Exercise Stress Testing

dr. Cholid Tri Tjahjono,MKes,SpJP

Laboratorium Kardiologi dan Kedokteran Vaskular
Fakultas Kedokteran Universitas Brawijaya
Malang
Objectives
To evaluate quantitatively
Aerobic capacity
Hemodynamic changes
Limiting clinical sign & symptoms
Electrical function of the heart
ST segment displacement
Treadmill Protocols
Bruce
Modified Bruce
Naughton
Ramp
Safety
Relative safe procedure
Mortality < 1/50,000
Non-fatal MI < 4/10,000
Non-fatal arrhythmias 2.3%
Indications
Diagnosis of CAD
Risk assessment in patients with established
CAD
Pre-discharge after myocardial infarction
Ventilatory assessment
Before and after revascularization
Evaluation of arrhythmias
Contra-indications
Absolute
Recent complicated MI.
Unstable angina.
Episode of sudden
death.
Obstructive aortic
outflow disorder.
Uncontrolled
hypertension.
Cardiac vegetations.
Acute pericarditis.
Acute pulmonary
embolism.
Relative
Left Main Coronary
stenosis or equivalent.
Electrolyte
abnormalities.
Tachyarrhythmias or
bradiarrhythmias.
Atrial fibrillation with
uncontrolled ventricular
rate.
Mental impairment,
inability to cooperate.
High Degree AV block.
The standard Bruce protocol
Bayes Theorem
The likelihood that a positive test
represents true disease is directly
related to the prevalence of the disease
in the population being evaluated.
It is important therefore to assess the
patients likelihood of having CHD.
Pretest Likelihood (%)
Age A-symptomatic Non-angina
Chest pain
A-typical
Angina
Typical
Angina
years Men Women Men Women Men Women Men Women
35 1.9 0.3 5.2 0.8 21.8 4.2 69.7 25.8
45 5.5 1.0 14.1 2.8 46.1 13.3 87.3 55.2
55 9.7 3.2 21.5 8.4 58.9 32.4 92.0 79.4
65 12.3 7.5 28.1 18.6 67.1 54.4 94.3 90.6
Post-test likelihood (%)
Sensitivity = 75%, Specificity = 85%
ECG responses
ST segment depression.
ST segment elevation.
Change in R wave amplitude
Supraventricular & Ventricular Arrhythmias
Hemodynamic responses
Blood Pressure
Heart Rate
Stroke Volume
Schematic of various ST-segment pattern
A. Normal
B. STJ depression 0.08 s
C. STJ depression < 0.08 s
D. Horizontal ST depression
E. Downsloping ST depression
F. ST elevation
Systolic & Diastolic BP responses
SV and HR during exercise
Indications to terminate test
THR achieved
Worsening angina
Excessive breathlessness
Patient request to stop
Atrial arrhythmias
Ventricular tachycardia
Worsening ST segment shift
Fall or failure to rise in BP
Exaggerate hypertensive response to exercise
New high grade AV block or BBB
Criteria for positive
Planar ST depression > 1 mm
ST elevation
Increase QRS voltage
Failure BP to rise
Ventricular arrhythmias
Typical ischemic symptoms
Causes of a false positive test
Cardiomyopathies
Hipertension LVH strain pattern
LV outflow tract obstruction
Hyperventilation
LBBB, pre-excitation, digoxin resting pattern
Electrolyte abnormalities
Syndrome X
Coronary artery spasm
Important that merit angiography
ST depression,< 6 min, Bruce
Abnormal BP response
Ventricular arrhythmias