EXERCISE STRESS TEST

INDICATIONS

• Assessment of cardiovascular risk

• Detection of CAD

• Evaluation of coronary artery disease

• Assessment of therapeutic response

• Assessment of perioperative risk for non cardiac surgery

• Exercise prescription

• Determine degree of disability

RISKS

• Risk is very small

• Risk that exist is the hazard of provoking MI

• Patients must be selected with care

SELECTION OF PATIENT

• Patients with suspected IHD

• Always begin by assessing the patients probability of having IHD: Bayesian approach

• Probability that the test will reveal disease depends on the patients risk of actually having the
disease: Pre-test probability

• Pre-test probability depends on risk factors

• Purpose of pre-test probability is to :

- Identify patients with very low probability and very high probability of the disease.
CONTRAINDICATIONS

Absolute Contraindiactions
• Pulmonary embolism in acute phase
• Aortic dissection
• Severe aortic stenosis
• Acute MI within 48 hours
• Endocarditis
• Unstable angina
• DVT
• Presence of potentially serious arrhythmias

• Decompensated heart failure

CONTRAINDICATIONS • Severe Hyperthyroidism

Relative Contraindiactions • Moderate to severe aortic stenosis

• Severe HTN • 2nd or 3rd degree AV block

• Left main coronary artery stenosis • Stroke within one month

• Severe electrolyte imbalance

Preperation for exercise stress tesing

Laboratory and personnel

• EST may be conducted by physician, nurses, physiotherapist or other professionals

• All personnel's must be appropriately trained and laboratory must be equipped with defibrillators
and other emergency instruments

• Personnel formally trained to assess CV response, symptoms and ECG changes

• Personnel trained in resuscitation

Subject Preperation

• Procedure explained carefully to the patient

• 3 hrs fasting before the test is recommended

• Shoes and clothing should be suitable for exercise

• Most recently recorded 12 lead ECG should be at hand before start of exercise

• Physical examination and anamnesis must be obtained before the start of the exercise

• Cardiopulmonary auscultation is mandatory

• Symptoms, medical history, allergies and contraindications must checked carefully

• BP is measured at rest before start of exercise

Cardioactive Medications

• In some circumstances it is necessary to with hold cardio-active medications during exercise test

Exercise ECG protocol and Equipment

• Treadmill and cycle ergometer are most frequently used test methods
Treadmill Training

• Equipped with front and side rails

• Speed varies from 1mph to 8mph

• Elevation is possible upto 20 degrees

• Work intensity higher with treadmill testing

• Several exercise protocols for treadmill

Bicycle Ergometry

• Less intense than on a treadmill

• Cycle ergometer is cheaper than treadmill and it requires less space in laboratory

• Measuring BP is easier on cycle than on treadmill

• ECG easier to record and less artifacts

• Exercise resistance usually measured in Watts (W)

• Men: 50W, Women: 40W

• Resistance then increased with 15W for females and 15-30 W for males every other minute

• Total duration: 7-10mins

• Drawback: dependency on the quadriceps muscle.

Evaluation of Exercise Stress test

• Final results depends on the integrated assessment of 6 components:

- Symptoms

- Exercise Performance

- Heart Rate

- BP reaction

- ECG reaction

- Cause of termination
Symptoms

• Perceived exertion

• Chest pain

• Dyspnea

• Leg fatigue

Exercise Performance

• Best Predictor for risk for future adverse events in healthy individuals

• Estimated using HR, Rate Pressure Product, Duration of the test, RPE

HR response

• Inability to reach 85% of age expected max HR

BP response

• SBP must exceed 140mmHg during the test

• SBP >200mmHg is abnormal

• Fall in BP indicate CAD or Cardiomyopathy

• Test should be stopped if BP drops 10mmHg or more

ECG reaction

• ST segment depression during EST: MI

• PR interval and QRS duration is shortened during exercise

• R wave amplitude may reduce during exercise

• T wave amplitude may increase or decrease

• Arrythmias

- Supraventricular and ventricular arrhythmias may occur during exercise

- More common in persons taking digoxin

- Ventricular Tachycardia

Exercise Termination Criteria

Absolute

• > 10mmHg drop in SBP

• SBP > 280mmHg

• Pronounced angina pectoris

• Dizziness, pre-syncope
• Cyanosis, Paleness

• Patients desire to terminate

• Ventricular tachycardia with duration >30sec

• ST segment elevation 1mm or higher in leads without significant Q waves

Relative

• > 10mmHg drop in SBP

• > 115 mmHg DBP

• Marked change in electrical axis

• AV block II, III

• Multifocal premature ventricular beats

• Exhaution

• Leg cramps

• Bradycardia

Recovery Period

• Occasionally ST segment depressions are only seen during recovery period

• Duration : 6-8mins

• Test is completed when all parameters have returned to their baseline values.