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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
patient’s 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