are lower in patients with ischemic disease than in normal subjects.101 At the same time, increasing HR during graded exercise is what influences pro-gressive ST-segment depression because it is a major deter-minant of myocardial oxygen demand.109 As a consequence, it is physiologically rational to adjust observed ST-segment depression for the change in HR associated with its produc-tion to derive indices of the presence and extent of obstructive CAD. HR adjustment of ST-segment depression can improve the sensitivity of the exercise test with preservation of test specificity, primarily from improved classification of patients with equivocal test responses attributable to upsloping ST segments.90,110 Differences in test performance among studies with these methods could result from population differences and from technical differences in methodology. The methods are not accurate in the early phase after Q-wave infarction in patients with resting abnormalities of repolarization, but they do seem to increase the sensitivity of the exercise ECG in gen-eral populations.111 Further prospective evaluation of their val-ues and limitations for specific purposes of testing is required.

The ST/HR Slope and the ST/HR Index. Calculation of max-imal ST-segment (ST)/HR slope in microvolts per beat per minute is performed by linear regression analysis relating the measured amount of ST-segment depression in individual leads to the HR at the end of each stage of exercise, starting at end exercise. An ST/HR slope >2.4 µV/bpm is considered abnor-mal, and values >6 µV/bpm are suggestive of anatomically extensive disease, including 3-vessel or left main CAD.111 The practical use of this measurement requires an exercise proto-col with gradual increments in HR, such as the Cornell Pro-tocol, because large increments in rate between stages of the Bruce Protocol limit the ability to calculate statistically valid ST/HR slopes by regression.48 A modification of the ST/HR slope method is the simple ST/HR index calculation, which represents the average changes of ST-segment depression with HR throughout the course of the exercise test and requires no regression calculation. The ST/HR index measurements dur-ing ischemia are lower than the ST/HR slope measurements

because ST change is averaged over the entire HR change of exercise, with an ST/HR index of >1.6 µV/bpm defined as abnormal.90,111 Because it is calculated from only upright con-trol and peak exercise data, the ST/HR index can be derived from tests that are not gently graded. The ST/HR index has been shown in retrospective application to improve prediction of coronary events in asymptomatic higher-risk men112 and also in asymptomatic lower-risk men and women.113 These methods require further prospective evaluation.

Recovery Phase ST/HR Loops and Hysteresis. As the HR slows during early recovery from peak exercise, the recovery phase behavior of the depressed ST segment as it returns to normal differs in normal subjects and patients with ischemia. ST/HR loops and hysteresis provide alternative criteria for test positivity and negativity. After 1 minute of recovery, ST depression attributable to ischemia is generally greater than it was at the same HR during exercise, whereas in normal subjects it is less.114 Extension of this principle to encompass measurement of the recovery phase area above or below the ST depression occurring with exercise forms the basis of ST/HR hysteresis, where the term hysteresis is used to indicate asymmetry of measured responses with respect to another variable occurring during exercise and recovery, such as time from peak effort, or in this case to matched HR during exercise and recovery. ST/HR hysteresis appears to provide higher diagnostic and prognostic test accuracy than that found for simultaneously measured standard ST-segment depression criteria and for the ST/HR indices.115–117

Beyond the ST SegmentBecause the surface ECG reflects uncancelled summation of individual action potentials in the heart, and because demand-induced ischemia affects action potentials beyond alterations in plateau phase and resting membrane potential, it is reasonable to expect changes in the exercise ECG that extend beyond the ST segment, either alone or as modified for HR behavior.116,118 Several changes in the ECG during exercise-induced ischemia have been proposed as markers for obstructive CAD. Even though these findings are not used in routine test interpretation, they are described briefly in the

Figure 4. Definition of ST-segment depression changes during exercise. Positive standard test responses include horizontal or downsloping depression ≥1.0 mm (0.1 mV), whereas upsloping ST depression ≥1.0 mm is considered equivocal (a change that does not usefully separate normal from abnormal). All ST depression <1.0 mm additional from baseline is defined as negative. The waveforms depicted are modified from Tavel610 with permission of the publisher, copyright © 2001, American College of Chest Physicians, but the classification and definitions represent the consensus of the writing group.


Pearl of wisdom• With resting ST depression, further ST

depression is measured

• With resting ST elevation due to early repolarization, only ST depression related to baseline is measured

• Baseline is P-Q segment as T-P is often too short during exercise.

Indications for Exercise Stress testing

• 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: Miller TD, Askew JW, Anavekar NS.

• Noninvasive Stress Testing for Coronary Artery Disease. Heart Fail Clin. 2016 Jan;12(1):65-82.

-Symptoms suggesting myocardial ischemia -Acute chest pain in whom acute coronary syndrome (ACS) and myocardial infarction have been excluded -Recent ACS treated without coronary angiography -Known coronary heart disease and change in clinical status -Prior coronary revascularization -Valvular heart disease (asymptomatic) -Newly diagnosed heart failure or cardiomyopathy (compensated) -Certain cardiac arrhythmias -An indication for cardiac assessment prior to non-cardiac surgery

Contraindications to Stress Testing

876 Circulation August 20, 2013

intensity and is below the ventilatory threshold. The ventila-tory threshold is another measure of relative work effort and represents the point at which ventilation abruptly increases in response to increasing carbon dioxide production (V̇co2) associ-ated with increased work rate, despite increasing oxygen uptake. In most cases, the ventilatory threshold is highly reproducible, although it might not be achieved or readily identified in some patients, particularly those with very poor exercise capacity.4

It is convenient to express oxygen uptake in multiples of resting oxygen requirements—that is, METs, whereby a unit of sitting/resting oxygen uptake (1 MET) is defined as ≈3.5 mL O2 per kilogram of body weight per minute (mL kg−1 min−1). For example, an oxygen uptake expressed as a 7-MET level would equal 24.5 mL kg−1 min−1. V̇o2max is influenced by age, sex, exercise habits, heredity, and cardiovascular clinical status.

V.o2max is equal to the product of maximum cardiac output

and maximum arteriovenous oxygen difference. V̇o2max divided by the HR at peak exercise (a quantity defined as the oxygen pulse) is therefore equal to the forward stroke volume (ie, cardiac output divided by HR) at peak exercise times the arteriovenous oxygen difference at peak exercise. Because the arteriovenous oxygen difference at peak exercise reaches a physiological limit and usually varies little across a wide spectrum of cardiovascular function, most of the clinical variation in the oxygen pulse at peak exercise is therefore attributable to variation in the forward stroke volume at peak exercise. Valid inferences about a patient’s forward stroke volume at peak exercise therefore can be made from determinations of the oxygen pulse at peak exercise. Normal values for the oxygen pulse (and stroke volume) at peak exercise are dependent on a patient’s age, size, and sex. Predicted values can be calculated easily, however, by dividing the patient’s predicted V̇o2max (in milliliters per minute) by the predicted peak HR.20 The oxygen pulse also is influenced by hemoglobin levels and the arterial oxygen saturation. Proper interpretation of oxygen pulse data therefore should take into account abnormalities in these indices.

AgeMaximum values of V̇o2max occur between the ages of 15 and 30 years and decrease progressively with age. At age 60 years, mean V̇o2max in men is approximately two thirds of that at 20 years.1 A longitudinal decline in peak V̇o2max was observed in each of 6 age decades in both sexes; however, the rate of decline accelerated from 3% to 6% per 10 years in individuals in their 20s and 30s to >20% per 10 years in individuals in their 70s and beyond,21 as seen in Figure 1.

SexWomen demonstrate a lower V̇o2max than that of men.22 This lower V̇o2max in women is attributed to their smaller muscle mass, lower hemoglobin and blood volume, and smaller stroke volume relative to men.1 The rate of decline for each decade is larger in men than in women from the fourth decade onward.21

Exercise HabitsPhysical activity has an important influence on V̇o2max. In moderately active young men, V̇o2max is ≈12 METs, whereas young men performing aerobic training such as distance run-ning can have a V̇o2max as high as 18 to 24 METs (60 to 85 mL kg−1 min−1).1 A similar relationship was found in active versus sedentary women.22

Cardiovascular Clinical StatusV̇o2max is affected by the degree of impairment caused by disease. In particular, preexisting LV dysfunction or the devel-opment of such with exercise-induced myocardial ischemia can greatly affect V̇o2max. In addition, the development of signs or symptoms associated with the need for exercise test termination, such as angina pectoris, hypertension, or cardiac dysrhythmia, can greatly impact V̇o2max. Thus, it is difficult to accurately predict V̇o2max from its relation to exercise hab-its and age alone because of considerable scatter because of underlying disease. However, achieved values for V̇o2max can be compared with average normal values by age and sex.1

Exercise Testing Procedures

Absolute and Relative Contraindications to Exercise TestingAbsolute and relative contraindications to exercise testing balance the risk of the test with the potential benefit of the information derived from the test. Assessment of this balance requires knowledge of the purpose of the test for the individ-ual subject or patient and what symptom or sign end points will be for the individual test.

Absolute Contraindications

● Acute myocardial infarction (MI), within 2 days ● Ongoing unstable angina ● Uncontrolled cardiac arrhythmia with hemodynamic

compromise ● Active endocarditis ● Symptomatic severe aortic stenosis ● Decompensated heart failure ● Acute pulmonary embolism, pulmonary infarction, or deep

vein thrombosis ● Acute myocarditis or pericarditis ● Acute aortic dissection ● Physical disability that precludes safe and adequate testing

Relative Contraindications

● Known obstructive left main coronary artery stenosis ● Moderate to severe aortic stenosis with uncertain relation

to symptoms ● Tachyarrhythmias with uncontrolled ventricular rates ● Acquired advanced or complete heart block ● Hypertrophic obstructive cardiomyopathy with severe rest-

ing gradient ● Recent stroke or transient ischemic attack ● Mental impairment with limited ability to cooperate ● Resting hypertension with systolic or diastolic blood pres-

sures >200/110 mm Hg ● Uncorrected medical conditions, such as significant ane-

mia, important electrolyte imbalance, and hyperthyroidism

Subject PreparationPreparations for exercise testing include the following:

● The purpose of the test should be clear in advance to maxi-mize diagnostic value and to ensure safety. If the indication


Contraindications to Stress Testing


intensity and is below the ventilatory threshold. The ventila-tory threshold is another measure of relative work effort and represents the point at which ventilation abruptly increases in response to increasing carbon dioxide production (V̇co2) associ-ated with increased work rate, despite increasing oxygen uptake. In most cases, the ventilatory threshold is highly reproducible, although it might not be achieved or readily identified in some patients, particularly those with very poor exercise capacity.4

It is convenient to express oxygen uptake in multiples of resting oxygen requirements—that is, METs, whereby a unit of sitting/resting oxygen uptake (1 MET) is defined as ≈3.5 mL O2 per kilogram of body weight per minute (mL kg−1 min−1). For example, an oxygen uptake expressed as a 7-MET level would equal 24.5 mL kg−1 min−1. V̇o2max is influenced by age, sex, exercise habits, heredity, and cardiovascular clinical status.

V.o2max is equal to the product of maximum cardiac output

and maximum arteriovenous oxygen difference. V̇o2max divided by the HR at peak exercise (a quantity defined as the oxygen pulse) is therefore equal to the forward stroke volume (ie, cardiac output divided by HR) at peak exercise times the arteriovenous oxygen difference at peak exercise. Because the arteriovenous oxygen difference at peak exercise reaches a physiological limit and usually varies little across a wide spectrum of cardiovascular function, most of the clinical variation in the oxygen pulse at peak exercise is therefore attributable to variation in the forward stroke volume at peak exercise. Valid inferences about a patient’s forward stroke volume at peak exercise therefore can be made from determinations of the oxygen pulse at peak exercise. Normal values for the oxygen pulse (and stroke volume) at peak exercise are dependent on a patient’s age, size, and sex. Predicted values can be calculated easily, however, by dividing the patient’s predicted V̇o2max (in milliliters per minute) by the predicted peak HR.20 The oxygen pulse also is influenced by hemoglobin levels and the arterial oxygen saturation. Proper interpretation of oxygen pulse data therefore should take into account abnormalities in these indices.

AgeMaximum values of V̇o2max occur between the ages of 15 and 30 years and decrease progressively with age. At age 60 years, mean V̇o2max in men is approximately two thirds of that at 20 years.1 A longitudinal decline in peak V̇o2max was observed in each of 6 age decades in both sexes; however, the rate of decline accelerated from 3% to 6% per 10 years in individuals in their 20s and 30s to >20% per 10 years in individuals in their 70s and beyond,21 as seen in Figure 1.

SexWomen demonstrate a lower V̇o2max than that of men.22 This lower V̇o2max in women is attributed to their smaller muscle mass, lower hemoglobin and blood volume, and smaller stroke volume relative to men.1 The rate of decline for each decade is larger in men than in women from the fourth decade onward.21

Exercise HabitsPhysical activity has an important influence on V̇o2max. In moderately active young men, V̇o2max is ≈12 METs, whereas young men performing aerobic training such as distance run-ning can have a V̇o2max as high as 18 to 24 METs (60 to 85 mL kg−1 min−1).1 A similar relationship was found in active versus sedentary women.22

Cardiovascular Clinical StatusV̇o2max is affected by the degree of impairment caused by disease. In particular, preexisting LV dysfunction or the devel-opment of such with exercise-induced myocardial ischemia can greatly affect V̇o2max. In addition, the development of signs or symptoms associated with the need for exercise test termination, such as angina pectoris, hypertension, or cardiac dysrhythmia, can greatly impact V̇o2max. Thus, it is difficult to accurately predict V̇o2max from its relation to exercise hab-its and age alone because of considerable scatter because of underlying disease. However, achieved values for V̇o2max can be compared with average normal values by age and sex.1

Exercise Testing Procedures

Absolute and Relative Contraindications to Exercise TestingAbsolute and relative contraindications to exercise testing balance the risk of the test with the potential benefit of the information derived from the test. Assessment of this balance requires knowledge of the purpose of the test for the individ-ual subject or patient and what symptom or sign end points will be for the individual test.

Absolute Contraindications

● Acute myocardial infarction (MI), within 2 days ● Ongoing unstable angina ● Uncontrolled cardiac arrhythmia with hemodynamic

compromise ● Active endocarditis ● Symptomatic severe aortic stenosis ● Decompensated heart failure ● Acute pulmonary embolism, pulmonary infarction, or deep

vein thrombosis ● Acute myocarditis or pericarditis ● Acute aortic dissection ● Physical disability that precludes safe and adequate testing

Relative Contraindications

● Known obstructive left main coronary artery stenosis ● Moderate to severe aortic stenosis with uncertain relation

to symptoms ● Tachyarrhythmias with uncontrolled ventricular rates ● Acquired advanced or complete heart block ● Hypertrophic obstructive cardiomyopathy with severe rest-

ing gradient ● Recent stroke or transient ischemic attack ● Mental impairment with limited ability to cooperate ● Resting hypertension with systolic or diastolic blood pres-

sures >200/110 mm Hg ● Uncorrected medical conditions, such as significant ane-

mia, important electrolyte imbalance, and hyperthyroidism

Subject PreparationPreparations for exercise testing include the following:

● The purpose of the test should be clear in advance to maxi-mize diagnostic value and to ensure safety. If the indication


Another case

• 47 year old man complaining of decreased exercise tolerance and palpitations with exertion.

• No cardiac risk factors.

EST

Cobequid Community Health Centre Ward40 Freer Lane Telephone: Lower Sackville, N.S.

EXERCISE STRESS TEST REPORTPatient Name: SIMMONS, GREGORY DOB: 15-Feb-1972Patient ID: 0010647048 Age: 44 yrHeight: in Gender: MaleWeight: lb Race: Caucasian

Study Date: 25-Jul-2016 Referring Physician: RATIKA PARKASHTest Type: Stress Echo Attending Physician: RAMER, M.D., SarahProtocol: BRUCE Technician: LINDA BOURBONNAIS

Medications: NIL

Medical History:

Reason for Exercise Test:Screening for CAD



PRETEST STANDING 09:37 1.0 0.0 85 134/74Exercise STAGE 1 03:00 1.7 10.0 91 150/74 STAGE 2 03:00 2.5 12.0 112 156/66 STAGE 3 03:00 3.4 14.0 146 172/60 STAGE 4 03:00 4.2 16.0 153 09:45 Target heart rate

achieved STAGE 5 02:16 4.8 18.0 187 172/60 13:05 breathing getting

labouredRecovery 1 Minute 01:00 0.0 0.0 137 2 Minute 01:00 0.0 0.0 122 3 minute 01:00 0.0 0.0 113 4 minute 01:00 0.0 0.0 110 5 MINUTE 00:36 0.0 0.0 109 The patient exercised according to the BRUCE for 14:15 min:s, achieving a work level of Max. METS: 17.2. The resting heart rate of 72 bpm rose to a maximal heart rate of 187 bpm. This value represents 106 % of the maximal, age-predicted heart rate. The resting blood pressure of 134/74 mmHg , rose to a maximum blood pressure of 172/60 mmHg. The exercise test was stopped due to Dyspnea.

Interpretation

Conclusions

cc: Dr. Farah Kapur

RestSIMMONS, GREGORYPatient ID: 001064704825.07.2016 9:43:25am



BRUCE 0.0 mph 0.0 %

76 bpm 134/74 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

V1

PeakSIMMONS, GREGORYPatient ID: 001064704825.07.201610:07:06am

GECASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V3,V4)


BRUCE 0.0 mph 0.0 %

151 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

V1

Peak (continued - cardiologist becoming anxious)SIMMONS, GREGORY

Patient ID: 001064704825.07.201610:07:20am

GECASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V3,V4)


BRUCE 0.0 mph 0.0 %

157 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

V1

RecoverySIMMONS, GREGORYPatient ID: 001064704825.07.201610:10:40am

GECASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V1,II)


BRUCE 0.0 mph 0.0 %

111 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

V1

MediansSIMMONS, GREGORY ID:0010647048 25-JUL-2016 09:42:27 NSES


25mm/s10mm/mV150Hz


cc: Dr. Farah Kapur

A stress echo was performed.Non-diagnostic stress test.Wide complex tachycardia noted.See echo report.

Confirmed by RAMER, M.D., SARAH (10381) on 8/9/2016 10:35:11 AM

15-FEB-1972 (44 yr) MaleWt: Ht:Med: NIL

Referred by: RATIKA PARKASHTechnician:LINDA BOURBONNAISTest ind: Screening for CADTest type: Stress Echo

Confirmed By: SARAH RAMER, M.D. Date:09-AUG-2016

BASELINE


I0.5 mm0.4 mV/s

II1.10.7

III0.70.1

aVR-0.8-1.0

aVL-0.10.1

aVF0.90.5

V10.7

-0.2

V20.1

-0.1

V30.60.3

V40.70.5

V50.70.5

V60.60.5

MAX ST

EXERCISE STAGE 3 141 bpm ST @ 10mm/mVLeadSTSlope8:50 10.1 172/60 60ms postJ

I-1.4-0.5

II2.1

17.3

III3.5

17.8

aVR-0.3

-11.5

aVL-2.4-9.6

aVF2.8

17.5

V1-5.2-9.8

V2-3.5

-12.6

V30.1

10.4

V40.6

11.4

V51.0

11.6

V61.5

11.7

8.0.1 SID: 0001283363 EID:10381 EDT: 10:35 09-AUG-2016 ORDER: ACCOUNT: 27750333CASE V6.61-0.0

What happened here and how are you going to report it?

Complications of Stress Testing

Fletcher et al Exercise Standards for Testing and Training 881

W every 2 or 3 minutes until end points are reached. If arm ergometry is substituted for cycle ergometry, a similar protocol may be used, except that initial power output and incremental increases are lower. Two-minute stages are most popular with arm ergometry.51,52 However, most subjects who are unable to use their legs for treadmill or bicycle exercise generally undergo pharmacological stress testing with imaging.

The 6-minute walk test is a functional test that can be used to evaluate submaximal exercise capacity. This assessment has frequently been used in patients with chronic disease, such as heart failure, chronic obstructive pulmonary disease, and peripheral arterial occlusive disease.53–55 Patients are instructed to walk down a 100-foot corridor at their own pace, attempting to walk as much distance as possible in 6 minutes. At the end of the 6-minute interval, the total distance walked is determined and the symptoms experienced by the patient recorded. Detailed guidelines describing the administration of the 6-minute walk test are available.56 The intensity of effort associated with the 6-minute walk test is variable, ranging from submaximal to maximal, and accordingly it correlates only modestly with V̇o2max (r≈0.50).53,57 Electrocardiographic monitoring is not routinely done with 6-minute walk testing, thus limiting its diagnostic value for ischemia or arrhythmia.

Exercise Test SupervisionExercise testing should be performed under the supervision of a qualified health professional who is appropriately trained to administer exercise tests.43 Good clinical judgment should be foremost in deciding indications and contraindications for exercise testing.58 Although absolute contraindications are clear, in selected cases with relative contraindications to high level exercise, even submaximal testing can provide valuable information about functional capacity and progno-sis. Absolute and relative contraindications to exercise testing are subsequently discussed. In any procedure with a risk of complications, the test administrator should be certain that the subject understands the risks and benefits of the test, and writ-ten informed consent should be obtained. Good communica-tion with the patient about testing is mandatory.

The physician should be responsible for ensuring that the exercise laboratory is properly equipped and that exercise test-ing personnel are appropriately trained. Exercise testing should be conducted only by well-trained personnel with sufficient knowledge of exercise physiology and ability to recognize important changes in rhythm and repolarization on the ECG.43 The degree of subject supervision needed during a test can be determined by the clinical status of the subject being tested. This determination is made by the physician or physician’s des-ignated staff member, who asks pertinent questions about the subject’s medical history, performs a brief physical examina-tion, and reviews the standard 12-lead ECG performed immedi-ately before testing. Supervision can be assigned to a properly trained nonphysician (ie, a nurse, physician assistant, or exer-cise physiologist or specialist) for testing apparently healthy younger people (<40 years of age) and those with stable chest pain syndromes. Recent recommendations permit additional flexibility with regard to supervision personnel.43 Possibly with the exception of young, apparently healthy individuals (eg, exercise testing of athletes), a physician should be immediately

available during all exercise tests. For additional details about supervision and interpretation of exercise tests, reference is made to the document on clinical competence in stress testing from the ACCF, AHA, and American College of Physicians.59

Although exercise testing is considered a safe procedure,60 acute MI and deaths have been reported during testing. The physician or senior medical (healthcare) professional conduct-ing the test must be trained in advanced cardiopulmonary resus-citation. A defibrillator and appropriate medications also should be immediately available. Surveys suggest that 0 to 6 deaths or cardiac arrests per 10 000 tests and 2 to 10 MIs per 10 000 tests might be expected, but these estimates will vary markedly with the prevalence and severity of underlying heart disease in the tested population.60,61 Risk is higher in patients being evaluated for malignant ventricular arrhythmias and in the unrevascular-ized post-MI patient, whereas serious complications are very rare in clinically normal subjects. Table 1 lists several classes of complications that can result from exercise tests.

Perceived ExertionThe subjective rating of the intensity of exertion perceived by the person exercising is generally a sound indicator of rela-tive fatigue. As an alternative to using HR alone to clinically determine intensity of exercise, the 6-to-20 Borg scale of per-ceived exertion62 is useful (Table 2). Special verbal and writ-ten explanations about the rating of perceived exertion (RPE) are available for subjects. Although there is some variation among subjects in their actual rating of fatigue, they seem to rate consistently from test to test. Thus, the Borg scale can assist the clinician in judging the degree of fatigue reached from one test to another and in correlating the level of fatigue during testing with that experienced during daily activities. In general, a Borg scale rating >18 indicates the patient has performed maximal exercise, and values higher than 15 to 16 suggest that the ventilatory threshold has been exceeded.

Angina Characteristics and ScaleLevels of anginal discomfort in those with known or suspected CAD are also excellent subjective end points. Whether typi-cal angina occurs with exercise or is the reason for termina-tion of the test is an important observation in evaluation of the exercise test, and it is an important factor in calculation of the Duke Treadmill Score.63

Table 1. Complications Secondary to Exercise Testing

Cardiac Bradyarrhythmias

Tachyarrhythmias

Acute coronary syndromes

Heart failure

Hypotension, syncope, and shock

Death (rare; frequency estimated at 1 per 10 000 tests, perhaps less)

Noncardiac Musculoskeletal trauma

Soft-tissue injury

Miscellaneous Severe fatigue (malaise), sometimes persisting for days; dizziness; body aches; delayed feelings of illness

Reproduced with permission from Fletcher et al.1 © 2001 American Heart Association, Inc.


Indications to Stop a Stress Test


Indications for Termination of Exercise TestingThe decision to terminate exercise is an important function of test supervision that is generally determined by the purpose of testing in individual subjects. Symptom-limited testing is desirable for general evaluation, but this recommendation could be modified in several situations.58

Absolute Indications

● ST-segment elevation (>1.0 mm) in leads without preexist-ing Q waves because of prior MI (other than aVR, aVL, and V1)

● Drop in systolic blood pressure >10 mm Hg, despite an increase in workload, when accompanied by any other evi-dence of ischemia

● Moderate-to-severe angina ● Central nervous system symptoms (eg, ataxia, dizziness,

near syncope) ● Signs of poor perfusion (cyanosis or pallor) ● Sustained ventricular tachycardia (VT) or other arrhythmia,

including second- or third-degree atrioventricular (AV) block, that interferes with normal maintenance of cardiac output during exercise

● Technical difficulties in monitoring the ECG or systolic blood pressure

● The subject’s request to stop

Relative Indications

● Marked ST displacement (horizontal or downsloping of >2 mm, measured 60 to 80 ms after the J point [the end of the QRS complex]) in a patient with suspected ischemia

● Drop in systolic blood pressure >10 mm Hg (persistently below baseline) despite an increase in workload, in the absence of other evidence of ischemia

● Increasing chest pain

● Fatigue, shortness of breath, wheezing, leg cramps, or claudication

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

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

● Development of bundle-branch block that cannot immedi-ately be distinguished from VT

The Postexercise PeriodSome abnormal responses occur only in recovery.64 A cool-down period of walking slowly in early recovery is commonly used, although this can delay or eliminate the appearance of ST-segment depression as compared with abrupt placement in the supine position, which increases cardiac work because of increased venous return.65 Monitoring should continue for 6 to 8 minutes after exercise, or longer if the patient is symptomatic or if blood pressure, HR, and ST segments have not returned to near-baseline values. Even when no abnormalities occur at peak exercise, postexercise attention is necessary because an abnormal electrocardiographic response might occur only during the recovery period. Mechanical dysfunction and elec-trophysiological abnormalities in the ischemic ventricle after exercise can persist for minutes to hours. Monitoring of blood pressure should continue during recovery because abnormal responses could occur, particularly hypotension, and arrhyth-mias also might be present in the recovery period.

Management of Pacemakers and Implantable DefibrillatorsExercise testing can be used to assess rate responsiveness of implanted pacemakers and occasionally reveals abnormalities of tracking function that can limit effort capacity. In patients with implanted defibrillators that are triggered by rapid rate alone, firing function should be temporarily disabled before maximum testing if the threshold HR might be reached during exercise. In the presence of a ventricular paced rhythm, the ECG cannot be evaluated for ischemia, and it should be noted that “pacemaker memory” could produce abnormal repolarization that can mimic ischemia when long-term pacing is discontinued to examine the underlying electrocardiographic waveform.66

Clinical and Cardiopulmonary Responses During Exercise

Clinical Responses

SymptomsAssessment of perceived symptoms is an integral component of the exercise test. Symptom assessment typically includes separate quantification of dyspnea, angina, and perceived exertion. Scales for each of these symptoms are provided in the present statement and other documents.43 Typical anginal symptoms induced by the exercise test are predictive of CAD and are even more predictive with associated ST-segment depression.67 Exercise limited by dyspnea seems to portend a worse prognosis than does angina or leg fatigue.68,69 It is important to obtain from the patient a careful description of all perceived symptoms during exercise and to document what the patient considers to be the primary limiting factor. An accurate

Table 2. Borg Scale for Rating Perceived Exertion

20-Grade Scale

6

7 Very, very light

8

9 Very light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very, very hard

20

Reprinted from Borg219 with permission of the publisher. Copyright ©1982, the American College of Sports Medicine.


Indications to Stop a Stress Test






















Clinical Responses



20-Grade Scale

6

7 Very, very light

8

9 Very light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very, very hard

20
























Clinical Responses



20-Grade Scale

6

7 Very, very light

8

9 Very light

10

11 Fairly light

12

13 Somewhat hard

14

15 Hard

16

17 Very hard

18

19 Very, very hard

20



Another case

• 54 year old man with exertional chest pain.

• Restrosternal pressure ‘like somebody sitting on chest’

• Relieved with Rest

• CRF = high cholesterol and pos family history

EST


EXERCISE STRESS TEST REPORTPatient Name: SOKOLIC, VALERIANO DOB: 03-Feb-1966Patient ID: 0006354559 Age: 51 yrHeight: in Gender: MaleWeight: 0 lb Race: --

Study Date: 13-Apr-2017 Referring Physician: GENEVIEVE MORTERATest Type: Treadmill Stress Attending Physician: TECH CLINICProtocol: BRUCE Technician: LINDA BOURBONNAIS

Medications: TECTA , rosuvastatin

Medical History:




PRETEST STANDING 05:43 1.0 0.0 63 130/80Exercise STAGE 1 03:00 1.7 10.0 100 164/82 STAGE 2 01:39 2.5 12.0 112 160/84 03:04 chest discomfort

starting into right shoulder04:16 Chest Discomfort Increasing 3/10

Recovery 1 Minute 01:00 0.0 0.0 83 158/84 00:55 discomforrt easing 2 Minute 01:00 0.0 0.0 63 158/84 3 minute 01:00 0.0 0.0 62 4 minute 00:55 0.0 0.0 61 148/80 03:37 chest and right

shoulder discomfort gone The patient exercised according to the BRUCE for 04:39 min:s, achieving a work level of Max. METS: 6.5. The resting heart rate of 60 bpm rose to a maximal heart rate of 112 bpm. This value represents 66 % of the maximal, age-predicted heart rate. The resting blood pressure of 130/80 mmHg , rose to a maximum blood pressure of 164/82 mmHg. The exercise test was stopped due to usual chest, right shoulder discomfort increasing.

Interpretation

Summary: Functional Capacity: Class II.Chest Pain: limiting.ST Changes: Depression horizontal.Overall Impression: Positive stress test typical of ischemia.

Conclusions

Rest12-Lead ReportSOKOLIC, VALERIANO

Patient ID: 00063545592017/04/1313:50:57



BRUCE 0.0 mph 0.0 %

60 bpm 130/80 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Peak12-Lead Report (PEAK EXERCISE)SOKOLIC, VALERIANO

Patient ID: 00063545592017/04/1314:01:12


EXERCISESTAGE 204:39

BRUCE 2.5 mph 12.0 %

112 bpm 160/84 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Recovery 00:1512-Lead ReportSOKOLIC, VALERIANOPatient ID: 00063545592017/04/1314:01:27



BRUCE 1.5 mph 0.0 %

107 bpm

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Recovery 2:0012-Lead ReportSOKOLIC, VALERIANOPatient ID: 00063545592017/04/1314:03:12



BRUCE 0.0 mph 0.0 %

63 bpm 158/84 mmHg

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Medians SummarySOKOLIC, VALERIANO ID:0006354559 13-APR-2017 13:50:51 NSES


25mm/s10mm/mV150Hz


cc: Dr. Shalini VeerassamyFunctional Class 2Normal heart rate responseNormal blood pressure responseNo chest painSignificant ST depressionPositive test for ischemia

03-FEB-1966 (51 yr) MaleWt: 0lbMed: TECTA, rosuvastatin

Referred by: GENEVIEVE MORTERATechnician:LINDA BOURBONNAISTest ind: Screening for CADTest type: Treadmill Stress

Unconfirmed Date:13-APR-2017

BASELINE


I0.1 mm0.1 mV/s

II0.30.1

III0.2

-0.2

aVR-0.3-0.7

aVL0.10.1

aVF0.3

-0.1

V10.30.0

V20.80.5

V30.60.5

V40.20.2

V50.20.1

V60.30.0

MAX ST


I-0.50.2

II-2.1-0.3

III-1.6-0.6

aVR1.3

-0.0

aVL0.60.3

aVF-1.9-0.5

V11.30.5

V21.21.2

V30.21.0

V4-1.00.1

V5-1.6-0.4

V6-1.4-0.4


Stress test interpretation

What is his Duke Score and what is the risk?

• Exercise time (minutes on Bruce) - 5 x (max ST depression in mm) - 4 x (angina index)

• 0 = no angina

• 1 = non-limiting

• 2 = limiting

Duke ScoreSOKOLIC, VALERIANO ID:0006354559 13-APR-2017 13:50:51 NSES


25mm/s10mm/mV150Hz


cc: Dr. Shalini VeerassamyFunctional Class 2Normal heart rate responseNormal blood pressure responseNo chest painSignificant ST depressionPositive test for ischemia

03-FEB-1966 (51 yr) MaleWt: 0lbMed: TECTA, rosuvastatin

Referred by: GENEVIEVE MORTERATechnician:LINDA BOURBONNAISTest ind: Screening for CADTest type: Treadmill Stress

Unconfirmed Date:13-APR-2017

BASELINE


I0.1 mm0.1 mV/s

II0.30.1

III0.2

-0.2

aVR-0.3-0.7

aVL0.10.1

aVF0.3

-0.1

V10.30.0

V20.80.5

V30.60.5

V40.20.2

V50.20.1

V60.30.0

MAX ST


I-0.50.2

II-2.1-0.3

III-1.6-0.6

aVR1.3

-0.0

aVL0.60.3

aVF-1.9-0.5

V11.30.5

V21.21.2

V30.21.0

V4-1.00.1

V5-1.6-0.4

V6-1.4-0.4






Medical History:








Interpretation


Conclusions

Duke Score

• 4 - 5 (2) - 4 (2) = -14

• High Risk

Elements of a report• Patient name

• Referring provider

• Indication for test

• Date performed

• Protocol performed

• Duration of exercise

Elements of a report• Baseline and Max HR, BP Workload.

• Description of abnormal HR or BP response

• Symptoms - when and what. Specifically mention presence or absence of chest pain.

• Reason for Stopping

• ECG changes - baseline, peak, and when significant

• Arrhythmias - rest and stress

• Comparison to age matched controls

Summary• “Positive”, “Negative” or “Equivocal”

• “Normal”, “Abnormal” or “Non-diagnostic”

• For detection of ischemia a reasonable RPP must be achieved. (10th percentile 25,000, 90th 40,000)

• THR = 85% max age predicted (220-age)

Report• Mr. Bob Smith

• Referred by: Dr. S. Ramer

• Indication: Exertional chest pain, ? ischemia

• Date: April 24, 2020





Medical History:








Interpretation


Conclusions

Report• Decreased exercise capacity (FC II) with endpoint of chest

discomfort. Usual CP developed at 4:30 at a HR of 100 beats per minute.

• Blunted HR response to exercise - target HR not achieved

• BP response to exercise - normal resting BP, normal BP response to exercise

• Arrhythmias - none

• ECG changes - Normal resting ECG. Diagnostic ST depression at 4 minutes in the protocol. At peak exercise there is 2 mm ST segment depression, downsloping.

Summary

• Positive Stress test, typical of ischemia at a FCII workload.

• High risk based on a Duke score of -14.

Important definitions

Normal HR response to exercise

• Increase of 10 beats per min per MET

• Expect less if beta blocked

• Chronotropic incompetence can cause symptoms and correlates with poorer prognosis.

Abnormal BP response to exercise

• Hypertensive increase in SBP >60 for men, >50 for women or increase to above the 90th percentile (>210 in men and >190 in women). DBP increase >10 mmHg or absolute value >90mmHg.

• Blunted = an increase of less than 20-25 mmHg.

• Hypotensive = drops below resting value or rises initially and then drops by >/= 10 mmHg.

Oral Scenario

• A 62 year old man presents for outpatient exercise stress testing for evaluation of chest pain. His resting ECG is normal. After 4 minutes on a Bruce Protocol he develops 2 mm of ST elevation in the anterior leads associated with his usual chest pain (retrosternal heaviness).

How to Manage this Patient?

Summary

• Exercise stress testing is ‘bread and butter’ cardiology.

• There will be stress testing on your exam - could be in any section of the exam.

• Know your Duke Score!

Thank you!

Intro to Exercise Stress Testing*

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