Treadmill Stress Testing

Dr ELFIANI Sp.PD
Blok 4.1 FKIK UNJA
Maret 2015

Indications: Diagnose Obstructive CAD

Class I
Adult patients (including those with RBBB and 1mm
resting ST depression) with an intermediate pretest 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

male relative before 55;

female before 65.
Smoker or quit within 6
months.
Hypertension
Hypercholesterolemia:
TCHOL > 200; HDL <35;
LDL > 130.
Impaired fasting glucose:
>110.
Obesity: BMI >30.
Sedentary
HDL >60 is a negative risk
factor.

CAD Signs/Symptoms

Pain in the chest, neck,

jaw, arms that may be
due to ischemia
SOB at rest or exertion
Dizziness or syncope
Orthopnea/PND
Ankle edema
Claudication
Known heart murmur
Unusual fatigue or SOB
with usual activities

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

ST Elevation

Exercise-Induced Bundle Branch

Block

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 segment elevation in the
absence of Q waves usually
indicates transmural ischemia.

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
Myocardial Ischemia

Horizontal or
downsloping ST
depression >1.0 mm at
60ms past the J point
ST elevation >1.0 mm at
60ms past the J point
Upsloping ST depression
>1.5 at 80 ms past the
J point

Negative for
Myocardial Ischemia

Patient has exercised to

atleast 85% of maximal
predicted heart rate
and none of the above
are present.

Suggestive of
Myocardial Ischemia

Horizontal or
downsloping ST
depression 0.5 1.0
ST elevation 0.5 1.0
Upsloping ST depression
>.7 <1.5
Exercise-induced
hypotension
Chest pain that seems
like angina
High grade ventricular
ectopy
A new third heart sound

Inconclusive

Patient does not achieve

85% of maximum HR and
has no ischemia.

The Final Report

First Paragraph: (General Summary)

Pts 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