Treadmill Stress Testing

for the Primary Care Physician

Anthony Beutler, MD
Primary Care Sports Medicine

The Electrocardiogram

What is
VO2max?

The Electrocardiographic Response

Objectives
Review essential Exercise Test Terminology
Describe the Performance of the Exercise Stress Test
Review Exercise Test Responses
Discuss Interpretation of the Exercise Stress Test
Discuss Special Considerations in Athletes

Exercise Test Terminology

The Electrocardiogram
VO2max
METs
Myocardial Oxygen
Consumption

Maximal Oxygen Uptake

(VO2max)
Greatest amount of oxygen an individual utilizes with
maximal exercise (ml O2 per kilogram per minute)
Gold Standard for cardiorespiratory fitness
Fick Equation

VO2max = (HRmax x SVmax) x (CaO2max - CvO2max)

FICK EQUATION
(220 - Age)

PaO2

Sinus Node Dysfunction

Hgb [ ]

Drugs (e.g., B - blockers)

SaO2

Diffusion
Ventilation
Perfusion

VO2max = (HRmax X SVmax) X (CaO2max - CvO2max)

Genetic Factors (Heart Size)
Conditioning Factors
Contractility/Afterload/Preload
Disease Factors
Wall Motion/Ventricular Fxn Valve
Stenosis or Regurgitation

Skeletal Muscles
Aerobic Enzymes
Fiber Type
Muscle Disease
Capillary Density

METS
The MET

Metabolic Equivalents (METs)

1 MET = 3.5 ml O2 per kilogram of body

weight per minute

Key MET Values (part 1)

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;
limit immediate post MI;
cost of basic activities of daily living

Key MET Values (part 2)

10 METs = As good a prognosis with medical

therapy as CABS
13 METs = Excellent prognosis, regardless of other
exercise responses

16 METs = Aerobic master athlete

20 METs = Ooh lah lah Aerobic athlete

Myocardial (MO2)

Accurate measurement requires cardiac

catheterization

Coronary Flow x Coronary a - VO2 difference

Wall Tension (Pressure x Volume, Contractility,

Stroke Work, HR)
Systolic Blood Pressure x HR

Angina and ST Depression usually occurs at same

Double Product in an individual

** Direct relationship to VO2 is altered by beta-blockers, training,...

Myocardial Oxygen Consumption

Indirectly measured as the Double Product

Double Product = HR x systolic blood pressure
A normal value is greater than 20,000 25,000

Performance of the Exercise

Stress Test

Indications/Contraindications
Running the Exercise Test
Physician Responsibilities

ACSMs Guidelines
for Exercise Testing and Prescription
ACSM. Lippincott, Williams & Wilkins
6th Edition 2000

Indications for Exercise Testing

Class I: Conditions for which there is evidence and/or general

agreement that a given procedure or treatment is useful and effective.
Class II: Conditions for which there is conflicting evidence and/or a
divergence of opinion about the usefulness/efficacy of a procedure or
treatment.

II a: weight of evidence is in favor of usefulness/efficacy.

II b: usefulness is less well established by the evidence.

Class III: Conditions for which there is evidence and/or general

agreement that the procedure/treatment is not useful/effective and in
some cases may be harmful.

Class I Indications for Performing an

Exercise Test

To assist in the diagnosis of CAD in adult patients with an

intermediate pretest probability of disease.
To assess functional capacity and to aid in assessing the
prognosis of patients with known CAD.
To evaluate the prognosis and functional capacity of patients
with CAD soon after an uncomplicated myocardial
infarction.
To evaluate patients with symptoms consistent with
recurrent, exercise-induced cardiac arrhythmias.

Class II Indications for Performing

an Exercise Test

To evaluate asymptomatic men >40 and women >50

who:

are involved in special, high risk occupations;

plan to start a vigorous exercise program;
have multiple cardiac risk factors.

To assist in the diagnosis of CAD in adult patients with a

high or low pretest probability of disease.
To evaluate patients with a Class I indication who have
baseline electrocardiographic changes.

Class III Indications for Performing

an Exercise Test

Routine screening of asymptomatic men or women.

To evaluate men or women with a history of chest
discomfort not thought to be of cardiac origin.
To evaluate patients with simple PVCs on a resting
ECG with no other evidence of CAD.
To assist in the diagnosis of CAD in patients with
evidence of LBBB or WPW on a resting ECG.

Pre Test Probability of Coronary Disease by

Symptoms, Gender and Age
Age

Gender

Typical/Definite
Angina Pectoris

Atypical/Probable
Angina Pectoris

NonAnginal
Chest Pain

Asymptomatic

30-39
30-39

Males

Intermediate

Intermediate

low (<10%)

Very low (<5%)

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%
Very Low = <5%

Low = <10%

Contraindications to GXT Testing:

Absolute

Recent acute MI
Unstable angina
Ventricular tachycardia
Dissecting aortic
aneurysm
Acute CHF

Severe aortic stenosis

Active myocarditis
Thrombophlebitis or
intracardiac thrombi
Recent pulmonary embolus
Acute infection

Contraindications to GXT Testing:

Relative

Uncontrolled severe
hypertension
Moderate aortic stenosis
Severe subaortic stenosis
Supraventricular dysrhythmias
Ventricular aneurysm

Complex ventricular ectopy

Cardiomyopathy
Uncontrolled metabolic disease
Recurrent infectious disease
Complicated pregnancy

So What Do You Do.

39 yo female with risk factors and a

squirrelly story.

Comparison of Tests for Diagnosis

of CAD

Which Protocol?

Vast Majority (82+%) use BRUCE

So, why not you?

How to read an Exercise ECG

Good

skin prep
PR isoelectric line
Not one beat
Three consistent complexes
Averages can help
Garbage in, garbage out
Why watch during recovery?

Symptom-Sign Limited Testing Endpoints

When to stop!

Dyspnea, fatigue, chest pain

Systolic blood pressure drop

ECG--ST changes, arrhythmias

Physician Assessment

Borg Scale (17 or greater)

Problems with Age-Predicted Maximal Heart

Rate

Which Regression Formula? (2YY - .Y x Age)

Big scatter around the regression line
poor

correlation [-0.4 to -0.6]

One SD is plus/minus 12 bpm

A percent value target will be maximal for some and

sub-max for others

Confounded by Beta Blockers

Borg scale is better for evaluating Effort

Target Heart Rate does have a place as an Indicator

of Effort or adequacy of test

Heart Rate Recovery and Treadmill

Exercise Score as Predictors of Mortality
in Patients Referred for Exercise ECG
Nishime EO, et al: JAMA, September 20, 2000.
Vo 284, No 11, 2000.

Following the GXT, patients walked for 2 minutes at 1.5 mph

and at a grade of 2.5%.
Heart rate recovery was the difference in heart rate at peak
exercise and one minute into recovery; 12/min or less was
considered abnormal.
9454 patients were followed for a median of 5 years; 20 % had
abnormal heart rate recovery; they represented 8% of deaths
vs. 2%; hazard ratio of 4.16.
Heart rate recovery is an independent predictor of mortality.

Should Heart Rate Drop in

Recovery be added to ET?
Long known as a indicator of fitness: perhaps
better for assessing physical activity than
METs
Recently found to be a predictor of prognosis
after clinical treadmill testing
Does not predict angiographic CAD
Studies to date have used all-cause mortality
and failed to censor

Heart Rate Drop in Recovery

Probably not more predictive than Duke
Treadmill Score or METs
Studies including censoring and CV
mortality needed

Heart Rate Drop in Recovery vs

METs
10 to 15% increase in survival per MET
METS can be increased by 25% by a
training program
What about Heart Rate Recovery???

METS
The MET

Interpretation of the Exercise Stress Test

Must Contain Following Elements:
Exercise Capacity
Clinical
Hemodynamic
Electrocardiographic

Positive vs Suggestive

ST Depression

or 1mm at
60msec
1.5mm at
80msec

ST Elevation

1mm at 60msec

ST Depression

or 0.5 - 1mm
at 60msec
0.7 - 1.5mm at
80msec

ST Elevation

0.5 1mm at
60msec

Negative vs Inconclusive

Above criteria not

met and pt
exercised to at least
85% MPHR

Pt did not reach

85% MPHR, but
no evidence of
ischemia (BBlocker??)

DUKE Treadmill Score for

Stable CAD
METs - 5 X [mm E-I ST Depression] 4 X [Treadmill Angina Index]
******Nomogram*******
E-I = Exercise Induced

Duke Treadmill Score (uneven lines, elderly?)

But Can Physicians do as well as the

Scores?

954 patients - clinical/TMT reports

Sent

to 44 expert cardiologists, 40
cardiologists and 30 internists

Scores

did better than all three but was

most similar to the experts

Special Considerations in
Athletes

Indications
Athletic Heart
Syndrome
Test Interpretation

Initial ACSM Risk Stratification

Low Risk
Younger individuals (men<45,
women<55) who are asymptomatic
and meet no more than one risk
factor threshold (Table 1-A).
Moderate Risk
Older individuals or those who
meet two or more risk factors.
High Risk
Individuals with signs/symptoms of
disease (Table 1-B) or known
cardiovascular, pulmonary or
metabolic disease.

Does the patient need a GXT?

Controversial
ACSM- Must be able to distinguish:

Moderate vs. vigorous exercise

Apparently healthy vs. higher risk
Older vs. younger

ACSM Recommendations for Medical Examination and

Exercise Testing Prior to Participation

Moderate
Exercise
Vigorous
Exercise

Low Risk

Mod Risk

High Risk

Not
Necessary

Not
Necessary

Recommend

Not
Necessary

Recommend

Recommend

ACSM Initial Risk Stratification by Age

and Cardiac Risk

Low Risk
Men < 45, Women <55
No cardiac symptoms
1 risk factor

Moderate Risk
Older individuals
2 risk factors

Cardiac
CardiacRisk
RiskFactors
Factors
-

- Cigarette
Cigarettesmoking
smoking

- - Fam

FamHx.
Hx.of
ofearly
earlyCAD
CAD
- - LDL >130)
LDL >130)
- - Hypertension
Hypertension
- - Impaired fasting gluc
Impaired fasting gluc
(>110mg/dL)
(>110mg/dL)
- - Obesity (BMI >30)
Obesity (BMI >30)
- - Sedentary lifestyle
Sedentary lifestyle

PositiveRisk
RiskFactor:
Factor: High serum HDL (>60)
Positive

ACSM Initial Risk Stratification by Age

and Cardiac Risk

Low Risk
Men < 45, Women <55
No cardiac symptoms
1 risk factor

Moderate Risk
Older individuals
2 risk factors

High Risk
Signs or Symptoms of cardiac dz
Known cardiac, pulmonary or
metabolic (DM) disease.

Signs/Sx. CV Disease
- Chest

pain or anginal equiv

- Dyspnea w/ mild exertion
- Dizziness or syncope
- Orthopnea/PND
- Ankle edema
- Palpitations or tachycardia
- Intermittent claudication
- Fatigue w/ normal activities

Who Needs a GXT?

Low Risk
Moderate
Exercise
Vigorous
Exercise

Not
Necessary
Athlete
with

Mod Risk

Not
Necessary
Recommend

High Risk

Not
Necessary
Recommend
Recommend

known CAD
Anyone with symptoms of CAD
Moderate risk patient for vigorous exercise
Anyone with known medical disease

Questions???