

IINTRODUCTION
 DEFINITION

Exercise testing is a non invasive procedure that
provides diagnostic and prognostic information and
evaluates an individual’s capacity for dynamic exercises.
 EXERCISE TEST
TERMINOLOGY

 VO2max
 METs
 Myocardial Oxygen Consumption
Maximum Oxygen Uptake
(VO2max)

 Greatest amount of oxygen an individual utilizes with
maximal exercise (ml O2 /kg/ min)
 “Gold Standard” for cardiorespiratory fitness
 Fick Equation
VO2max = (HRmax x SVmax) x (CaO2max -
CvO2max)
CONTINUE..

 METs
 (MET) is defined as
One metabolic equivalent
the amount of oxygen consumed while sitting at rest
and is equal to 3.5 ml O2 per kg body weight per
min.

 Myocardial Oxygen
consumption

 Myocardial oxygen uptake(Mo2) is determined by intra-
myocardial wall tension (left ventricular(LV) systolic
pressure times end-diastolic volume, divided by LV wall
thickness), contractility, and HR.
 MO2= HR X SBP
 EXERCISE
PHYSIOLOGY

 Sympathetic activation

 Parasympathetic withdrawal

 Vasoconstriction, except in- • Exercising muscles •

Cerebral circulation • Coronary circulation

 ↑norepinephrine and epinephrine

 
 ↑ventricular contractility
 ↑O2 extraction(up to 3)
 ↓peripheral resistance
 ↑SBP,MBP,PP
 DBP –no significant change
 Pulmonary vascular bed can accommodate 6 fold CO
 CO - ↑ 4-6 times
 EXERCISE TESTING
INDICATIONS
CLEAR INDICATION

Patients with Suspected or Proven Coronary Artery
Disease:
 Diagnosis: men with atypical symptoms
 Prognostic assessment and functional capacity
evaluation in patients with chronic stable angina or post
myocardial infarction
 Symptomatic recurrent exercise-induced arrhythmias
 Evaluation after revascularization procedure
 
TEST MAY BE INDICATED
1. Diagnosis: women with typical or atypical angina pectoris
2. Functional capacity evaluation to monitor cardiovascular
therapy in patients with CAD or heart failure
3. Evaluation of patients with variant angina
4.Annual follow-up of patients with known CAD
5. Evaluation of asymptomatic men over 40; those who are in
special occupations (pilots, firemen, police officers, bus or truck
drivers, and railroad engineers) or who have two or more
atherosclerotic risk factors or who plan to enter a vigorous exercise
program
TEST PROBABLY NOT INDICATED
 1.Evaluation of patients with isolated premature ventricular beats
and no evidence of CAD 
2.Multiple serial testing during the course of cardiac rehabilitation
program
3.Diagnosis of CAD in patients who have pre-excitation syndrome
or complete left bundle branch block or are on digitalis therapy
4.Evaluation of young or middle-aged asymptomatic men or
women; those who have no atherosclerotic risk factors or who have
non-cardiac chest discomfort
 
INDICATIONS FOR EXERCISE TESTING IN
PATIENTS WITH VALVULAR HEART DISEASE OR
HYPERTENSION
Test in Common Usage:
1.Evaluation of functional capacity in selected patients
with valvular heart disease
2.Evaluation of blood pressure of hypertensive patients
who wish to engage in vigorous dynamic or static exercise
 CONTRAINDICATIONS
Absolute contraindications
 (within 2 days)
 Acute myocardial infarction
 High-risk unstable angina
 Uncontrolled cardiac arrhythmias causing symptoms or
hemodynamic compromise
 symptomatic, severe aortic stenosis
 Uncontrolled symptomatic heart failure
 Acute pulmonary embolus or pulmonary infarction
 Suspected or known dissecting aneurysm
 Active or suspected myocarditis, pericarditis, or endocarditis
 Acute non-cardiac disorder that may affect exercise
performance or be aggravated by exercise (e.g., infection,
renal failure, or thyrotoxicosis)
 Considerable emotional distress (psychosis)
Relative contraindications


 Left main coronary stenosis or its
equivalent
 Moderate stenotic valvular heart disease
 Resting diastolic blood pressure >110 mm
Hg or resting systolic blood pressure >200
mm Hg
 Electrolyte abnormalities (e.g.,
hypokalaemia, hypomagnesemia)
 Fixed-rate pacemaker
 Frequent or complex ectopy
 Ventricular aneurysm
 
 High degree atrio-ventricular block
 Uncontrolled metabolic disorder(diabetes,
thyrotoxicosis, myxoedema)
 Chronic infectious disease (mononucleosis, hepatitis,
AIDS)
 Neuromuscular, musculoskeletal, or rheumatoid
disorders exacerbated by exercise
 Advanced or complicated pregnancy
 Hypertrophic cardiomyopathy and other forms of
outflow tract obstruction
 Mental impairment leading to inability to cooperate
EXERCISE PROTOCOL
 Arm Ergometry

 Bicycle Ergometry
 Treadmill Protocol
 Bruce treadmill protocol
 Balke Ware treadmill protocol
 Naughton treadmill protocol
Ramp testing
ARM ERGOMETRY

BICYCLE ERGOMETER

TREADMILL

 BRUCE TREADMILL
PROTOCOL

 This protocol comprised of multiple exercise stages of 3
min each. At each stage, the gradient and speed of the
treadmill are elevated to increase work output, called
METS.
 For Individuals with limited exercise capacity, Bruce’s
protocol can be modified by 2-3 min warm up stages at
1.7 mph and 0% grade and 1.7mph with 5% grade and
speed gradually increased up to 6 mph in stages.
 Limitation -Large increase in O2 between stages and
traditional energy cost of running as compared with
walking at stages in excess of Bruce’s stage III.
STANDARD BRUCE PROTOCOL

MODIFIED BRUCE PROTOCOL

 BALKE WARE PROTOCOL

 The Balke protocol and modifications of it, has been
widely used for clinical exercise testing.
 It uses constant walking speeds and modest increments in
grade (2.5% or 5%) and it has been used particularly often
in studies assessing angina responses.
 NAUGHTON
TREADMILL
 It is a low level test 
that has become common for multi-
center trials in patients with chronic heart failure.
 The test begins with 2 min stages at 1 and 2mph and
0%grade, then continually increases grade in approximately 1
MET increments at a constant speed of 2mph for the next
8min.
 Speed then increase to 3mph with a slight drop in grade,
followed by increases in grade equivalent to approximately 1
MET.
 This protocol has been used extensively in patient with
congestive heart failure.

 RAMP PROTOCOL

 Ramp protocols start the patient at a relatively slow
treadmill speed, which is gradually increased until the
patient has a good stride.
 The ramp angle of incline is progressively increased at
fixed intervals (e.g., 10 to 60 seconds) starting at zero
grade with the increase in grade calculated on the
patient's estimated functional capacity such that the
protocol will be complete at between 6 and 10 minutes.
 PRETEST
CONSIDERATIONS

 All patient should undergo a complete medical history
and a physical examination to identify contraindications
to exercise testing.
 Detailed verbal and written instruction, provided to the
patient in advance, it include refrain from ingesting food,
alcohol, and caffeine or using tobacco products within 3
hours of testing.
 Patient should be well rested and avoid vigorous activity
the day of the test..
 
 Clothing should be comfortable and provide freedom of
movement as well as allow access for electrode and blood
pressure cuff placement.
 Properly fitting shoes with rubber soles should be worn to
ensure good traction, particularly if a treadmill is the mode
of testing.
 Provide written and verbal informed consent
 
 A demonstration of how to get on and off the testing
apparatus should be given, what is expected of the
patient should be described (reporting of symptoms,
level of exertion, testing endpoints), and any questions
the patient has should be answered.
 In some circumstances it is necessary to withhold
cardioactive medications during the exercise test.
 PREPARATION FOR
ECG

 Sites of ECG electrode placement should be rubbed
with alcohol pad to remove skin oil.
 Place the electrode after applying conducting gel.
 Mason-Likar limb lead placement is the standard
configuration clinically because it provides a 12 lead
ECG with fewer artifact and less restriction to
movement than the standard lead placement

INTERPRETATION OF EXERCISE TEST
RESPONSE

 Heart rate

 Blood pressure
 Exercise capacity
 Electrocardiographic response
 Subjective response
 HEART RATE

 Heart rate increases linearly with oxygen uptake during
exercise.
 The inability to appropriately increase heart rate during
exercise has been associated with the presence of heart
disease.
 BLOOD PRESSURE

 Assess the BP at rest and during exercise.
 BP should be assessed during last minute of each
exercise stage and more frequently if hypotensive or
hypertensive responses are observed.
 Systolic > 250 mmHg and diastolic >115mmHg is an
indication of termination of exercise.
 A decrease in systolic BP with progressive exercise
suggest that cardiac output is unable to increase in
accordance with the work rate and is reflection of
ischemia.
 EXERCISE CAPACITY

 Exercise capacity is expressed in METs (metabolic
equivalents).
 MET value can be ascribed to any speed and grade on
a treadmill or workload achieved on a cycle ergometer;
therefore exercise capacity can be compared uniformly
between protocol.
 MET refers to a unit of O2 uptake. 1MET is
3.5mlO2/Kg/min of body wt.
ELECTROCARDIOGRAPHIC RESPONSES


 ST changes should be read at 60 to 80 ms from the J
point, and the test should be considered positive for
ischemia if there is a 2 mm or more rapidly up-sloping
ST depression (when the slope is more than 1 mV/s),
1.5 mm or more slowly up-sloping ST depression
(when the slope is less than 1 mV/s), or a 1 mm or more
horizontal or down sloping ST depression.
 ST elevation along with Q wave has diagnostic value.


 SUBJECTIVE
RESPONSE

 Angina and dyspnoea are the most common
cardiopulmonary symptoms elicited during exercise and
each is typically evaluated using a four-point scale.

 TEST TERMINATION
Absolute indications 
 Drop in Systolic BP> 10mmHG with signs of ischemia
 Moderate to severe Angina
 Increasing nervous system symptoms(e.g., ataxia, dizziness,
syncope)
 Signs of poor perfusion( cyanosis or pallor)
 Technical difficulties in monitoring electrocardiogram or
systolic blood pressure
 Subjects desire to stop
 Sustained Ventricular Tachycardia
 ST elevation(>1.0mm)in leads without diagnostic Q waves
Relative indications

 Drop in BP without ischemia
 ST segment depression of > 2mm
 Arrhythmias other than sustained VT
 Fatigue, shortness of breath, wheezing, leg cramps, or
claudication
 Development of BBB or IVCD( intra-ventricular
conduction delay) not able to distinguish from VT
 Worsening chest pain
 Hypertensive response (Systolic BP> 250, Diastolic
BP>115)
 RECOVERY PERIOD

 It may be active or passive process. This decision should
be made on the basis of the purpose of the exercise test.
 If the test is performed for diagnostic purposes, then it
appears to be of value to place the patient in the supine
position immediately after stopping exercise.
 If the test is performed for non-diagnostic purposes such
as for a fitness evaluation in a healthy or athletic person,
then an active recovery may be safer and more
comfortable.
 ASSESSING TEST
ACCURACY

 Specificity
 Sensitivity
 Predictive value
 
Calculations used to determine Sensitivity, Specificity, Positive predictive value and
Negative predictive value

Sensitivity (TP\TP+FN) X 100

Specificity (TP\ TN+ FP) X 100

Positive predictive value (TP\ TP + FP) X 100

Negative predictive value (TN\ TN+ FN) X 100

 FALSE POSITIVE AND
FALSE NEGATIVE

Causes of False-Positive
 Resting repolarization abnormalities (e.g., left bundle-
branch block)
 Cardiac hypertrophy,
 Accelerated conduction defects (e.g., Wolff-Parkinson-
White syndrome)
 Digitalis
 Non-ischemic cardiomyopathy
 
 Hypokalaemia
 Vasoregulatory abnormalities
 Mitral valve prolapse
 Pericardial disease
 Coronary spasm in absence of CAD
 Anaemia
 Female gender
 
Causes of False-Negative
 Failure to reach ischemic threshold secondary to
medications (e.g., beta blockers)
 Monitoring an insufficient number of leads to
detect electrocardiographic changes
 Angiographically significant disease
compensated by collateral circulation
 Musculoskeletal limitations preceding cardiac
abnormalities
NURSE’S RESPONSIBILITIES

 DRUGS AND EXERCISE
TESTING

 Beta Blockers
 Vasodilators
 Angiotensin converting enzyme inhibitors
 Calcium Antagonists
 Digitalis
 Other drugs
CONCLUSION
