Clinical Exercise Testing and Interpretation

Chapter 5
Clinical Exercise Testing and

Interpretation
Introduction
• Clinical exercise testing has been part of the differential diagnosis of
patients with suspected ischemic heart disease (IHD) for more than 50
yr.
• Although there are several indications for clinical exercise testing, most
tests are likely performed as part of the diagnosis and evaluation of IHD.
• There are several evidence-based statements from professional
organizations related to the conduct and application of clinical exercise
testing.
– GXT, exercise stress test, ETT, CPX, CPET
Copyright © 2018 American College of Sports Medicine

Indications for a Clinical Exercise Test
• Indications for clinical exercise testing encompass three general
categories: (a) diagnosis (e.g., presence of disease or abnormal
physiologic response), (b) prognosis (e.g., risk for an adverse
event), and (c) evaluation of the physiologic response to exercise
(e.g., blood pressure [BP] and peak exercise capacity).
– The most common diagnostic indication is the assessment of
symptoms suggestive of IHD.

21. Gibbons RJ, Balady GJ, Bricker JT, et al. Committee to Update the 1997 Exercise Testing Guidelines.
ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997
Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40.

Indications for a Clinical Exercise Test
• The clinical utility of exercise testing is aimed at specific cardiac
diagnoses (Box 5.1).
– STEMI
– NSTE ACS
– IHD
– PreOp CV Evaluation
– HF
– PCI
– VHD
• Also, an exercise test can be useful in the evaluation of patients

who present to emergency departments with chest pain.

Conducting the Clinical Exercise Test
• When administering clinical exercise tests, it is important to
consider contraindications, the exercise test protocol and mode,
test endpoint indicators, safety, medications, and staff and facility
emergency preparedness
• Box 5.2

• Testing Mode and Protocol
– The mode selected for the exercise test can impact the
results & be based on test purpose + patient preference
• Treadmill
• Cycle ergometer
• Other exercise testing modes may be considered
– Figure 5.1

VO2 required for each stage

• Monitoring SS & Additional CPX measurements
– HR; ECG; cardiac rhythm; BP; perceived exertion; clinical
signs and patient-reported symptoms of myocardial
ischemia, inadequate blood perfusion, inadequate gas
diffusion, & limitations in pulmonary ventilation
– Measurement of expired gases through open circuit
spirometry during a CPET & oxygen saturation of blood
through pulse oximetry and/or arterial blood gases (when
indicated*)

•• CPX & GXT
– The analysis of expired gas during a CPET overcomes the potential
inaccuracies associated with estimating exercise capacity from peak
workload (e.g., treadmill speed and grade).
– Direct measurement of 2 is the most accurate measure of exercise
capacity & is a useful index of overall cardiopulmonary health
– Exertional dyspnea
– SpO2
• Termination criteria
– When the goal is a symptom-limited maximal exercise test, a
predetermined intensity should not be used as an endpoint

• Postexercise and safety

– Each laboratory should develop standardized procedures for
the postexercise recovery period
• active vs. inactive and monitoring duration with the
laboratory’s medical director that considers the indication
for the exercise test and the patient’s status during the
test
– Althought events do occur, clinical exercise testing is
generally safe when performed by appropriately trained
clinicians

Interpreting the Clinical Exercise Test
• Multiple factors considered for the interpretation of
exercise test data
– Sign & symptoms,
– ECG responses,
– Exercise capacity,
– Hemodynamic responses,
– Combination of multiple responses -Duke Treadmill
Score

• GXT /CPX Heart Rate Responses
– The normal HR response increase with workloads at a rate
of ~10 beats  min-1 per 1 MET
– Several equations have been published to predict HRmax
– All estimates have large interindividual variability with
standard deviations of 10 beats or more
• HRmax decreases with age
• Also attenuated in patients on -adrenergic blocking
agents.

• Heart Rate Max + Recovery Interpretation
– Failure to reach age-predicted HRmax >85% in the
presence of maximal effort = chronotropic incompetence (CI)
– CI= increased risk of morbidity and mortality
– HR following exercise provides independent information
related to prognosis
• >12 bpm during 1 min of recovery OR
• >22 bpm during 2 min of recovery
• Increased Mortality + Risk for IHD
• Failure to re-assert vagal tone = Increased Ventricle
Dsyrythmias

• GXT/CPX BP Response
– SBP increase with workloads at a rate of ~10 mm Hg per 1
MET.
– Normally no change or a slight decrease in diastolic blood
pressure (DBP)
– SBP
– Exaggerated Response: SBP > 210 (M) or > 190 (F)
– Hypertensive response: SBP > 250 (Relative Indication to Stop
GXT)
– Increased Hypertension Risk: SBP > 250 or > 140 above rest

• Blunted Response:
• Lower than expected SBP response
• Hypotensive Response:
• SBP < 10 or SBP < resting value w/ increase in workload
(Relative Indication to Stop GXT)
• Accompanied by SS = Increased risk for MI, LV Dys., &
Cardiac Events (Absolute Indication to Stop GXT)
• SBP Post-exercise response
• Returns to resting values = 6 min recovery
• Delay in SBP recovery = ischemia & poor prognosis

• DBP
• Abnormal response = DBP > 90 or 10 mmHg above rest
• May occur w/ ischemia
• DBP > 115 (Relative Indication to Stop GXT)

• Rate Pressure Product (RPP) Interpretation
• Linear relationship between myocardial oxygen uptake and both
coronary blood flow and exercise intensity
• HR x SBP = mmHg*bpm = measure of LV work rate
• Normal Max values = 25,000-40,000 mmHg*bpm
• Onset IHD SS correlate w/ RPP = Ischemic threshold
• RPP can be used as reliable marker of onset of IHD SS
• Report both max values and ischemic threshold values

• ECG Interpretation
• The normal response of the ECG during exercise includes the
following:
• P-wave: increased magnitude among inferior leads
• PR segment: shortens and slopes downward among inferior leads
• QRS: Duration decreases, septal Q-waves increase among lateral
leads, R waves decrease, and S waves increase among inferior
leads.

• ECG
• The normal response of the ECG during exercise includes the
following:
• J point (J junction): depresses below isoelectric line with
upsloping ST segments that reach the isoelectric line within 80
ms
• T-wave: decreases amplitude in early exercise, returns to
preexercise amplitude at higher exercise intensities, and may
exceed preexercise amplitude in recovery
• QT interval: Absolute QT interval decreases. The QT interval
corrected for HR increases with early exercise and then
decreases at higher HRs.

Normal ECG

• ECG - ST Segment
– ST-segment changes (i.e., depression and elevation) are widely
accepted criteria for myocardial ischemia and injury.
– The interpretation of ST segments may be affected by the resting
ECG configuration and the presence of digitalis therapy

ST Depression = Myocardial Ischemia

ST Elevation & Q Waves

• ECG
• Abnormal response of the ST segment during exercise includes
the following:
– ST-segment depression or elevation should be present in at least three
consecutive cardiac cycles within the same lead.
– The level of the ST segment should be compared relative to the end of
the PR segment. Automated computer-averaged complexes should be
visually confirmed.
– Horizontal or downsloping ST-segment depression > 1 mm (0.1 mV) at
80 ms after the J point is a strong indicator of myocardial ischemia.

ST Depression

• ECG
• Abnormal response of the ST segment during exercise includes
the following:
– Clinically significant ST-segment depression that occurs during
postexercise recovery is an indicator of myocardial ischemia.
– ST-segment depression at a low workload or low rate-pressure product is
associated with worse prognosis and increased likelihood for multivessel
disease.
– When ST-segment depression is present in the upright resting ECG, only
additional ST-segment depression during exercise is considered for
ischemia.

• Electrocardiogram
• Abnormal response of the ST segment during exercise includes the
following:
– When ST-segment elevation is present in the upright resting ECG, only ST-
segment depression below the isoelectric line during exercise is considered
for ischemia.
– Upsloping ST-segment depression > 2 mm (0.2 mV) at 80 ms after the J
point may represent myocardial ischemia, especially in the presence of
angina. However, this response has a low positive predictive value; it is often
categorized as equivocal (early repolarization)

following (Cont.):
– Among patients after myocardial infarction (MI), exercise-induced ST-segment
elevation (> 1 mm or > 0.1 mV for 60 ms) in leads with Q waves is an
abnormal response and may represent reversible ischemia or wall motion
abnormalities.
– Among patients without prior MI, exercise-induced ST-segment elevation most
often represents transient combined endocardial and subepicardial ischemia
but may also be due to acute coronary spasm.

following (Cont.):
– Repolarization changes (ST-segment depression or T-wave
inversion) that normalize with exercise may represent exercise-
induced myocardial ischemia but is considered a normal
response in young subjects with early repolarization on the
resting ECG.
• In general, dysrhythmias that increase in frequency or
complexity with progressive exercise intensity
– associated with ischemia or with hemodynamic instability
are more likely to cause a poor outcome than isolated
dysrhythmias

Ventricular Dysrhythmias: Types of PVCs

Atrial Dysrhythmias

PVCs

PVCs gone wild “Vtach”

• Symptoms Interpretation
– Symptoms that are consistent with myocardial ischemia
(e.g., angina, dyspnea) or hemodynamic instability
(e.g., light-headedness)
– Record the onset and associated ECG, HR & BP on
GXT form during exercise and recovery

• Exercise Capacity
– Evaluating exercise capacity is an important
aspect of exercise testing
• A high exercise capacity is indicative of a high peak Q and
therefore suggests the absence of serious limitations of left
ventricular function
• A significant issue relative to exercise capacity is the
imprecision of estimating exercise capacity from exercise time
or peak workload.
• Minimal standard error in estimating exercise capacity >  1MET
• 7-8% error w/ VO2 peak/max = 13-15 METS
• 13-25% error w/ VO2peak/max = 4-8 METS

Predicted Vo2 peak for patients w/ CVD

• Cardiopulmonary Exercise Testing
– A major advantage of measuring gas exchange during
exercise is a more accurate measurement of exercise
capacity (< 3% TEM)
– CPET data may be particularly useful in defining prognosis
and defining the timing of cardiac transplantation and
other advanced therapies in patients with heart failure
– CPET is also helpful in the differential diagnosis of patients
with suspected cardiovascular and respiratory diseases

•• Maximal versus Peak Cardiorespiratory Stress
– When an exercise test is performed as part of the evaluation of IHD,
patients should be encouraged to exercise to their maximal level of
exertion or until a clinical indication to stop the test is observed
– Various criteria have been used to confirm that a maximal effort
has been elicited during a GXT:
• A plateau in 2peak (< 2ml/min/kg increase w/ workload)
• a minimum RER value of 1.05 is often considered acceptable
• Achieved Volitional Fatigue
• Validation of VO2max (20 min recovery then 105% TTE test)
• Failure of HR to increase with increases in workload

• A post exercise venous lactate concertation > 8.0 mmol  L-1
• RPE at peak exercise > 17 (6-20 scale) or >7 (0-10 scale)
• A peak RER > 1.10

Diagnostic Value of Exercise Testing for
the Detection of Ischemic Heart Disease
• The diagnostic value of the clinical exercise test for

the detection of IHD is influenced by the principles
of conditional probability
• The factors that determine the diagnostic value of
exercise testing are the sensitivity and specificity of
the test procedure and prevalence of IHD in the
population tested

• Sensitivity, Specificity and Predictive Value
– Sensitivity refers to the ability to positively identify patients
who truly have IHD
– Specificity refers to the ability to correctly identify patients
who do not have IHD.
– The predictive value of clinical exercise testing is a measure
of how accurately a test result (True positive or True
negative) correctly identifies the presence or absence of
IHD in patients
• False Positive and False negative have to be minimized

• Clinical Exercise Test Data and Prognosis
• First introduced in 1991 when the Duke Treadmill Score
was published, the implementation of various exercise test
scores that combine information derived during the exercise
test into a single prognostic estimate has gained popularity.
• The most widely accepted and used of these prognostic
scores is the Duke Treadmill Score or the related Duke
Treadmill Nomogram.

Field Walking Test
• Non–laboratory-based clinical exercise tests frequently used
in patients with chronic disease.
– Generally classified as field or hallway walking tests and
are typically considered submaximal
• Similar to maximal exercise tests, field walking tests are
used to evaluate exercise capacity, estimate prognosis, and
evaluate response to treatment
– 6MWT, incremental and endurance shuttle walk tests

Clinical Exercise Tests with Imaging
• When the resting ECG is abnormal, exercise testing may be
coupled with other techniques or additional tests warranted
– augment the information provided by the ECG or to replace the
ECG when resting abnormalities (Box 5.5) make evaluation of
changes during exercise impossible
• Radioistopes such as 201thallium and 199mtechnetium sestamibi
(Cardiolite) - Perfusion of myocardium
• Stress Echocardiogram (ultasound)
• Angiogram (radioisotope and xray imaging)
• Electrophysiology (3D - electrical imaging of heart)

Exercise echocardiography
Hypokinetic (decreased), Dyskinetic (impaired), Akinetic (absent) wall
motion
http://www.youtube.com/watch?v=3dssbDeow50&sns=em

Professionals in the Cardiology Lab
• Diagnostic Cardiologists
• Interventional Cardiologists
• Electrophysiologists
• Registered Nurses
• GXT/CPX Technicians (CPET)
• Pacemaker Technicians
• Cardiovascular Technicians
• Electrophysiology Technicians
• Cardiac Rehabilitation
• Radiology Technicians

• GXT/CPX/CPET Testing Staff
– Over the past several decades, there has been a transition
in many exercise testing laboratories from tests being
administered by physicians to nonphysician allied health
professionals, such as clinical exercise physiologists,
nurses, physical therapists, and physician assistants.
– According to the ACC and AHA, the nonphysician allied
health care professional who administers clinical exercise
tests should have cognitive skills similar to, although not as
extensive as, the physician who provides the final
interpretation

ACSM Skills & Certifications
• ACSM Certifications
– Appendix D Table D.1 (pg 449-451,453-454)
• ACSM Certified Exercise Physiologist (Appendix D pg 453)
– Bachelors Degree
– AHA or Red Cross CPR/AED
• ACSM Certified Clinical Exercise Physiologist (Appendix D pg 453)
– Bachelors Degree
– 400 hr of clinical experience
– AHA BLS HealthCare Provider or Red Cross CPR/AED Professional
Rescuer
• ACSM Registered Clinical Exercise Physiologists (Appendix pg 454)
– Graduate Degree
– 600 hr of clinical experience
– AHA BLS HealthCare Provider or Red Cross CPR/AED Professional
Rescuer

Electrophysiology & Cardiac Catheterization Laboratory
• Left & Right Heart Catheterization
• Right Ventricle Biopsy
• Peripheral Vascular (i.e., lower extremities, carotids, renals)
• Angioplasty & Stent Placement
• Electrophysiology Study
• Radiofrequency Ablation
• Cardioversion
• Pacemaker/ICD Implant
• Loop Recorder Implant
• Tilt Table Testing

Heart Cath Set-up

Electrophysiology Lab

E.P. Catheter Placement

CARTO Mapping System EnSite Cardiac Mapping

Cath/EP Lab Careers
• Cath/E.P. Lab Staff
– Registered Nurse
– Cardiovascular Tech
– Electrophysiology Tech
– Radiology Tech
• Industry
– Sales Representative
– Clinical Educator
– Pacemaker/ICD Representative

Clinical Exercise Testing and Interpretation

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Clinical Exercise Testing and Interpretation

Uploaded by

Copyright:

Available Formats

Chapter 5

Clinical Exercise Testing and

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

• Also, an exercise test can be useful in the evaluation of patients

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

• Postexercise and safety

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

• Failure of HR to increase with increases in workload

Copyright © 2018 American College of Sports Medicine

• The diagnostic value of the clinical exercise test for

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

Copyright © 2018 American College of Sports Medicine

You might also like