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St ress Testing
1. St ress t est ing 1
2. WHAT IS STRESS TESTING 2  Test s used in Medicine t o measure t he heart’s ability t o respond to external st ress in a controlled clinical environment .
3. TYPES OF STRESS TESTING 3  EXERCISE a. Treadmill b. Bicycle  P HARMACOLOGIC a. Adenosine b. Dipyridam ole c. Dobut am ine d. Isoproterenol  OTHER a. Pacing
4. INDICATIONS OF EXERCISE TESTING 4 • Elicit abnorm alit ies not present at rest • Est im at e funct ional capacit y • Estim ate prognosis of CAD • Likelihood of coronary art ery disease • Extent of coronary art ery disease • Effect of t reat ment
5. INDICATIONS O F P HARM ACOLOGICAL STRESS TESTING 5  Pat ients inabilit y t o exercise adequat ely because of physical or psychological limit at ions.  The chosen t est cannot be performed readily wit h exercise (e.g. PET scanning).
6. METHODS OF DETECTING ISCHEMIA DURING STRESS TESTING 6  Elect rocardiography  Echocardiography  Myocardial perfusion im aging  Posit ron emission t omography  Magnetic resonance im aging
7. 7 ACC/AHA GUIDELINES (Am erican C ollege of Cardiology/ American Heart A ssociation)
8. Indicat ions for exercise t est ing t o diagnose obst ruct ive coronary art ery disease 8  Adult patients with right bundle branch block or less than 1mm of resting ST depression wit h an interm ediate pretest probabilt y CAD on t he basis of gender , age and symptom s.
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10. Indicat ions in pat ients w it h prior hist ory of coronary heart disease 10  Patient s undergoing init ial evaluat ion with suspected or known CAD, including t hose with complet e right bundle branch block or less t han 1m m of rest ing ST depression.  Pat ient s with suspect ed or known CAD , previously evaluated , now presenting wit h significant change in clinical stat us .  Low risk (on pretest probabilit y), unst able angina pat ients 8 – 12 hours after presentat ion who have been free of act ive ischem ia or heart failure sym pt oms.  Int ermediat e risk (on pre t est probability),unst able angina pat ient s 2 to 3 days after present ation w ho have been free of act ive ischem ic or heart failure sym pt oms.
11. Indications in pat ient s wit h Valvular heart disease 11 1. In Chronic Aort ic Regurgit ation for assessment of funct ional capacity and sympt omatic responses in patients with a hist ory of equivocal sym ptoms. 2. Aortic st enosis – role of exercise t est ing in asympt om atic AS pat ient s , w it h recomm endations t hat aortic valve replacement be considered in those wit h exercise induced symptom s or abnorm al blood pressure response.
12. Indications in pat ient s wit h Valvular heart disease 12  Mit ral stenosis – class 1 reommendation for stress echocardiography in patient s wit h MS and discordance bet ween sympt oms and st enosis severity.  Threshold values proposed for considerat ion of int ervent ion: a. Mean t ransmitral pressure gradient >15 mm Hg during exercise. B. A peak pulmonary artery syst olic pressure > 60 mm Hg during exercise.
13. Indicat ions in patient s with Valvular heart disease 13  Mitral regurgit at ion – In asym ptomat ic pat ients with severe M R, exercise stress echo helps identify: a. Patient s with subclinical lat ent LV dysfunct ion b. Worsening of MR severit y c. M arked increase in pulm onary art erial pressure d. Im paired exercise capacity
14. Indicat ions in patient s with Valvular heart disease 14  P rost het ic heart valves – Stress echocardiography used in confirm ing or excluding the presence of hemodynam ically significant prosthetic valve st enosis or Pat ient prost hesis mismat ch (PPM).
15. RHYTHM DISODERS 15  Evaluation of congenit al complet e heart block in pat ient s considering increased physical act ivity or participat ion in com pet it ive sport s .
16. CONTRAINDICATIONS FOR STRESS TESTING 16  Acute myocardial infarct ion ( within 2 days )  High risk(on pret est probability) unst able angina  Uncont rolled cardiac arrt hymias causing sympt oms or hem odynamic com promise  Sym ptomat ic severe aort ic st enosis  Acut e pulmonary em bolus or pulm onary infarction  Acut e m yocarditis or pericardit is  Acut e aort ic dissect ion
17. EXERCISE P HYSIOLOGY 17 • Patient position – supine or upright. • At rest CO and SV more in supine posit ion than in upright posit ion. • C hange from supine t o upright position causes , CO as a result of in SV and HR. • The net effect on exercise performance is an approx . 10 % increase exercise t ime cardiac index , heart rat e, and rat e pressure product at peak exercise in t he upright as com pared with the supine posit ion.
18. 18  The main types of exercise are isotonic or dynam ic exercise, isom etric or stat ic exercise, and resist ive (com bined isom et ric and isot onic) exercise.  Isometric a. Holding a st atic pushup position; b. Holding a dumbbell in one hand; c. Pushing against an imm ovable object , such as a wall.
19. 19  Isot onic a. W eight lifting b. Swimming c. Rock climbing d. Cycling
20. CARDIOP ULM ONARY EXERCISE TESTING 20 • Involves m easurements of respiratory oxygen uptake (VO2),carbon diox ide production (VCO2), and ventilat ory param eters during a sympt om -limited exercise t est . • VO2 m ax is t he product of max im al arterial-venous oxygen difference and cardiac output and represent s t he largest amount of oxygen a person can use while perform ing dynam ic exercise involving a large part of t ot al muscle m ass. • The VO2 m ax decreases w it h age, is usually less in women t han in m en, and dim inished by degree of cardio-vascular im pairm ent and by physical inact ivity. • Peak exercise capacit y is decreased when the ratio of m easured t o predict ed VO2 max is less than 85 t o 90 percent .
21. METABOLIC EQUIVALENT 21 • Metabolic equivalent (MET) refers t o a unit of ox ygen uptake in a sit ting, rest ing person. • 1 MET is equivalent t o 3.5 VO2 m l 02/kg/min of body weight . M easured VO2 in ml 02/kg/m in divided by 3.5 ml 02/kg/min det erm ines the number of METs associat ed wit h activit y. • Work act ivit ies can be calculated in multiples of METs; t his measurement is useful t o determine exercise prescript ions, assess disability, and st andardize the reporting of submax imal and peak exercise w orkloads when different prot ocols are used.
22. METHODS 22  General concerns prior to performing an exercise t est include – • Safet y precautions and equipments needs. • Pat ient preparat ion • Choosing a t est t ype • Choosing a t est protocol • Patient m onit oring • Reasons t o t erm inat e a t est • Post test m onit oring
23. SAFETY P RECAUTIONS AN D EQUIP MENT 23 The t readmill should have front and side rails for subjects t o steady t hem selves. It should be calibrat ed monthly. An emergency st op butt on should be readily available to the staff only.  Exercise t est should be performed under the supervision of a physician who has been trained to conduct exercise t est s.
24. TMT ROOM 24
25. TREADMILL 25
26. Emergency st op butt on 26
27. P RETEST P R EPARATION 27 Any history of light headed or faint ed while exercising sholud be asked. The physician should also ask about fam ily hist ory and general medical hist ory, making note of any considerat ions t hat may increase the risk of sudden death. A brief physical examinat ion should always be performed prior to test ing to rule out significant outflow obstruction
28. P reparation for exercise test ing include the following- 28 1. The subject should be inst ruct ed not t o eat or smoke at least 2 hours prior t o the t est . 2. Unusual physical exert ion should be avoided before testing. 3. Specific quest ioning should determine w hich drugs are being t aken. The labeled medications should be brought along so that medications can be ident ified and recorded. 4. Because of a great er potential for cardiac event s wit h t he sudden cessat ion of –blockers , t hey should not be automat ically st opped prior t o testing but done so gradually under physician guidance, only after consideration of t he purpose of t he test.
29. EXERCISE PROTOCOLS 29  Dynamic prot ocols m ost frequent ly are used t o assess cardiovascular reserve, and t hose suit able for clinical t est ing should include a low int ensity warm-up phase.  In general, 6 t o 12 minutes of continuous progressive exercise during w hich the m yocardial ox ygen demand is elevat ed to the patient’s m aximal level is opt im al for diagnostic and prognost ic purposes. The protocol should include a suit able recovery or cool-dow n period.
30. VARIOU S P ROTO COLS 30  Treadm ill protocols a. Bruce b. Cornell c. Balke ware d. Acip e. mAcip f. Naught on g. Weber  Bicycle ergom et er
31. TREADMILL P ROTOCOL 31  In healt hy individuals, t he st andard Bruce prot ocol is normally used.  The Bruce multist age max imal t readmill prot ocol has 3-m inute periods to allow achievement of a st eady st at e before work-load is increased for next st age. In older individuals or those whose exercise capacity is limit ed by cardiac disease, t he protocol can be m odified by t wo 3-minut e warm –up stages at 1.7 mph and 0 percent grade and 1.7 mph and 5 percent grade.
32. BRUCE PROTOCOL 32
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34. The 6-M inute W alk Test 34  Used for pat ients w ho have marked left ventricular dysfunct ion or peripheral arterial occlusive disease and who cannot perform bicycle or treadmill exercise. Patient s are inst ruct ed to walk down a 100-foot corridor at t heir own pace, att empt ing t o cover as much ground as possible in 6 m inut es.At t he end of t he 6-minut e int erval, t he tot al dist ance walked is det erm ined and the sympt om s experienced by t he pat ient are recorded.
35. MEASUREMENTS 35  ECG  Exercise capacity (METS – met abolic equivalent)  Sympt oms  B lood pressure  Heart rat e response & recovery
36. 36  Posit ive t est a. A flat or downsloping depression of the ST segment > 0.1 m V below baseline (i.e t he P R segment ) and last ing longer than 0.08s b. Upsloping or junct ional ST segm ent changes are not considered charact erist ic of ischem ia and do not constitut e a positive test.  Negat ive test a. Target heart rate (85% of max im al predicted heart for age and sex ) is not achieved .
37. 37  The norm al and rapid upsloping ST segment responses are norm al responses t o exercise.  M inor ST depression can occur occasionally at subm ax imal workloads in pat ients with coronary disease.  The slow upsloping ST segment patt ern often demonst rat es an ischem ic response in pat ient s wit h know n coronary disease or t hose with a high pret est clinical risk of coronary disease. Downsloping ST segment depression represent s a severe ischemic response.  ST segm ent elevation in an infarct t errit ory (Q wave lead) indicates a severe w all m otion abnormalit y and, in most cases, is
38. 38  Bruce prot ocol. Lead V4, the exercise electrocardiographic (ECG) result is abnormal early in the test , reaching 0.3m V (3mm ) of horizontal ST segm ent depression at t he end of exercise.  The ischem ic changes persist for at least 1 minut e and 30 seconds int o t he recovery phase.  The right panel provides a continuous plot of the J point , ST slope, and ST segment displacement at 80m sec after t he J point (ST level) during exercise and in the recovery phase. Exercise ends at t he vertical line at 4.5 m inutes (red arrow). The comput er t rends permit a more precise identificat ion of init ial onset and offset of ischemic ST segm ent depression.  This t ype of ECG pat tern, with early onset of ischem ic ST segm ent depression, reaching m ore t han 3mm of horizont al ST segment displacement and persisting several minut es into the recovery phase, is consist ent wit h a
39. 39  A 48-year-old m an w it h several at herosclerotic risk fact ors and a normal resting electrocardiographic (ECG) result , developed marked ST segment elevat ion (4 mm [arrows]) in leads V2 and V3 w it h lesser degrees of ST segm ent elevat ion in leads V1 and V4 and J point depression w ith upsloping ST segm ents in lead II, associat ed with angina.  This t ype of ECG patt ern is usually associated with a full-t hickness, reversible m yocardial perfusion defect in the corresponding left vent ricular m yocardial segm ents and high-grade intraluminal narrowing at coronary angiography.
40. 40  False posit ive : a. In asym pt omatic m en < 40 years. B. In pat ients t aking cardioactive drugs c. In patient s wit h int raventricular conduction dist urbances,ventricul ar hypert rophy , abnormal pot assium levels.  False negative : a. In pat ient s wit h obst ruct ive diseases limit ed t o circum flex coronary art ery(lat eral port ion is not w ell represent ed on t he surface 12 lead ECG.)
41. 41  Bruce protocol. The exercise elect rocardiographic (ECG) result is not yet abnorm al at 8:50 minutes but becomes abnormal at 9:30 m inut es (horizont al arrows, right) of a 12-minut e exercise t est and resolves in t he im mediate recovery phase.  This ECG pat tern in which t he ST segment becomes abnormal only at high exercise workloads and ret urns t o baseline in t he im mediat e recovery phase m ay indicate a false-posit ive result in an asym ptomat ic individual w ithout atherosclerot ic risk fact ors.  Vert ical arrow indicat es term inat ion of exercise.
42. T WAVE CHANGES 42 Influenced by:  Body position  Respirat ion  Hyperventilat ion  Drug Rx  M yocardial ischaem ia  Necrosis Pseudonorm alisat ion of T wave:  Usually non-diagnostic and consider ancillary imaging in such cases.
43. 43  Pseudonormalization of T waves in a 49-year-old m an referred for exercise testing.  The rest ing elect rocardiogram in this pat ient with coronary artery disease show s inferior and ant erolat eral T wave inversion, an adverse long-term prognosticat or.  The patient exercised to 8 METs, reaching a peak heart rat e of 142 beat s/min and a peak systolic blood pressure of 248 m m H g. At that point, t he t est was stopped because of hypertension. During exercise, pseudonorm alizat ion of T waves occurs, and it returns t o baseline (inverted T wave) in the post exercise phase. Transient conversion of a negat ive T wave at rest t o a positive T wave during exercise is a nonspecific finding in patients without prior m yocardial infarct ion and does not enhance
44. MAXIMAL W ORK CAPACITY 44 In patients with known or suspect ed CAD, a limited exercise capacit y is associat ed with an increased risk of cardiac event s and in general the m ore severe t he lim it ation, t he worse t he CAD ext ent and prognosis. In est im at ing funct ional capacity the amount of w ork perform ed (or exercise st age achieved) ex pressed in METs and not t he num ber of minut es of exercise, should be t he paramet er m easured. Major reduction in exercise capacity indicat es significant worsening of cardiovascular status.
45. BLOOD P RESSURE RESP ONSE 45  The norm al exercise response is to increase systolic blood pressure progressively with increasing workloads t o a peak response ranging from 160 to 200mm Hg wit h t he higher range of t he scale in older pat ient s wit h less com pliant vascular syst em s. Failure t o increase syst olic blood pressure beyond 120m mHg or a sust ained decrease great er than 10mm Hg repeatable w it hin 15 seconds or a fall in syst olic blood pressure below standing rest ing values during progressive exercise when t he blood pressure has ot herwise been increasing appropriately, is abnormal .
46. HEART RATE RESP ONSE 46  Peak HR > 85% of max imal predict ed for age  HR recovery >12 bpm (erect)  HR recovery >18 bpm (supine)
47. 47 Chronot ropic incom pet ence is det erm ined by decreased heart rat e sensitivity to t he norm al increase in sym pat het ic tone during exercise and is defined as inability t o increase heart rat e t o atleast 85 percent of age predict ed max im um . Heart rat e reserve is calculat ed as follows – % HRR used = (Hrpeak- Hrres) / (220-age-Hrres) Abnormal heart rat e recovery refers t o a relatively slow decelerat ion of heart rate following exercise cessat ion. This type of response reflects decreased vagal tone and is associat ed w it h increased mortality.
48. HEART RATE RESP ONSE 48
49. TERMINATION EXERCISE TESTING 49
50. P ROGNOSTIC VALUE OF STRESS TESTING 50 Parameters associated with adverse prognosis or mult i- vessel disease :  Durat ion of sympt om-limit ing exercise <5 METs  Failure t o increase sBP ≥120mm Hg, or a sust ained decreased ≥ 10mm Hg, or below rest levels, during progressive exercise  ST segm ent depression ≥2m m, dow nsloping ST segment, st arting at <5 M ETs, involving ≥5 leads, persisting ≥5 min int o recovery  Exercise-induced ST segment elevation (aVR excluded)  Angina pect oris at low exercise workloads  Reproducible sust ained (>30 sec) or symptom at ic vent ricular t achycardia
51. LIM ITATIONS OF TREADMILL STRESS TEST 51  N on-diagnostic ECG change  W om en – false posit ives  Elderly – m ore sensit ive/less specific  Diabet ics – autonomic dysfunct ion  Hypert ension  Inability t o exercise  Drugs – digoxin; ant i-anginals
52. NON-CORONARY CAUSES OF ST SEGMENT DEP RESSION 52  Anaemia  Cardiomyopat hy  Digox in  Glucose load  Hyperventilation  Hypokalaemia  Intravent ricular conduct ion disturbance  M it ral valve prolapse  P re-excitat ion syndrom e  Severe aortic stenosis  Severe hypertension  Severe hypoxia  Severe volum e overload (aortic or m it ral rgurgit ation)  Sudden excessive exercise  Supravent ricular tachycardias
53. LIM ITATIONS OF TREADMILL STRESS TEST 53  Sensitivit y 68%  Specificit y 77%
54. ANCILLARY TECHNIQUES TO ENHANCE CONTENT 54  Echocardiography  Radionuclide imaging
55. STRESS ECHO CARDIO GRAP HY 55
56. STRESS ECHOCARDIO GRAP HY 56 Com pares pre & post: Regional contract ilit y  Overall syst olic function  Volumes  P ressure gradients  Filling pressures  P ulm onary pressures  Valvular function
57. DOBUTAMINE STRESS ECHO 57
58. 58  Dipyridamole or Adenosine can be given t o creat e a coronary “st eal” by t em porarily increasing flow in nondiseased segment s of t he coronary vasculat ure at t he ex pense of diseased segm ent s.  Alternat ively, a graded increment al infusion of dobutam ine may be administered to increase M VO2
59. STRESS ECHO – LIMITATIONS 59 Fact ors which effect im age quality: Body habit us  Lung disease  B reast implants
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62. NORM AL STRESS ECHOCARDIOGRAM 62
63. NUCLEAR SP ECT IM AGING 63  Radio-tracer inject ion  Isot opes: A) Thallium-201 B) Technet ium 99m (sest amibi)  Myocardial upt ake  P hoton em ission capt ured by gamm a cam era  Rest & redistribution phases  Pharmacologic protocols available  Digit al presentat ion
64. NUCLEAR SP ECT IMAGING 64
65. THALLIUM- 201 SCAN 65  Myocardial perfusion problem s are separated from non viable myocardium by t he fact that thallium event ually w ashes out of the m yocardial cells and back int o the circulat ion .  If a defect det ect ed on init ial thallium im aging disappears over a period of 3-24 hours , t he area is presumably viable .  A persist ent defect suggest s a m yocardial scar.
66. TECHNETIUM – 99M(sest amibi) 66  The t echnet ium – 99m (sest amibi) based agent s t ake advantage of the short er half – life ( 6 hours; thallium 201’s is 73 hours)  This allows for use of a larger dose , w hich results in higher energy em issions and higher qualit y im ages.  Technetium 99m’s higher energy emissions scat ter less and are at tenuat ed less by chest wall struct ures, reducing the number of art ifact s.
67. P OSITRON EM ISSION TOMOGRAP HY 67  Is a t echnique using t racers t hat sim ult aneously emit two high energy phot ons .  A circular array of det ectors around the pat ient can detect t hese simultaneous event s and accurat ely ident ify their origin in t he heart.  This results in im proved spatial resolut ion , compared with SPECT .  PET can be used to assess myocardial perfusion and m yocardial met abolic activit y separat ely by using different t racers coupled to different molecules.
68. 68  Agents used-  Ox ygen 15(half t ime 2mins)  Nitrogen -13(half life 10 mins)  Carbon -11(half time 20 m ins)  Flourene -18(half 110 m ins)  B ecause R ubidium – 82 w it h a half life of 75 seconds , does not reqiure a cyclot ron and can be generated on sit e , it is frequent ly used with PET scanning , especially for perfusion im ages.
69. NUCLEAR SP ECT IMAGING 69
70. NUCLEAR SP ECT IMAGING 70
71. 71 Reversible inferior wall defect Milder reversible inferior wall defect
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75. LIMITATIONS OF NUCLEAR SP ECT IM AGING 75  Time-consuming  Artifacts  Radiation
76. LIMITATIONS OF NUCLEAR SP ECT IMAGIN G 76 Breast att enuat ion
77. LIMITATIONS OF NUCLEAR SP ECT IM AGING 77
78. LIM ITATIONS OF NUCLEAR SP ECT IMAGING 78  Risk of iat rogenic m alignancy  Consider:  age  gender  background
79. LIM ITATIONS OF NUCLEAR SP ECT IMAGIN G 79 Einstein, A. J. et al. Circulation 2007;116:1290-1305
80. MRI CAR DIAC STRESS TEST 80  Useful for:  Patient s unable t o exercise  ECG unint erpretable  Unsuit able for DSE  And… .  No radiation  But…  Not current ly available
81. MRI CARDIAC STRESS TEST 81
82. CARDIAC STRESS TESTING 82  So….which one t o choose?
83. CARDIAC STRESS TESTING TEST 83
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86. 86 THANK YOU