Exercise Treadmill Testing

Prof Gusbakti. MD

gusbakti11
 Balke Test - treadmill
aim: the Test was developed as a
clinical test to determine peak VO2
in cardiac patients, though it can also
be used to estimate cardiovascular
fitness in athletes.

gusbakti11
 Balke Test - treadmill
equipment required:
Treadmill, stopwatch,
electrocardiograph (optional)
procedure: (note: there is also the
different Balke 15 minute run test)
The athlete walks on a treadmill to
exhaustion, at a constant walking
speed while gradient/slope is
increased every one or two minutes.
gusbakti11
Procedure
Starts the stopwatch at the
beginning of the test and stops it
when the subject is unable to
continue.
Several modification or variation of
the Balke test that are used, with
variations in the treamill speed, time
at each level and/or increase in
gradient. gusbakti11
Test protocols
 For men the treadmill speed is set at 3.3
mph, with the gradient starting at 0%.
After 1 minute it is raised to 2%, then 1%
each minute thereafter.
For women the treadmill speed is set at 3.0
mph, with the gradient starting at 0%, and
increased by 2.5% every three minutes.
walking speed constant at 3 km/hr whilst the
grade was increased by 2.5 percent every two
minutes
gusbakti11
Results
Test score  time taken in minutes
Ideally between 9-15 minutes
Can also be converted to an estimated
VO2max score using the following formulas
where the value "T" is the total time
completed (expressed in minutes and
fractions of a minute e.g. 9 minutes 15
seconds = 9.25 minutes)
(note: this is only applicable if the same
protocol is used as when these formula were
developed)
gusbakti11
Results
For men: VO2 max = 1.444 (T)
+ 14.99 [Pollock et al., 1976)
For women: VO2 max = 1.38 (T)
+ 5.22 [Pollock et al., 1982)

gusbakti11
 Bruce Treadmill
Test Protocol
•aim: to evaluate cardiac function
and fitness.
•equipment required :
•Treadmill
• Stopwatch
•12-lead ECG
•Leads, sticking tape, clips

gusbakti11
 Procedurs
•Exercise is performed on a treadmill
•If required, the leads of the ECG are
placed on the chest wall
• Treadmill is started at 2.74 km/hr
(1.7 mph) and at a gradient (or
incline) of 10%

gusbakti11
 Procedurs
•At three minute intervals the incline
of the treadmill increases by 2%, and
the speed increases as shown in the
table below

gusbakti11
 Gradient
Stage Speed (km/hr) Speed (mph)
(%)
1 2.74 1.7 10
2 4.02 2.5 12
3 5.47 3.4 14
4 6.76 4.2 16
5 8.05 5.0 18
6 8.85 5.5 20
7 9.65 6.0 22
8 10.46 6.5 24
9 11.26 7.0 26
10 12.07 gusbakti11
7.5 28
 Bruce Treadmill
Test Protocol
Treadmill test says to increase the
grade percent/speed every 3-
minutes until exhaustion
Length of time on the treadmill is
the test score used to determine the
V02 max.

gusbakti11
 Bruce Treadmill
Test Protocol
Stage 1 = 1.7 mph at 10% Grade
Stage 2 = 2.5 mph at 12% Grade
Stage 3 = 3.4 mph at 14% Grade
Stage 4 = 4.2 mph at 16% Grade
Stage 5 = 5.0 mph at 18% Grade
Stage 6 = 5.5 mph at 20% Grade
Stage 7 = 6.0 mph at 22% Grade
Stage 8 = 6.5 mph at 24% Grade
Stage 9 = 7.0 mph at 26% Grade
gusbakti11
 Bruce Protocol
Sub maximal
Stage Minutes % grade km/h MPH METS

1 3 10 2.7 1.7 4.7

2 6 12 4.0 2.5 7.0
3 9 14 5.4 3.4 10.1
4 12 16 6.7 4.2 12.9
5 15 18 8.0 5.0 15.0
6 18 20 8.8 5.5 16.9
7 21 22 9.6 6.0 19.1

gusbakti11
What is a MET?
 Metabolic Equivalent Term

1 MET = "Basal" aerobic oxygen

consumption to stay alive = 3.5 ml O2
/Kg/min

 Actually differs with thyroid status, post

exercise, obesity, disease states

gusbakti11
Key MET Values

 1 MET = "Basal" = 3.5 ml O2 /Kg/min

 2 METs = 2 mph on level

 4 METs = 4 mph on level

 < 5METs = Poor prognosis if < 65;

gusbakti11
 Key MET Values (part 2)

 10 METs = As good a prognosis with

medical therapy as CABG

 13 METs = Excellent prognosis, regardless

of other exercise responses

 16 METs = Aerobic master athlete

 20 METs = Aerobic athlete

gusbakti11
Calculation of METs on the Treadmill

METs = Speed x [0.1 + (Grade x 1.8)] + 3.5

3.5

Calculated automatically by Device!

Note: Speed in meters/minute
conversion = MPH x 26.8
Grade expressed as a fraction

gusbakti11
 Modifications
Commonly used Modified Bruce
protocol which starts at a lower
workload than the standard test, and
is typically used for elderly or
sedentary patients.

gusbakti11
 Modifications
The fist two stages of the Modified
Bruce Test are performed at a
1.7 mph and 0% grade and 1.7 mph
and 5% grade, and the third stage
corresponds to the first stage of the
Standard Bruce Test protocol as
listed above.

gusbakti11
 Results
Score  time taken in minutes
Can also be converted to an
estimated VO2max score using the
calculator below and the following
formulas, where the value "T" is the
total time completed (expressed in
minutes and fractions of a minute
e.g. 9 minutes 15 seconds = 9.25
minutes) gusbakti11
 Results

 Many exercise test equations, there

have been many regression
equations developed that may give
varying results.
If possible, use the one derived
from a similar population and which
best suits your needs.
gusbakti11
 Results

VO2max (ml/kg/min) = 14.76 - (1.379 × T) + (0.451 × T²) - (0.012 × T³)

Women: VO2max (ml/kg/min) = 2.94 x T + 3.74
Women: VO2max (ml/kg/min) = 4.38 × T - 3.9
•Men: VO2max (ml/kg/min) = 2.94 x T + 7.65
•Young Men: VO2max (ml/kg/min) = 3.62 x T + 3.91
ref: ACSM's Health-Related Physical Fitness Assessment Manual

•VO2max calculator:
•Enter your total time on the Bruce Test in the box below and
click calculate. The time in minutes should be expressed in
minutes and fractions of a minute e.g. 9 minutes 15 seconds =
9.25 minutes.

gusbakti11
 Karvonen method

• Resting heart rate (HRrest) to calculate target heart

rate (THR), using a range of 50–85%:
THR = ((HRmax − HRrest) × %Intensity) + HRrest
Example for someone with a HRmax of 180 and a HRrest
of 70:
50% intensity: ((180 − 70) × 0.50) + 70 = 125 bpm
85% intensity: ((180 − 70) × 0.85) + 70 = 163 bpm

gusbakti11
 Astrand-Rhyming Cycle
Ergometer Test
The Astrand Test is a submaximal cycle ergometer aerobic fitness test.
There are many other aerobic fitness tests.
•equipment required: cycle ergometer, clock or stopwatch, heart rate
monitor, ECG monitor (optional)
•description: Athletes pedal on a cycle ergometer at a constant workload
for 7 minutes. Heart rate is measured every minute, and the steady state
heart rate is determined.

scoring: Generally the lower the heart beat the better your fitness. The
steady state heart rate is looked up on published tables (nomogram) to
determine an estimation of VO2max. Here is also the formula (Buono et al.
1989) that the nomogram is based on, where predicted VO2max is in
L/min, HRss is the steady heart rate after 6 min of exercise, and the
workload in kg.m/min. To convert a load in watts to kg.m/min, multiply the
watts by 6.12.

gusbakti11
• Per-Olof Åstrand is one of the founding
fathers of modern exercise physiology.
He was born in 1922. He graduated
from the College of Physical Education,
Stockholm (1946), and Karolinska
Institute-Medical School, Stockholm,
Sweden (1952). He is awarding the
Nobel Prize in physiology or medicine
(1977-1988).

gusbakti11
 Astrand-Rhyming Cycle
Ergometer Test
• Females: VO2max = (0.00193 x workload + 0.326) / (0.769 x HRss - 56.1) x 100
• Males: VO2max = (0.00212 x workload + 0.299) / (0.769 x HRss - 48.5) x 100

•equipment required: cycle ergometer, clock or stopwatch, heart rate

monitor, ECG monitor (optional)
•description: Athletes pedal on a cycle ergometer at a constant workload
for 7 minutes. Heart rate is measured every minute, and the steady state
heart rate is determined.

scoring: Generally the lower the heart beat the better your fitness. The
steady state heart rate is looked up on published tables (nomogram) to
determine an estimation of VO2max. Here is also the formula (Buono et al.
1989) that the nomogram is based on, where predicted VO2max is in
L/min, HRss is the steady heart rate after 6 min of exercise, and the
workload in kg.m/min. To convert a load in watts to kg.m/min, multiply the
watts by 6.12.

gusbakti11
 Overview
• Basic EKG Review
• Introduction to Treadmill Test
– Indications and Safety
– Equipment and Protocols
– Exercise End Points
– Basics of Interpretation of the Exercise Test
• Exercise Testing to Diagnose Obstructive
Coronary Artery Disease
– Rationale and Guidelines
– Pretest Probability
– ST-Segment Interpretation
– Confounders of Stress ECG Interpretation
• Result Reporting

gusbakti11
Basic EKG Review

gusbakti11
 Simple Method of EKG Interpretation

• Rate
• Rhythm
• Axis
• Hypertrophy
• Infarction and Ischemia

gusbakti11
Rate

gusbakti11
Rhythm
• Identify basic rhythm…
– …then scan entire tracing for pauses,
premature beats, irregularity, and abnormal
waves.
• Always:
– Check for:
• P before each QRS.
• QRS after each P.

gusbakti11
Axis

gusbakti11
Hypertrophy

gusbakti11
gusbakti11
Infarction and Ischemia

gusbakti11
gusbakti11
gusbakti11
Normal EKG

gusbakti11
Atrial Fibrillation with Rapid
Ventricular Response

gusbakti11
Inferior Acute MI and RBBB

gusbakti11
Anterior Acute MI

gusbakti11
Left Ventricular Hypertrophy

gusbakti11
Ventricular Fibrillation

gusbakti11
 Overview
• Basic EKG Review
• Introduction to Treadmill Test
– Indications and Safety
– Equipment and Protocols
– Exercise End Points
– Basics of Interpretation of the Exercise Test
• Exercise Testing to Diagnose Obstructive Coronary
Artery Disease
– Rationale and Guidelines
– Pretest Probability
– ST-Segment Interpretation
– Confounders of Stress ECG Interpretation
• Result Reporting

gusbakti11
 Indications and Safety

• Generally a safe procedure, but both myocardial

infarction and death have been reported and can be
expected to occur at a rate of up to 1 per 2500 tests.
• Good clinical judgment should therefore be used in
deciding which patients should undergo exercise testing.
• Exercise testing should be supervised by an
appropriately trained physician.
• The electrocardiogram (ECG), heart rate, and blood
pressure should be monitored carefully and recorded
during each stage of exercise and during ST-segment
abnormalities and chest pain.

gusbakti11
Equipment and Protocols
• Both treadmill and cycle ergometer devices are
available for exercise testing.
• Much of the published data are based on the
Bruce protocol, there are clear advantages to
customizing the protocol to the individual patient
to allow 6 to 12 minutes of exercise.
• Exercise capacity should be reported
in estimated metabolic equivalents
(METs) of exercise.

gusbakti11
Exercise Endpoints
• Commonly terminated when subjects
reach an arbitrary percentage of predicted
maximum heart rate.
• Other end points (summarized next slide)
are strongly preferred.
• The use of rating of perceived exertion
scales, such as the Borg scale is often
helpful in assessment of patient fatigue.
gusbakti11
gusbakti11
The Modified Borg Scale
SCALE SEVERITY
0 No Breathlessness* At All
0.5 Very Very Slight (Just Noticeable)
1 Very Slight
2 Slight Breathlessness
3 Moderate
4 Somewhat Severe
5 Severe Breathlessness
6
7 Very Severe Breathlessness
8
9 Very Very Severe (Almost Maximum)
10 Maximum
gusbakti11
 Basics of Interpretation of
the Exercise Treadmill Test

• Interpretation of the exercise test should include exercise

capacity and clinical, hemodynamic, and
electrocardiographic response.
• The occurrence of ischemic chest pain consistent with
angina is important, particularly if it forces termination of
the test.
• The most important electrocardiographic findings are ST
depression and elevation.
• Positive exercise test result is greater than or equal to 1
mm of horizontal or downsloping ST-segment
depression or elevation for at least 60 to 80 milliseconds
(ms) after the end of the QRS complex
gusbakti11
 Overview
• Basic EKG Review
• Introduction to Treadmill Test
– Indications and Safety
– Equipment and Protocols
– Exercise End Points
– Basics of Interpretation of the Exercise Test
• Exercise Testing to Diagnose Obstructive Coronary
Artery Disease
– Rationale and Guidelines
– Pretest Probability
– ST-Segment Interpretation
– Confounders of Stress ECG Interpretation
• Result Reporting

gusbakti11
 Rationale for Using ETT to
Diagnose Obstructive CAD

• Most predictive clinical finding is a history of chest pain

or discomfort.
• Myocardial ischemia is the most important cause of
chest pain and is most commonly a consequence of
underlying coronary disease.
• CAD that has not resulted in sufficient luminal occlusion
to cause ischemia during stress can still lead to ischemic
events through spasm, plaque rupture, and thrombosis,
but most catastrophic events are associated with
extensive atherosclerosis.
• These nonobstructive lesions explain some of the events
that occur after a normal exercise test.
• Although the coronary angiogram has obvious
limitations, angiographic lesions remain the clinical gold
standard. gusbakti11
 The ACC/AHA Guidelines for the Diagnostic
Use of the Standard Exercise Test

 Class I (Definitely appropriate) - Adult males

or females (including RBBB or < 1mm resting ST
depression) with an intermediate pre-test
probability of coronary artery disease based on
gender, age and symptoms (specific exceptions
are noted under Class II and III below).
 Class IIa (Probably appropriate) - Patients with
vasospastic angina.

gusbakti11
The ACC/AHA Guidelines for the Diagnostic
Use of the Standard Exercise Test

• Class IIb (maybe appropriate)

– Patients with a high pretest probability of
CAD by age, symptoms, and gender.
– Patients with a low pretest probability of CAD
by age, symptoms, and gender.
– Patients with less than 1 mm of baseline ST
depression and taking digoxin.
– Patients with electrocardiographic criteria for
left ventricular hypertrophy (LVH) and less
than 1 mm of baseline ST depression.
gusbakti11
 The ACC/AHA Guidelines for the Diagnostic
Use of the Standard Exercise Test, cont’d

Class III (Not appropriate) -

1. To use the ST segment response in the diagnosis of coronary
artery disease in patients who demonstrate the following baseline
ECG abnormalities:
pre-excitation (WPW) syndrome;
electronically paced ventricular rhythm;
more than one millimeter of resting ST depression;
LBBB
2. To use the ST segment response in the
diagnosis of coronary artery disease in
MI patients

gusbakti11
 Pretest Probability
• Based on the patient's history (including age, gender, and
chest pain characteristics), physical examination and initial
testing, and the clinician's experience with this type of
problem.
• Typical or definite angina makes the pretest probability of
disease so high that the test result does not dramatically
change the probability.
• Atypical or probable angina in a 50-year-old man or a 60-
year-old woman is associated with approximately a 50%
probability of CAD.
• Diagnostic testing is most valuable in this intermediate
pretest probability category, because the test result has the
largest potential effect on diagnostic outcome.
• Typical or definite angina can be defined as 1) substernal
chest pain or discomfort that is 2) provoked by exertion or
emotional stress and 3) relieved by rest and/or nitroglycerin.
gusbakti11
 Pre Test Probability of Coronary Disease by
Symptoms, Gender and Age

Age Gender Typical/Definite Atypical/Probable Non- Asymptomatic

Angina Pectoris Angina Pectoris Anginal
Chest Pain
30-39 Males Intermediate Intermediate low (<10%) Very low (<5%)
30-39 Females Intermediate Very Low (<5%) Very low Very low
40-49 Males High (>90%) Intermediate Intermediate low
40-49 Females Intermediate Low Very low Very low
50-59 Males High (>90%) Intermediate Intermediate Low
50-59 Females Intermediate Intermediate Low Very low
60-69 Males High Intermediate Intermediate Low

60-69 Females High Intermediate Intermediate Low

High = >90% Intermediate = 10-90% Low = <10%

Very Low = <5%
gusbakti11
 ST Segment Interpretation
• Computer summaries can help find
possible areas of ischemia – then review
raw data carefully!
• Determine PQ junction, J point, ST80, and
estimate slope
• Elevation
• Depression
– Upsloping
– Horizontal
– Downsloping gusbakti11
Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with
a relatively stable baseline are selected. The PQ junction (1) and J point (2) are
determined; the ST 80 (3) is determined at 80 msec after the J point. In this example,
average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The
gusbakti11
average slope measurement from the J point to ST 80 is –1.1 mV/sec.
Normal

Rapid
Upsloping

Minor ST
Depression

Slow
Upsloping

gusbakti11
Horizontal

Downsloping

Elevation (non
Q lead)

Elevation (Q
wave lead)
gusbakti11
 Upsloping

J point depression of 2 to 3
mm in leads V4 to V6 with
rapid upsloping ST
segments depressed
approximately 1 mm 80
msec after the J point. The
ST segment slope in leads
V4 and V5 is 3.0 mV/sec.
This response should not
be considered abnormal.

gusbakti11
 • In lead V4 , the
exercise ECG result
is abnormal early in
the test, reaching
0.3 mV (3 mm) of
horizontal ST
segment depression
at the end of
exercise.
• Consistent with a
severe ischemic
response.

gusbakti11
 •The J point at peak
exertion is depressed 2.5
mm, the ST segment slope
is 1.5 mV/sec, and the ST
segment level at 80 msec
after the J point is
depressed 1.6 mm.
•This “slow upsloping” ST
segment at peak exercise
indicates an ischemic
pattern in patients with a
high coronary disease
prevalence pretest.
•A typical ischemic pattern
is seen at 3 minutes of the
recovery phase when the
ST segment is horizontal
and 5 minutes after exertion
when the ST segment is
downsloping.

gusbakti11
 •Becomes abnormal at
9:30 minutes (horizontal
arrow right) of a 12-
minute exercise test and
resolves in the immediate
recovery phase.
•This ECG pattern in
which the ST segment
becomes abnormal only
at high exercise
workloads and returns to
baseline in the immediate
recovery phase may
indicate a false-positive
result in an asymptomatic
individual without
atherosclerotic risk
factors.

gusbakti11
 •A 48-year-old man with several
atherosclerotic risk factors and a
normal rest ECG result developed
marked ST segment elevation (4 mm
[arrows]) in leads V2 and V3 with
lesser degrees of ST segment
elevation in leads V1 and V4 and J
point depression with upsloping ST
segments in lead II, associated with
angina.
•This type of ECG pattern is usually
associated with a full-thickness,
reversible myocardial perfusion defect
in the corresponding left ventricular
myocardial segments and high-grade
intraluminal narrowing at coronary
angiography. Rarely, coronary
vasospasm produces this result in the
absence of significant intraluminal
atherosclerotic narrowing.(
gusbakti11
Confounders of Exercise Treadmill Test Interpretation
• Digoxin
– Produces an abnormal ST-segment response to exercise. This abnormal ST
depression occurs in 25% to 40% of healthy subjects studied and is directly
related to age.
• Left Ventricular Hypertrophy
– Decreased specificity of exercise testing, but sensitivity is unaffected. Therefore,
a standard exercise test may still be the first test, with referrals for additional
tests only indicated in patients with an abnormal test result.
• Resting ST Depression
– Resting ST-segment depression has been identified as a marker for adverse
cardiac events in patients with and without known CAD.
• Left Bundle-Branch Block
– Exercise-induced ST depression usually occurs with left bundle-branch block and
has no association with ischemia. Even up to 1 cm of ST depression can occur in
healthy normal subjects. There is no level of ST-segment depression that confers
diagnostic significance in left bundle-branch block.
• Right Bundle-Branch Block
– The presence of right bundle-branch block does not appear to reduce the
sensitivity, specificity, or predictive value of the stress ECG for the diagnosis of
ischemia.
• Beta Blocker Therapy
– For routine exercise testing, it appears unnecessary for physicians to accept the
risk of stopping beta-blockers before testing when a patient exhibits possible
symptoms of ischemia or has hypertension. However, exercise testing in patients
taking beta-blockers may have reduced diagnostic or prognostic value because
of inadequate heart rate response.gusbakti11
 Overview
• Basic EKG Review
• Introduction to Treadmill Test
– Indications and Safety
– Equipment and Protocols
– Exercise End Points
– Basics of Interpretation of the Exercise Test
• Exercise Testing to Diagnose Obstructive Coronary
Artery Disease
– Rationale and Guidelines
– Pretest Probability
– ST-Segment Interpretation
– Confounders of Stress ECG Interpretation
• Result Reporting

gusbakti11
 Comparison of Tests for
Diagnosis of CAD
Grouping # of Total # Sens Spec Predictive
Studies Patients Accuracy
Standard ET 147 24,047 68% 77% 73%
 ET Scores 24 11,788 80%
 Score Strategy 2 >1000 85% 92% 88%
Thallium Scint 59 6,038 85% 85% 85%
SPECT 16+14 5,272 88% 72% 80%
Adenosine SPECT 10+4 2,137 89% 80% 85%
Exercise ECHO 58 5,000 84% 75% 80%
Dobutamine ECHO 5 <1000 88% 84% 86%
Dobutamine Scint 20 1014 88% 74% 81%
Electron Beam 16 3,683 60% 70% 65%
Tomography (EBCT) gusbakti11
Results Reporting
Hope Medical Group
Exercise Treadmill Test
Results Report – rev. 11/04

Patient Name: Date of Test:

Chart Number:
Reason for Test:
________________________________________________________________________
Digoxin? _______
Beta blocker? ________
Resting EKG interpretation:
________________________________________________________________________
________________________________________________________________________
LVH? ___________
LBBB? __________
RBBB? ___________
Resting ST Depression? _________
Cardiac Risk Factors (circle)

Age Gender Diabetes HTN

Hypercholesterolemia Smoker Sedentary/Obese Total Number:

Estimate pretest probability – use table for reference (very low, low, intermediate, high, very high):
_______________________________________________________________________
Reason for test if pretest probability not intermediate:
_______________________________________________________________________

gusbakti11
1. Exercise Capacity
METS achieved: _______________
Minutes exercised: _______________
Results Reporting – Page 2
2. Clinical response to exercise
Chest pain during test? ___________
Chest pain reason for stopping test? __________
Perceived exertion scale (BORG scale reached – 6 to 20): _________
Reason for stopping test:_____________
3. Electrocardiographic response to exercise
ST elevation (yes/no) ? ____________
ST depression (yes/no)? ____________
(positive = 1 mm of horizontal or downsloping ST-segment depression or
elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS
complex)
What leads? ___________
ST quality (upsloping, horizontal,
downsloping):_______________
ST depression amount (mm): ___________
Dysrhythmia? _____________
Other:
____________________________________________________
4. Hemodynamic response to exercise
Systolic BP response: ______________
Diastolic BP response: ______________
Maximum heart rate achieved: ________________
2 minute heart rate recovery (should be at least 22 bpm by 2
gusbakti11
minutes): ______________
 Results Reporting – Page 3

5. Duke treadmill scores (see nomogram or use calculator):

5-year survival _______

Average annual mortality __________

6. VA treadmill score: _________

7. Final conclusions and recommendation for follow-up:

______________________________________________________________
______________________________________________________________
______________________________________________________________

gusbakti11
Duke treadmill score = duration of exercise in minutes on the
Bruce protocol
- (minus) 5x maximal mm ST deviation
- (minus) 4x treadmill angina index

Treadmill Angina Index:

0 if no angina.
1 if non-limiting angina.
2 if limiting angina.

High Risk = treadmill score < -10

79% 4-year survival
Moderate Risk = treadmill score -10 to +4
95% 4-year survival
Low Risk = treadmill score >+5
99% 4-year survival
gusbakti11
Duke Nomogram for 2 mm depression,
non-limiting chest pain at 5 METS.

gusbakti11
 Variable Circle response Sum
Maximal Heart Rate Less than 100 bpm = 30 Males
100 to 129 bpm = 24
130 to 159 bpm =18
160 to 189 bpm =12 Choose
190 to 220 bpm =6 only one
Exercise ST Depression 1-2mm =15
per
Age
> 2mm =25
>55 yrs =20
group
40 to 55 yrs = 12

Angina History Definite/Typical = 5

Probable/atypical =3 <40=low prob

Non-cardiac pain =1 40-60=
Hypercholesterolemia? Yes=5 intermediate
Diabetes? Yes=5 probability
Exercise test Occurred =3 >60=high
induced Angina Reason for stopping =5 probability
Total Score:
gusbakti11
 Variable
Maximal Heart
Circle response
Less than 100 bpm = 20
Sum
Women
Rate 100 to 129 bpm = 16
130 to 159 bpm =12
160 to 189 bpm =8 Choose
190 to 220 bpm =4
only one
Exercise ST 1-2mm =6

Depression > 2mm =10

per
Age >65 yrs =25 group
50 to 65 yrs = 15
Angina History Definite/Typical = 10
Probable/atypical =6
Non-cardiac pain =2 <37=low prob
Smoking? Yes=10
37-57=
Diabetes? Yes=10
intermediate
Exercise test Occurred =9
probability
induced Angina Reason for stopping =15
Positive=-5, Negative=5
>57=high
Estrogen Status
Total Score probability
gusbakti11
 Review
• Basic EKG Review
• Introduction to Treadmill Test
– Indications and Safety
– Equipment and Protocols
– Exercise End Points
– Basics of Interpretation of the Exercise Test
• Exercise Testing to Diagnose Obstructive Coronary
Artery Disease
– Rationale and Guidelines
– Pretest Probability
– ST-Segment Interpretation
– Confounders of Stress ECG Interpretation
• Result Reporting

gusbakti11
gusbakti11