Treadmill Stress Testing

Indications: Diagnose Obstructive CAD

• Class I
– Adult patients (including those with RBBB and 1mm
resting ST depression) with an intermediate pre-
test probability of disease.
• Class IIa
– Patients with vasospastic angina.
• Class IIb
– Patients with a high or low pre-test probability of
disease.
– Patients with less than 1mm ST depression and
taking digoxin.
– Patients with LVH by voltage and less than 1mm of
baseline ST depression.
• Class III
– WPW; paced rhythm; >1mm ST depression; LBBB.
 ACSM Recommendations for Exercise
Testing Prior to Exercise Participation
• CAD Risk Factors • CAD Signs/Symptoms
– male relative before 55; – Pain in the chest, neck,
female before 65. jaw, arms that may be
– Smoker or quit within 6 due to ischemia
months. – SOB at rest or exertion
– Hypertension – Dizziness or syncope
– Hypercholesterolemia: – Orthopnea/PND
TCHOL > 200; HDL <35; – Ankle edema
LDL > 130. – Claudication
– Impaired fasting glucose: – Known heart murmur
>110.
– Unusual fatigue or SOB
– Obesity: BMI >30. with usual activities
– Sedentary
– HDL >60 is a negative risk
factor.
 Contraindications
• Absolute
– Acute myocardial
infarction (within 2d)
– High risk unstable
angina
– Uncontrolled
arrhythmias causing
symptoms or
hemodynamic
compromise
– Symptomatic severe
aortic stenosis
– Acute PE,
myocarditis or
pericarditis
– Acute aortic
dissection
 Contraindications
• Relative
– Left main coronary
stenosis
– Moderate stenotic valvular
heart disease
– Electrolyte Abnormalities
– Severe arterial
hypertension (200/110)
– Tachy/Bradyarrhythmias
– Hypertrophic
cardiomyopathy
– Mental or physical
impairment leading to
inability to exercise
adequately
– High degree AV block
Physician Responsibilities During the Test
• Patient Evaluation and
Clearance
– Careful history of symptoms and
past medical history; typical vs.
atypical.
– Risk factors
– Family history
– Informed Consent
• Physical Examination
– Vital signs
– Cardiovascular: murmurs, gallops
– Lungs
• Selection of Protocol
– Maximal vs. Sub-Maximal
– Treadmill vs. Cycle
 Performing the Test
• Preparing the
Patient
• Monitoring the
Patient
• Terminating the
Test
• Recovery of the
Patient
 Preparing the Patient
• Instructions:
– No eating two hours before
test; no consumption of
alcohol, caffeine, or tobacco
three hrs before.
– Comfortable clothing.
– Medications determined by
functional vs. diagnostic
testing.
• Skin Preparation
– Hair shaved; abrasive rub;
“tap” test.
• Appropriate Blood
Pressure cuff.
• Consent.
 Preparing the Patient
• Pre-Test Checklist
– Equipment and safety
check
– Informed Consent
– Pre-test history and
physical examination
– Electrode skin preparation
– Resting ECG reviewed
– Standing ECG and BP
– Patient Demonstration
– Patient Questions
 Terminating the Test

• All treadmill stress tests

should be completed to a
symptom-limited
endpoint, if possible.
• 85% of maximal
predicted heart rate is
required to identify a
test as adequate.
Indications for Test Termination
• Absolute
– Drop in SBP of >10 mmHg
from baseline, despite
increased workload, when
accompanied by other
ischemia
– Moderate to severe
angina
– Increasing ataxia,
dizziness, or pre-syncope
– Signs of poor perfusion
– Technical difficulties
– Subjects desire
– Sustained Vtach
– ST elevation in leads
without diagnostic Q
waves
Indications for Test Termination
• Relative
– Drop in SBP of >10 mmHg
from baseline, despite
increased workload
– ST depression >2mm from
baseline
– Multifocal PVCs, triplets,
SVT, heart block
– Fatigue, shortness of
breath, wheezing, leg
cramps
– Bundle branch block
– Increasing chest pain
– Hypertensive response
 Common Normal Responses to
Exercise Testing
• Symptoms
– Typical anginal symptoms
can be produced by testing
and increase the prognostic
value of a test.
– Symptoms, however, do not
define a positive test, and
define a test “suggestive of
ischemia.”
– Opportunity for “anginal
threshold” determination
and use of Borg Scale for
exercise prescription.
Electrocardiographic Responses to Exercise
• P wave:
– Superimposition of P and T; p
wave may increase in inferior
leads.
• PR segment:
– Shortens and downslopes in
the inferior leads.
• QRS complex:
– Increases in septal q waves;
slight decreases in R wave
amplitude; minimal shortening
of interval.
• J junction:
– Decreases with exercise; in
subjects with resting J
junction elevation, this
normalizes to baseline.
• ST segment:
– Demonstrates positive upslope
that returns to baseline by
80ms.
• T wave:
– initially a gradual decrease in
amplitude.
• QT interval:
– Rate-related shortening.
 Heart Rate
• Normal Heart Rate Response
– Increase in HR as a result of vagal tone withdrawal.
– Standard deviation for peak HR determination is 15 BPM.
• Chronotropic Incompetence
– Peak heart rate less than 120 BPM.
– Failure to achieve 85% of age-predicted maximum.
• Heart Rate Recovery
 Heart Rate Recovery
• 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.

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.
 Blood Pressure
• Normal:
– Systolic increases during exercise; returns to baseline by
five to six minutes in recovery.
• Hypotensive Response to Exercise:
– A drop in BP to baseline levels during exercise; poor
prognosis.
• Hypertensive Response to Exercise:
– Systolic greater than 220mmHg, or rise in diastolic of >
10mmHg, or Stage II age predicted 95% DBP.
• Singh et al: BP response during treadmill testing as a risk
factor for new-onset hypertension. Circulation.
1999;99:1831-1836.
• Blood Pressure in Recovery:
– 3 Minute Systolic BP Ratio: SBP 3 min/ SBP Peak > 0.91 is
abnormal.
• Taylor et al: Postexercise systolic BP response: clinical
application to the assessment of ischemic heart disease.
American Family Physician. Vol 58(5).
Common Abnormal Responses to
Exercise Stress Testing
 ST Depression and Elevation
• Measurement:
– Three Continuous beats
– Baseline is the junction of
downsloping PR and QRS complex
• Depression:
– If ST elevated at rest c/w early
repolarization, measure from
baseline.
– If ST depressed at rest,
measure deviation from the
baseline depression.
• Elevation:
– ST elevation is c/w transmural
ischemia, however needs to be
classified by whether it occurs
over Q waves.
– Over Q waves: ST elevation may
occur in the presence of prior
infarct, and may or may not
represent ischemia.
 Common Abnormal Responses
• Isolated Inferior Depression
– Atrial repolarization has been
demonstrated to cause J point
depression in the inferior leads.
– Isolated inferior lead ST
depression is frequently a false
positive.
• ST Elevation
– ST segment elevation in the
absence of Q waves usually
indicates transmural ischemia.
• Exercise-Induced Bundle Branch
Block
– Ischemia can be interpreted in
RBBB, but not LBBB.
– The Stress test should be
stopped and the patient should
have further evaluation for
structural heart disease.
• Exercise-Induced Hypotension
– Always serious symptoms that
warrant further evaluation for
structural heart disease.
 Common Abnormal Responses
• Exercise-Induced Arrhythmias
– Simple PVCs: not uncommon; low grade ectopy,
unifocal, and infrequent PVCs during exercise do
not increase risk.
– Complex Arrhythmias: complex arrhythmias at
low levels, in particular when associated with
ischemia, warrant further evaluation.
– Ventricular Tachycardia: require termination of
the test, with prognosis based upon status of
underlying heart disease.
– Paroxysmal Atrial Tachycardia/PSVT: treated
as patients who develop PSVT without exercise.
 Determining Myocardial Ischemia
• Diagnostic of • Suggestive of
Myocardial Ischemia Myocardial Ischemia
– Horizontal or – Horizontal or
downsloping ST downsloping ST
depression >1.0 mm at depression 0.5 – 1.0
60ms past the J point – ST elevation 0.5 – 1.0
– ST elevation >1.0 mm at – Upsloping ST depression
60ms past the J point >.7 <1.5
– Upsloping ST depression – Exercise-induced
>1.5 at 80 ms past the hypotension
J point – Chest pain that seems
• Negative for like angina
Myocardial Ischemia – High grade ventricular
– Patient has exercised to ectopy
atleast 85% of maximal – A new third heart sound
predicted heart rate and • Inconclusive
none of the above are – Patient does not achieve
present. 85% of maximum HR and
has no ischemia.
 The Final Report
• First Paragraph: (General Summary)
– Pt’s age, indication for testing, cardiac
medications and protocol.
– Baseline heart rate, BP and resting ECG
findings.
– Peak exercise data, BP, HR, peak METs,
RPE and reason for stopping.
– Description of abnormalities in ECG
response, hemodynamics, dysrhythmias, or
symptoms
• Second Paragraph: (Assessment)
– Presence or absence of ischemia
– Normal or abnormal HR/BP response
– Presence of dysrhythmias
– Presence of symptoms
– Maximal aerobic capacity