Performing Exercise Treadmill Testing

7/24/2019 Performing Exercise Treadmill Testing

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Treadmill Stress Testingfor the Primary Care Physician

Francis G. OConnor, MD, FACSM

Primary Care Sports Medicine


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O!ecti"es

#e"ie$ essential %&ercise Test Terminology

Descrie the Performance of the %&ercise Stress Test

Disc'ss (nterpretation of the %&ercise Stress Test

Disc'ss Special Considerations in Athletes

#e"ie$ (ndications for )$o'ld*e+ Athletes


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oring-.....


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Gonzales

Dietche Playford

Howe


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%&ercise Test Terminology

The %lectrocardiogram

O/ma&

M%Ts Myocardial O&ygen

Cons'mption


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The %lectrocardiogram


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The %lectrocardiographic #esponse


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0hat isO/ma&-


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Ma&imal O&ygen 1pta2e

3O/ma&4

Greatest amo'nt of o&ygen an indi"id'al 'tili5es $ith

ma&imal e&ercise 3ml O/ per 2ilogram per min'te4

)Gold Standard+ for cardiorespiratory fitness Fic2 %6'ation

O/ma& 7 38#ma& & Sma&4 & 3CaO/ma& * C"O/ma&4

Diff iF(C= %>1AT(O?


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VO2max= (HRmax X SVmax X (!aO2max " !#O2max

Genetic Factors 38eart Si5e4

Conditioning FactorsContractility9Afterload9Preload

Disease Factors

0all Motion9entric'lar F&n al"eStenosis or #eg'rgitation

S2eletal M'scles

:Aeroic %n5ymes

:Fier Type

:M'scle Disease

Capillary Density

PaO/

8g ; 1AT(O?

3//@ * Age4

Sin's ?ode Dysf'nction

Dr'gs 3e.g.,B* loc2ers4


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M%TS$he %&$


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Metaolic %6'i"alents 3M%Ts4

M%T 7 B. ml O/ per 2ilogram of ody$eight per min'te


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Key MET Values (part 1)

1 MET = "Basal" = 3.5 ml O2 /Kg/min

2 METs = 2 mph on level

4 METs = 4 mph on level

< 5METs = Poor prognosis i < !5

limi# imme$ia#e pos# M%

&os# o 'asi& aivi#ies o $ail( living


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Key MET Values (part 2)

1) METs = *s goo$ a prognosis +i#h me$i&al#herap( as ,*B-

13 METs = E&ellen# prognosis regar$less o o#hereer&ise responses

1! METs = *ero'i& mas#er a#hle#e

2) METs = Ooh lah lah *ero'i& a#hle#e

)


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Myocardial (MO2)

Acc'rate meas'rement re6'ires cardiaccatheteri5ation

,oronar( 0lo+ ,oronar( a O2 $ieren&e

all Tension Pressre olme ,on#raili#(-#ro6e or6 789

-(s#oli& Bloo$ Pressre 78 *ngina an$ -T :epression sall( o&&rs a# same:o'le Pro$ in an in$ivi$al;; :ire rela#ionship #o O2 is al#ere$ '( 'e#a'lo&6ers #raining...


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Myocardial O&ygen Cons'mption

(ndirectly meas'red as the )Do'le Prod'ct+

)Do'le Prod'ct+ 7 8# & systolic lood press're A normal "al'e is greater than /@,@@@ /,@@@


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O!ecti"es



Disc'ss (nterpretation of the %&ercise Stress Test

Disc'ss Special Considerations in Athletes



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Performance of the %&ercise

Stress Test

(ndications9Contraindications

#'nning the %&ercise Test

Physician #esponsiilities


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ACSMs G'idelines

for %&ercise Testing and Prescription

ACSM. Eippincott, 0illiams 0il2ins

th %dition /@@@

di i f i i


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(ndications for %&ercise Testing

Class (H Conditions for $hich there is e"idence and9or general

agreement that a gi"en proced're or treatment is 'sef'l and effecti"e Class ((H Conditions for $hich there is conflicting e"idence and9or a

di"ergence of opinion ao't the 'sef'lness9efficacy of a proced're or

treatment. (( aH $eight of e"idence is in fa"or of 'sef'lness9efficacy.

(( H 'sef'lness is less $ell estalished y the e"idence.

Class (((H Conditions for $hich there is e"idence and9or general

agreement that the proced're9treatment is not 'sef'l9effecti"e and in

some cases may e harmf'l.

Cl ( ( di ti f P f i


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Class ( (ndications for Performing an

%&ercise Test

Diagnosis of CAD in ad'lts $ith intermediatepretestproaility of disease

Assessfunctional capacityandprognosisof patients $ithH

Known CAD Recent uncomplicated myocardial infarction

%"al'ate symptoms of rec'rrent, e&ercise*ind'ced arrhythmias

Cl (( ( di ti f Pe f i


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Class (( (ndications for Performing

an %&ercise Test

To e"al'ate asymptomatic men IJ@ and $omen I@$hoH

are in"ol"ed in special, high ris2 occ'pationsK

plan to start a "igoro's e&ercise programK

ha"e m'ltiple cardiac ris2 factors. To assist in the diagnosis of CAD in ad'lt patients $ith a

high or lo$ pretest proaility of disease.

To e"al'ate patients $ith a Class ( indication $ho ha"e

aseline electrocardiographic changes.

Class ((( (ndications for Performing


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Class ((( (ndications for Performing

an %&ercise Test

#o'tine screening of asymptomatic men or $omen.

To e"al'ate men or $omen $ith a history of chest

discomfort not tho'ght to e of cardiac origin.

To e"al'ate patients $ith simple PCs on a resting%CG $ith no other e"idence of CAD.

To assist in the diagnosis of CAD in patients $ith

e"idence of E or 0P0 on a resting %CG.


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Pre Test Probability of Coronary Disease by

Symptoms, Gener an !"e

!"e Gener Typi#al$Definite!n"ina Pe#toris

!typi#al$Probable!n"ina Pe#toris

%on&!n"inal

C'est Pain

!symptomati#

3)3 Males %n#erme$ia#e %n#erme$ia#e lo+ o+

5)5 0emales %n#erme$ia#e %n#erme$ia#e >o+ 2er( lo+

!)! Males 7igh %n#erme$ia#e %n#erme$ia#e >o+

!)! 0emales 7igh %n#erme$ia#e %n#erme$ia#e >o+

7igh = ?) %n#erme$ia#e = 1)) >o+ = o+ =


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Contraindications to GLT TestingH

Asol'te #ecent ac'te M(

1nstale angina

entric'lar tachycardia Dissecting aortic

ane'rysm

Ac'te C8F

Se"ere aortic stenosis

Acti"e myocarditis

Thromophleitis orintracardiac thromi

#ecent p'lmonary emol's

Ac'te infection


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Contraindications to GLT TestingH

#elati"e 1ncontrolled se"ere

hypertension

Moderate aortic stenosis Se"ere s'aortic stenosis

S'pra"entric'lar dysrhythmias

entric'lar ane'rysm

Comple& "entric'lar ectopy

Cardiomyopathy

1ncontrolled metaolic disea #ec'rrent infectio's disease

Complicated pregnancy


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So 0hat Do o' DoN.

B yo female $ith ris2 factors and as6'irrelly storyN.

Comparison of Tests for Diagnosis


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Comparison of Tests for Diagnosisof CAD


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0hich Protocol-

ast Ma!ority 3/QR4 'se #1C%

So, $hy not yo'-


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How to read an Exercise ECG

Good sin prep!" isoelectric line#ot one $eatT%ree consistent complexesA&erages can %elp

Gar$age in' gar$age ot%y watc% dring reco&ery*

+ymptom +ign -imited Testing Endpoints


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+ymptom,+ign -imited Testing Endpoints.%en to stop/

Dyspnea, fati"ue, #'est pain

Systoli# bloo pressure rop

ECG&&ST #'an"es, arr'yt'mias

P'ysi#ian !ssessment

or" S#ale (1 or "reater)

!ro$lems wit% Age !redicted Maximal Heart


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!ro$lems wit% Age,!redicted Maximal Heart"ate

hi&h 8egression 0ormla@ 2AA .A *ge9 Big s&a##er aron$ #he regression line

poor &orrela#ion C).4 #o ).!D

One -: is pls/mins 12 'pm

* per&en# vale #arge# +ill 'e maimal or some an$s'ma or o#hers

,onon$e$ '( Be#a Blo&6ers

Borg s&ale is 'e##er or evala#ing Eor# Targe# 7ear# 8a#e $oes have a pla&e as an %n$i&a#oro Eor# or a$ea&( o #es#


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M%TS$he %&$

Heart "ate Drop in "eco&ery &s


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Heart "ate Drop in "eco&ery &sMETs

01 to 03increase in survival per MET

METS can be increased by 23by atraining program

What about Heart Rate Recovery???


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8eart #ate #eco"ery and Treadmill%&ercise Score as Predictors of Mortality

in Patients #eferred for %&ercise %CG

?ishime %O, et alH AMA, Septemer /@, /@@@.

o /J, ?o , /@@@.


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Follo$ing the GLT, patients $al2ed for / min'tes at . mphand at a grade of /.R.

8eart rate reco"ery $as the difference in heart rate at pea2

e&ercise and one min'te into reco"eryK /9min or less $as

considered anormal. JJ patients $ere follo$ed for a median of yearsK /@ R had

anormal heart rate reco"eryK they represented R of deaths

"s. /RK ha5ard ratio of J..

8eart rate reco"ery is an independent predictor of mortality.

+% ld H t " t D i


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+%old Heart "ate Drop in"eco&ery $e added to ET*

Long known as a indicator o itness! perhapsbetter or assessing physical activity than

METsRecently ound to be a predictor o prognosisater clinical treadmill testing

"oes not predict angiographic #$"

Studies to date have used all%cause mortalityand ailed to censor

Heart "ate Drop in "eco&ery


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Heart "ate Drop in "eco&ery

&robably not more predictive than "ukeTreadmill Score or METs

Studies including censoring and #'mortality needed


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O!ecti"es



Disc'ss (nterpretation of the %&ercise Stress Test Disc'ss Special Considerations in Athletes



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(nterpretation of the %&ercise Stress Test

%'st !ontain ollowin) &lements*

%&ercise Capacity

8emodynamic

Clinical

%lectrocardiographic

Optional Other St'ffN..


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Positi"e "s S'ggesti"e

ST Depression or 1mm at

60msec

1!"mm at#0msec

ST $le%ation 1mm at 60msec

ST Depression or 0!" & 1mm

at 60msec

0!' & 1!"mm at#0msec

ST $le%ation 0!" ( 1mm at

60msec


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?egati"e "s (nconcl'si"e

A)o%e criteria notmet and pte*ercised to at least#"+ ,-.R

-t did not reac/#"+ ,-.R )utno e%idence ofisc/emia 2&2loc3er445

"()E Treadmill Score or


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"()E Treadmill Score orStable #$"

METs % * + ,mm E%- ST "epression. %

/ + ,Treadmill $ngina -nde0.

1111112omogram1111111

E% = Eer&ise %n$&e$

Du3e Treadmill Score une%en lines elderly45


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3ut #an &hysicians do as well as the

Scores? 4*/ patients % clinical5ETT reports

Sent to // e0pert cardiologists6 /7cardiologists and 87 internists

Scores did better than all three but wasmost similar to the e0perts

! i


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O!ecti"es





Special Considerations inA hl


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Athletes

(ndications

Athletic 8eart

Syndrome

Test (nterpretation

O! i


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O!ecti"es






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Does the patient need a GLT-

Contro"ersial

ACSM* M'st e ale to disting'ishH

Moderate "s. "igoro's e&ercise Apparently healthy "s. higher ris2

Older "s. yo'nger

ACSM #ecommendations for Medical %&amination and


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ACSM #ecommendations for Medical %&amination and

%&ercise Testing Prior to Participation

RecommendRecommendVi)oro's&xercise

Recommend+ot

+ecessary%oderate&xercise

Hi)h Ris,%od Ris,-ow Ris,

+ot+ecessary

+ot+ecessary

ACSM (nitial #is2 Stratification y Age


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y g

and Cardiac #is2

%oderate Ris, )Older+ indi"id'als / ris2 factors

Cardiac #is2 Factors* Cigarette smo2ing

* Fam 8&. of early CAD

* EDE IB@4* 8ypertension

* (mpaired fasting gl'c

3I@mg9dE4

*

Oesity 3M( IB@4* Sedentary lifestyle

Cardiac #is2 Factors* Cigarette smo2ing

* Fam 8&. of early CAD

*

EDE IB@4* 8ypertension

* (mpaired fasting gl'c

3I@mg9dE4

* Oesity 3M( IB@4

* Sedentary lifestyle

)Positi"e+ #is2 FactorH 8igh ser'm 8DE 3I@4)Positi"e+ #is2 FactorH)Positi"e+ #is2 FactorH

-ow Ris, Men J, 0omen ?o cardiac symptoms ris2 factor

ACSM (nitial #is2 Stratification y Age


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y g

and Cardiac #is2

-ow Ris, Men J, 0omen ?o cardiac symptoms ris2 factor

%oderate Ris, )Older+ indi"id'als / ris2 factors

Hi)h Ris, Signs or Symptoms of cardiac d5 =no$n cardiac, p'lmonary or metaolic

3DM4 disease.

Signs9S&. C Disease*Chest pain or anginal e6'i"

*Dyspnea $9 mild e&ertion

*Di55iness or syncope

*Orthopnea9P?D

*An2le edema

*Palpitations or tachycardia

*(ntermittent cla'dication

*Fatig'e $9 normal acti"ities

Signs9S&. C Disease*Chest pain or anginal e6'i"

*Dyspnea $9 mild e&ertion

*Di55iness or syncope

*Orthopnea9P?D

*An2le edema

*Palpitations or tachycardia

*(ntermittent cla'dication

*Fatig'e $9 normal acti"ities

.ho +eeds a GX$/


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.ho +eeds a GX$/

+ot+ecessary

+ot+ecessary

Athlete $ith 2no$n CAD

Anyone $ith symptoms of CAD

Moderate ris2 patient for "igoro's e&erciseAnyone $ith 2no$n medical disease

Athlete $ith 2no$n CAD

Anyone $ith symptoms of CAD

Moderate ris2 patient for "igoro'se&erciseAnyone $ith 2no$n medical disease

-ow Ris, %od Ris, Hi)h Ris,

%oderate&xercise

+ot+ecessary

Recommend

Vi)oro's&xercise

Recommend Recommend

>'estions---


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>'estions---

!hris !hris $h dd


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!hris0Don1t !all

%e -t

!hris0Pa3a$eet

!hris04t1s %ya'lt

$hadde's

late's


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Performing Exercise Treadmill Testing

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