Intro to Exercise Stress Testing* - Dr. Sarah Ramer 2021
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Intro to Exercise
Stress Testing*
Dr. Sarah Ramer
2021
Resources • 2013 ACC/AHA guideline • Dr. Sarah Ramer - sarah.ramer@nshealth.ca
Exercise Prescription for Apparently exercise standa
Healthy Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . 907 fundamentals
cate or replace
63 pages to combat
Exercise Training Techniques . . . . . . . . . . . . . . . . . . . . 908
Behavioral Aspects of Initiating and American Hea
Sustaining an Exercise Program . . . . . . . . . . . . . . . . 911 Cardiology Fo
insomnia…..
The American Heart AHA Scientific
Association makes Statement
every effort to avoid any actual or potential conflicts of i
or a personal, professional, or business interest of a member of the writing panel. Specifically, al
and submit a Disclosure Questionnaire showing all such relationships that might be perceived as
ThisExercise
statement was Standards approved byfor TestingHeart
the American andAssociation
Training Science Advisory and Coor
document
A Scientific is available
Statement at http://my.americanheart.org/statements
From the American Heart Association by selecting either the “By Top
additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.
The Gerald
American Heart Association
F. Fletcher, MD, FAHA, requests thatA.this
Chair; Philip document
Ades, be cited as follows: Fletcher GF, Ad
MD, Co-Chair;
Paul Kligfield,
LA, FlegMD, JL,FAHA,Forman Co-Chair;
DE, Gerber Ross TC, Arena, PhD, M,
Gulati PT, Madan
FAHA; K, Gary J. Balady,
Rhodes MD, FAHA;
J, Thompson PD, Williams MA
Vera Cardiac
A. Bittner, MD, MSPH, FAHA;
Rehabilitation, Lola A. Coke,
and Prevention PhD, ACNS,
Committee FAHA;
of the CouncilJerome on L. Fleg, MD;
Clinical Cardiology, Council
Daniel E. Forman, MD, FAHA; Thomas C. Gerber, MD, PhD, FAHA;
onMartha
Cardiovascular
Gulati, MD,and MS,Stroke FAHA;Nursing, and Council
Kushal Madan, PhD, PT; on Jonathan
Epidemiology Rhodes,and MD; Prevention. Exercise sta
Paul the AmericanMD;
D. Thompson, Heart Mark Association.
A. Williams, Circulation . 2013;128:873–934.
PhD; on behalf of the American Heart Association
Exercise, Expert
Cardiac peer review ofand
Rehabilitation, AHA Scientific
Prevention Statements
Committee of theisCouncil
conducted by theCardiology,
on Clinical AHA Office of Science
development,
Council on Nutrition,visit Physicalhttp://my.americanheart.org/statements
Activity and Metabolism, Council on Cardiovascular and select the and“Policies
Stroke and Developm
Permissions: Nursing,
Multiple and Council
copies,onmodification,
Epidemiology alteration,
and Prevention enhancement, and/or distribution of
permission of the American Heart Association. Instructions for obtaining permission are located a
Table of Contents
Permission-Guidelines_UCM_300404_Article.jsp. Evaluation andA Exercise
link toPrescription
the in
“Copyright Permissions Request
Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 912
(Circulation.
Purposes of Exercise Testing . . .2013;128:873-934.)
. . . . . . . . . . . . . . . . . . 874 Effects of Exercise Training in
Physiology of©Exercise
2013 TestingAmerican . . . . . .Heart
. . . . . . .Association,
. . . . . . 874 Inc.Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914
Types of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Prognostic Benefits of Exercise in
Circulation
Cardiovascular Responses to Exercise is available at http://circ.ahajournals.org Patients With CVD. . . . . . . . . . . . . . . . . . . . . . . . . . . 914
in Normal Subjects. . . . . . . . . . . . . . . . . . . . . . . . . . . 874 Targeting Exercise Prescription to
Exercise Testing Procedures . . . . . . . . . . . . . . . . . . . . . 876 Relevant Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 915
Clinical and Cardiopulmonary Responses Downloaded from
References . . . . . http://circ.ahajournals.org/ 873
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 920at Capital HWhat is this?
Look familiar?
On the exam - Paper 1
• List absolute and relative contraindications to stress testing
• Complications of Exercise Testing
• Absolute and Relative Indications for Terminating EST
• Definition of positive, negative or equivocal ECG changes
during exercise
• Definitions of abnormal BP response
• Prognostic value of exercise stress testing - DUKE Score
• Exercise prescription
• Sens/Specificity, pre-test and post-test probabilitiesOn the exam - Paper 2
• Report a stress test (graphics provided)
• Could be normal or abnormal
• Clinical stem, stress test given - how to manage?
• Calculate a Duke score and estimate riskOn the Exam - Oral
• Clinical scenario where a stress test is ordered.
Interpret the stress test in front of the examiner and
develop an appropriate management strategy.
• Evaluation of chest pain
• Assessment of prognosis
• Indication for valve surgery based on symptom
assessment
• Assessment of arrhythmia, long QT, WPW etc.Case
• A 44 year old woman is referred for exercise
stress testing. She reports chest pain, sharp
stabbing retrosternal lasting a few seconds
several times per day. No relationship to
physical activity. She is concerned because of
a positive family history. She has no other
cardiac risk factors.Phase Stage Time Speed Grade HR BP Comment
Name Name in Stage (mph) (%) (bpm) (mmHg)
01:08 1.0 0.0 71 120/80
Stress test
PRETEST STANDING
Exercise STAGE 1 03:00 1.7 10.0 84 114/80
STAGE 2 03:00 2.5 12.0 98 126/76
STAGE 3 03:00 3.4 14.0 127 140/76
STAGE 4 01:11 4.2 16.0 144
Recovery 1 Minute 01:00 0.0 0.0 171 142/76 00:00 Target heart rate
achieved
2 Minute 01:00 0.0 0.0 84 150/76
3 minute 01:00 0.0 0.0 71
4 minute 01:00 0.0 0.0 75 130/70
5 MINUTE 00:52 0.0 0.0 72 120/70
The patient exercised according to the BRUCE for 10:11 min:s, achieving a work level of Max.
METS: 12.0. The resting heart rate of 73 bpm rose to a maximal heart rate of 171 bpm. This value
represents 103 % of the maximal, age-predicted heart rate. The resting blood pressure of 120/80
mmHg , rose to a maximum blood pressure of 150/76 mmHg. The exercise test was stopped due to
Target Heart Rate, Dyspnea.
Interpretation
Summary: Resting ECG: Early repolarization abnormality.
Functional Capacity: Class I.
HR Response to Exercise: appropriate.
BP Response to Exercise: normal resting BP - appropriate response.
Chest Pain: none.
Arrhythmias: see comments.
ST Changes: Depression upsloping see comments.LEPINE, PAUL 12-Lead Report
Patient ID: 0011176781 73 bpm PRETEST BRUCE
2017/04/20
9:25:46
Rest
120/80 mmHg STANDING
00:08
0.0 mph
0.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
GE
CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(II,V5)Peak LEPINE, PAUL 12-Lead Report (PEAK EXERCISE) Patient ID: 0011176781 144 bpm EXERCISE BRUCE 2017/04/20 STAGE 4 4.2 mph 9:36:57 10:11 16.0 % I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 GE CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(II,V5)
LEPINE, PAUL 12-Lead Report
Recovery 00:15
Patient ID: 0011176781 141 bpm RECOVERY BRUCE
2017/04/20 1 Minute 1.5 mph
9:37:12 00:15 3.1 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
GE
CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(II,V5)Recovery 2:00 LEPINE, PAUL 12-Lead Report Patient ID: 0011176781 84 bpm RECOVERY BRUCE 2017/04/20 150/76 mmHg 2 Minute 0.0 mph 9:38:57 02:00 0.0 % I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 GE CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(II,V5)
LEPINE, PAUL ID:0011176781 20-APR-2017 09:25:38 NSES
GRADED EXERCISE SUMMARY
09-JUN-1961 (55 yr) Male BRUCE Total Exercise Time:10:11
Medians Summary
Wt: Ht: Max HR: 171 bpm 103% of Max Predicted 165 bpm 25mm/s
Med: Tamsulosin, rosuvastatin Max BP: 150/76 Maximum Workload: 12.0 10mm/mV
150Hz
cc: Dr. Maged Gerges
Referred by: DOUGLAS HAYAMI Endpoint was THR and dyspnea
Technician:SARAH MCLEAN Functional Class I ( 12 METs)
Test ind: Ischemia Evaluation, R/O Arrhyth No chest pain
Test type: Treadmill Stress Resting EKG shows early repolarization abnormailty. At peak exercsie developed
> 1.5 mm ( beyond baseline) upsloping ST depression
In recovery had 18 second run of SVT at 160 bpm, withusual symptoms
Borderline positives test by EKG with SVT in recovery
Confirmed by MACDONALD, M.D., NANCY (9504) on 4/20/2017 11:33:05 AM
BASELINE MAX ST
Lead Lead
EXERCISE STAGE 1 71 bpm ST @ 10mm/mV ST EXERCISE STAGE 4 144 bpm ST @ 10mm/mV ST
00:00 1.3 60ms postJ Slope 10:11 12.0 60ms postJ Slope
I aVR V1 V4 I aVR V1 V4
0.4 mm -0.6 0.7 0.9 -0.1 0.8 1.1 -0.8
-0.3 mV/s -1.5 0.3 0.8 0.1 -1.3 0.5 2.4
II aVL V2 V5 II aVL V2 V5
0.8 0.1 1.7 0.7 -1.6 0.7 0.8 -1.3
0.3 -0.5 1.5 0.5 1.7 -0.8 2.2 1.5
III aVF V3 V6 III aVF V3 V6
0.3 0.5 1.4 0.4 -1.5 -1.5 0.3 -0.9
0.3 0.3 1.4 0.1 1.1 1.5 2.4 0.8
Confirmed By: NANCY MACDONALD, M.D. Date:20-APR-2017
8.0.1 CASE V6.73-0.0 SID: 0001644160 EID:9504 EDT: 11:33 20-APR-2017 ORDER: ACCOUNT: 28714882With respect to this stress test: • A) It’s normal - Negative • B) It’s abnormal - Positive • C) It’s equivocal - Non-diagnostic • D) Holy crap why did I order this stress test?
ECG changes with exercise
Fletcher et al Exercise Standards for Testing and Training 885
Figure 4. Definition of
ST-segment depression
changes during exercise.
Positive standard test
responses include horizontal
or downsloping depression
≥1.0 mm (0.1 mV), whereas
upsloping ST depression ≥1.0
mm is considered equivocal
(a change that does not
usefully separate normal from
abnormal). All ST depression
1.6 µV/bpm defined as
ischemic disease than in normal subjects.101 At the same time, abnormal.90,111 Because it is calculated from only upright con-
increasing HR during graded exercise is what influences pro- trol and peak exercise data, the ST/HR index can be derived
gressive ST-segment depression because it is a major deter- from tests that are not gently graded. The ST/HR index hasPearl of wisdom
• With resting ST depression, further ST
depression is measured
• With resting ST elevation due to early
repolarization, only ST depression related to
baseline is measured
• Baseline is P-Q segment as T-P is often too short
during exercise.Indications for Exercise
Stress testing
-Symptoms suggesting myocardial ischemia
-Acute chest pain in whom acute coronary syndrome (ACS) and
myocardial infarction have been excluded
-Recent ACS treated without coronary angiography
-Known coronary heart disease and change in clinical status
-Prior coronary revascularization
-Valvular heart disease (asymptomatic)
-Newly diagnosed heart failure or cardiomyopathy (compensated)
-Certain cardiac arrhythmias
-An indication for cardiac assessment prior to non-cardiac surgery
• 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with
stable ischemic heart disease: Miller TD, Askew JW, Anavekar NS.
• Noninvasive Stress Testing for Coronary Artery Disease. Heart Fail Clin. 2016 Jan;12(1):65-82.cardiac output Absolute and Relative Contraindications to Exercise
V̇o2max divided Testing
Absolute and relative contraindications to exercise testing
Contraindications to Stress
as the oxygen
ume (ie, cardiac balance the risk of the test with the potential benefit of the
information derived from the test. Assessment of this balance
e arteriovenous
e arteriovenous
siological limit
Testing
requires knowledge of the purpose of the test for the individ-
ual subject or patient and what symptom or sign end points
cardiovascular will be for the individual test.
xygen pulse at Absolute Contraindications
n in the forward
bout a patient’s ● Acute myocardial infarction (MI), within 2 days
e can be made ● Ongoing unstable angina
peak exercise. ● Uncontrolled cardiac arrhythmia with hemodynamic
ke volume) at compromise
size, and sex. ● Active endocarditis
ver, by dividing ● Symptomatic severe aortic stenosis
minute) by the ● Decompensated heart failure
influenced by ● Acute pulmonary embolism, pulmonary infarction, or deep
uration. Proper vein thrombosis
hould take into ● Acute myocarditis or pericarditis
● Acute aortic dissection
● Physical disability that precludes safe and adequate testing
ages of 15 and
At age 60 years, Relative Contraindications
ds of that at 20d stroke volume) at compromise
s age, size, and sex. ● Active endocarditis
however, by dividing Symptomatic severe aortic stenosis
Contraindications to Stress
●
rs per minute) by the ● Decompensated heart failure
lso is influenced by ● Acute pulmonary embolism, pulmonary infarction, or deep
n saturation. Proper vein thrombosis
ore should take into Testing
●
●
Acute myocarditis or pericarditis
Acute aortic dissection
● Physical disability that precludes safe and adequate testing
n the ages of 15 and
age. At age 60 years, Relative Contraindications
o thirds of that at 20
o2max was observed
● Known obstructive left main coronary artery stenosis
however, the rate of
● Moderate to severe aortic stenosis with uncertain relation
years in individuals to symptoms
ars in individuals in
● Tachyarrhythmias with uncontrolled ventricular rates
1.
● Acquired advanced or complete heart block
● Hypertrophic obstructive cardiomyopathy with severe rest-
ing gradient
n that of men.22 This ● Recent stroke or transient ischemic attack
heir smaller muscle ● Mental impairment with limited ability to cooperate
e, and smaller stroke ● Resting hypertension with systolic or diastolic blood pres-
ne for each decade is sures >200/110 mm Hg
rth decade onward.21 ● Uncorrected medical conditions, such as significant ane-
mia, important electrolyte imbalance, and hyperthyroidism
ence on V̇o2max. In
≈12 METs, whereas Subject Preparation
uch as distance run- Preparations for exercise testing include the following:Another case
• 47 year old man complaining of decreased
exercise tolerance and palpitations with exertion.
• No cardiac risk factors.Name Name in Stage (mph) (%) (bpm) (mmHg)
PRETEST STANDING 09:37 1.0 0.0 85 134/74
Exercise STAGE 1 03:00 1.7 10.0 91 150/74
STAGE 2 03:00 2.5 12.0 112 156/66
STAGE 3 03:00 3.4 14.0 146 172/60
Recovery
STAGE 4
STAGE 5
1 Minute
03:00
02:16
01:00
EST
4.2
4.8
0.0
16.0
18.0
0.0
153
187
137
172/60
09:45 Target heart rate
achieved
13:05 breathing getting
laboured
2 Minute 01:00 0.0 0.0 122
3 minute 01:00 0.0 0.0 113
4 minute 01:00 0.0 0.0 110
5 MINUTE 00:36 0.0 0.0 109
The patient exercised according to the BRUCE for 14:15 min:s, achieving a work level of Max.
METS: 17.2. The resting heart rate of 72 bpm rose to a maximal heart rate of 187 bpm. This value
represents 106 % of the maximal, age-predicted heart rate. The resting blood pressure of 134/74
mmHg , rose to a maximum blood pressure of 172/60 mmHg. The exercise test was stopped due to
Dyspnea.
Interpretation
Conclusions
cc: Dr. Farah KapurSIMMONS, GREGORY
Patient ID: 0010647048
25.07.2016
9:43:25am
76 bpm
Rest
134/74 mmHg
PRETEST
STANDING
00:58
BRUCE
0.0 mph
0.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
V1
GE
CASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(II,V4)Peak SIMMONS, GREGORY Patient ID: 0010647048 151 bpm RECOVERY BRUCE 25.07.2016 1 Minute 0.0 mph 10:07:06am 00:48 0.0 % I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 V1 GE CASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V3,V4)
Peak (continued - cardiologist
becoming anxious)
SIMMONS, GREGORY
Patient ID: 0010647048 157 bpm RECOVERY BRUCE
25.07.2016 2 Minute 0.0 mph
10:07:20am 01:02 0.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
V1
GE
CASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V3,V4)SIMMONS, GREGORY
Patient ID: 0010647048
25.07.2016
10:10:40am
Recovery
111 bpm RECOVERY
5 Minute
04:22
BRUCE
0.0 mph
0.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
V1
GE
CASE V6.61 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.3 HR(V1,II)SIMMONS, GREGORY ID:0010647048 25-JUL-2016 09:42:27 NSES
Medians
GRADED EXERCISE SUMMARY
15-FEB-1972 (44 yr) Male BRUCE Total Exercise Time:14:15
Wt: Ht: Max HR: 187 bpm 106% of Max Predicted 176 bpm 25mm/s
Med: NIL Max BP: 172/60 Maximum Workload: 17.2 10mm/mV
150Hz
cc: Dr. Farah Kapur
Referred by: RATIKA PARKASH
Technician:LINDA BOURBONNAIS A stress echo was performed.
Test ind: Screening for CAD Non-diagnostic stress test.
Test type: Stress Echo Wide complex tachycardia noted.
See echo report.
Confirmed by RAMER, M.D., SARAH (10381) on 8/9/2016 10:35:11 AM
BASELINE MAX ST
Lead Lead
EXERCISE STAGE 1 83 bpm ST @ 10mm/mV ST EXERCISE STAGE 3 141 bpm ST @ 10mm/mV ST
00:00 1.7 60ms postJ Slope 8:50 10.1 172/60 60ms postJ Slope
I aVR V1 V4 I aVR V1 V4
0.5 mm -0.8 0.7 0.7 -1.4 -0.3 -5.2 0.6
0.4 mV/s -1.0 -0.2 0.5 -0.5 -11.5 -9.8 11.4
II aVL V2 V5 II aVL V2 V5
1.1 -0.1 0.1 0.7 2.1 -2.4 -3.5 1.0
0.7 0.1 -0.1 0.5 17.3 -9.6 -12.6 11.6
III aVF V3 V6 III aVF V3 V6
0.7 0.9 0.6 0.6 3.5 2.8 0.1 1.5
0.1 0.5 0.3 0.5 17.8 17.5 10.4 11.7
Confirmed By: SARAH RAMER, M.D. Date:09-AUG-2016
8.0.1 CASE V6.61-0.0 SID: 0001283363 EID:10381 EDT: 10:35 09-AUG-2016 ORDER: ACCOUNT: 27750333What happened here and how are you going to report it?
ure with a risk of suggest that the ventilatory threshold has been exceeded.
be certain that the
Angina Characteristics and Scale
Good communica-
tory.
Complications of Stress
the test, and writ-
Levels of anginal discomfort in those with known or suspected
CAD are also excellent subjective end points. Whether typi-
cal angina occurs with exercise or is the reason for termina-
ensuring that the
d that exercise test- Testing
tion of the test is an important observation in evaluation of the
exercise test, and it is an important factor in calculation of the
cise testing should Duke Treadmill Score.63
nel with sufficient
bility to recognize
tion on the ECG.43 Table 1. Complications Secondary to Exercise Testing
uring a test can be Cardiac Bradyarrhythmias
bject being tested. Tachyarrhythmias
or physician’s des-
Acute coronary syndromes
uestions about the
Heart failure
physical examina-
performed immedi- Hypotension, syncope, and shock
gned to a properly Death (rare; frequency estimated at 1 per
assistant, or exer- 10 000 tests, perhaps less)
apparently healthy Noncardiac Musculoskeletal trauma
e with stable chest Soft-tissue injury
permit additional Miscellaneous Severe fatigue (malaise), sometimes persisting for
nel.43 Possibly with days; dizziness; body aches; delayed feelings of illness
y individuals (eg, Reproduced with permission from Fletcher et al.1 © 2001 American Heart
uld be immediately Association, Inc.
m http://circ.ahajournals.org/ at Capital Health on May 27, 201520 to near-baseline values. Eve
Reprinted from Borg219 with permission of the at peak exercise, postexercis
publisher. Copyright ©1982, the American College of an abnormal electrocardiogr
Indications to Stop a Stress
Sports Medicine.
Indications for Termination of Exercise Testing
during the recovery period. M
trophysiological abnormaliti
exercise can persist for minu
The decision to terminate exercise is an important function of
Test
test supervision that is generally determined by the purpose
of testing in individual subjects. Symptom-limited testing is
pressure should continue du
responses could occur, partic
mias also might be present in
desirable for general evaluation, but this recommendation
could be modified in several situations.58 Management of Pacemaker
Exercise testing can be used
Absolute Indications implanted pacemakers and o
of tracking function that can
● ST-segment elevation (>1.0 mm) in leads without preexist-
with implanted defibrillators
ing Q waves because of prior MI (other than aVR, aVL,
alone, firing function should
and V1)
maximum testing if the thres
● Drop in systolic blood pressure >10 mm Hg, despite an
exercise. In the presence of a v
increase in workload, when accompanied by any other evi-
cannot be evaluated for isch
dence of ischemia
“pacemaker memory” could
● Moderate-to-severe angina
that can mimic ischemia when
● Central nervous system symptoms (eg, ataxia, dizziness,
to examine the underlying ele
near syncope)
● Signs of poor perfusion (cyanosis or pallor)
● Sustained ventricular tachycardia (VT) or other arrhythmia,
Clinical and Cardiopulm
including second- or third-degree atrioventricular (AV)
Exercise
block, that interferes with normal maintenance of cardiac Clinical Responses
output during exercise
Symptoms
● Technical difficulties in monitoring the ECG or systolic
Assessment of perceived sym
blood pressure
of the exercise test. Sympto
● The subject’s request to stop
separate quantification of d
Relative Indications exertion. Scales for each of● Signs of poor perfusion (cyanosis or pallor)
● Sustained ventricular tachycardia (VT) or other arrhythmia,
Clinical and Cardi
Exercise
Indications to Stop a Stress
including second- or third-degree atrioventricular (AV)
block, that interferes with normal maintenance of cardiac
output during exercise
Clinical Responses
Symptoms
●
●
Test
Technical difficulties in monitoring the ECG or systolic
blood pressure
The subject’s request to stop
Assessment of perceiv
of the exercise test. S
separate quantificatio
Relative Indications exertion. Scales for ea
the present statement
● Marked ST displacement (horizontal or downsloping of >2 symptoms induced by
mm, measured 60 to 80 ms after the J point [the end of the and are even more p
QRS complex]) in a patient with suspected ischemia depression.67 Exercise
● Drop in systolic blood pressure >10 mm Hg (persistently a worse prognosis th
2013 below baseline) despite an increase in workload, in the important to obtain fro
absence of other evidence of ischemia perceived symptoms d
● Increasing chest pain patient considers to be
Perceived ● Fatigue, shortness of Downloaded
breath, wheezing, leg cramps, or
from http://circ.ahajournals.org/ at Capital Health on
claudication
● Arrhythmias other than sustained VT, including multifocal
ectopy, ventricular triplets, supraventricular tachycardia,
and bradyarrhythmias that have the potential to become
Very, very light more complex or to interfere with hemodynamic stability
● Exaggerated hypertensive response (systolic blood pressure
Very light >250 mm Hg or diastolic blood pressure >115 mm Hg)
● Development of bundle-branch block that cannot immedi-
Fairly light ately be distinguished from VTAnother case
• 54 year old man with exertional chest pain.
• Restrosternal pressure ‘like somebody sitting on
chest’
• Relieved with Rest
• CRF = high cholesterol and pos family historyExercise Test Summary
Phase Stage Time Speed Grade HR BP Comment
Name Name in Stage (mph) (%) (bpm) (mmHg)
EST
PRETEST STANDING 05:43 1.0 0.0 63 130/80
Exercise STAGE 1 03:00 1.7 10.0 100 164/82
STAGE 2 01:39 2.5 12.0 112 160/84 03:04 chest discomfort
starting into right shoulder
04:16 Chest Discomfort
Increasing 3/10
Recovery 1 Minute 01:00 0.0 0.0 83 158/84 00:55 discomforrt easing
2 Minute 01:00 0.0 0.0 63 158/84
3 minute 01:00 0.0 0.0 62
4 minute 00:55 0.0 0.0 61 148/80 03:37 chest and right
shoulder discomfort gone
The patient exercised according to the BRUCE for 04:39 min:s, achieving a work level of Max.
METS: 6.5. The resting heart rate of 60 bpm rose to a maximal heart rate of 112 bpm. This value
represents 66 % of the maximal, age-predicted heart rate. The resting blood pressure of 130/80 mmHg
, rose to a maximum blood pressure of 164/82 mmHg. The exercise test was stopped due to usual
chest, right shoulder discomfort increasing.
Interpretation
Summary: Functional Capacity: Class II.
Chest Pain: limiting.
ST Changes: Depression horizontal.
Overall Impression: Positive stress test typical of ischemia.
ConclusionsSOKOLIC, VALERIANO 12-Lead Report
Rest
Patient ID: 0006354559 60 bpm PRETEST BRUCE
2017/04/13 130/80 mmHg STANDING 0.0 mph
13:50:57 00:06 0.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
GE
CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(V2,II)SOKOLIC, VALERIANO 12-Lead Report (PEAK EXERCISE)
Peak
Patient ID: 0006354559 112 bpm EXERCISE BRUCE
2017/04/13 160/84 mmHg STAGE 2 2.5 mph
14:01:12 04:39 12.0 %
I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
GE
CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(V2,II)Recovery 00:15 SOKOLIC, VALERIANO 12-Lead Report Patient ID: 0006354559 107 bpm RECOVERY BRUCE 2017/04/13 1 Minute 1.5 mph 14:01:27 00:15 0.0 % I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 GE CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(V2,II)
Recovery 2:00 SOKOLIC, VALERIANO 12-Lead Report Patient ID: 0006354559 63 bpm RECOVERY BRUCE 2017/04/13 158/84 mmHg 2 Minute 0.0 mph 14:03:12 02:00 0.0 % I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 GE CASE V6.73 25mm/s 10mm/mV 60Hz 0.01Hz FRF+ HEART V5.4 HR(V2,II)
SOKOLIC, VALERIANO ID:0006354559 13-APR-2017 13:50:51 NSES
GRADED EXERCISE SUMMARY
Medians Summary
03-FEB-1966 (51 yr) Male BRUCE Total Exercise Time:4:39
Wt: 0lb Max HR: 112 bpm 66% of Max Predicted 169 bpm 25mm/s
Med: TECTA, rosuvastatin Max BP: 164/82 Maximum Workload: 6.5 10mm/mV
150Hz
cc: Dr. Shalini Veerassamy
Referred by: GENEVIEVE MORTERA Functional Class 2
Technician:LINDA BOURBONNAIS Normal heart rate response
Test ind: Screening for CAD Normal blood pressure response
Test type: Treadmill Stress No chest pain
Significant ST depression
Positive test for ischemia
BASELINE MAX ST
Lead Lead
EXERCISE STAGE 1 63 bpm ST @ 10mm/mV ST EXERCISE STAGE 2 112 bpm ST @ 10mm/mV ST
00:00 1.7 60ms postJ Slope 4:39 6.5 160/84 60ms postJ Slope
I aVR V1 V4 I aVR V1 V4
0.1 mm -0.3 0.3 0.2 -0.5 1.3 1.3 -1.0
0.1 mV/s -0.7 0.0 0.2 0.2 -0.0 0.5 0.1
II aVL V2 V5 II aVL V2 V5
0.3 0.1 0.8 0.2 -2.1 0.6 1.2 -1.6
0.1 0.1 0.5 0.1 -0.3 0.3 1.2 -0.4
III aVF V3 V6 III aVF V3 V6
0.2 0.3 0.6 0.3 -1.6 -1.9 0.2 -1.4
-0.2 -0.1 0.5 0.0 -0.6 -0.5 1.0 -0.4
Unconfirmed Date:13-APR-2017
8.0.1 CASE V6.73-0.0 SID: 0000542668 EID:9100 EDT: 15:21 13-APR-2017 ORDER: ACCOUNT: 28597681Stress test interpretation
What is his Duke Score and
what is the risk?
• Exercise time (minutes on Bruce) - 5 x (max ST
depression in mm) - 4 x (angina index)
• 0 = no angina
• 1 = non-limiting
• 2 = limitingExercise Test Summary
Phase
SOKOLIC, Stage
VALERIANO Time ID:0006354559
Speed Grade 13-APR-2017
HR BP
13:50:51 Comment NSES
Name Name in Stage (mph) (%) GRADED (bpm) (mmHg)
EXERCISE SUMMARY
Duke Score
PRETEST 03-FEB-1966 (51 yr)
STANDING 05:43 1.0 Male 0.0 BRUCE63 130/80 Total Exercise Time:4:39
Wt: STAGE 1 0lb 03:00 Max HR: 112 bpm 66% of Max Predicted 169 bpm 25mm/s
Exercise 1.7 10.0 100 164/82 10mm/mV
Med: TECTA, rosuvastatin Max BP: 164/82 Maximum Workload: 6.5
STAGE 2 01:39 2.5 12.0 112 160/84 03:04 chest discomfort 150Hz
cc: Dr. Shalini Veerassamy starting into right shoulder
Referred by: GENEVIEVE MORTERA Functional Class 2 04:16 Chest Discomfort
Technician:LINDA BOURBONNAIS Normal heart rate response Increasing 3/10
Recovery Test ind: Screening for CAD 01:00
1 Minute 0.0 0.0 Normal83blood pressure response 00:55 discomforrt easing
158/84
Test type: Treadmill Stress No chest pain
2 Minute 01:00 0.0 0.0 63 ST depression
Significant 158/84
3 minute 01:00 0.0 0.0 62
Positive test for ischemia
4 minute 00:55 0.0 0.0 61 148/80 03:37 chest and right
shoulder discomfort gone
The patient exercised
BASELINEaccording to the BRUCE for 04:39 min:s, achieving a work MAX levelSTof Max.
Lead Lead
METS: STAGE
EXERCISE 6.5. The
1 resting heart
63 bpmrate ofST
60@bpm rose to a ST
10mm/mV maximal heart rate of
EXERCISE 1122 bpm. This 112
STAGE value
bpm ST @ 10mm/mV ST
00:00 1.7 60ms postJ Slope 4:39 6.5 160/84 60ms postJ Slope
represents 66 % of the maximal, age-predicted heart rate. The resting blood pressure of 130/80 mmHg
, rose to a maximum blood pressure of 164/82 mmHg. The exercise test was stopped due to usual
chest, right shoulder discomfort increasing.
I aVR V1 V4 I aVR V1 V4
Interpretation
0.1 mm -0.3 0.3 0.2 -0.5 1.3 1.3 -1.0
0.1 mV/s -0.7 0.0 0.2 0.2 -0.0 0.5 0.1
Summary: Functional Capacity: Class II.
Chest Pain: limiting.
ST Changes: Depression horizontal.
II aVL V2 V5 II aVL V2 V5
Overall
0.3 Impression:
0.1 Positive stress
0.8 test typical of0.2ischemia. -2.1 0.6 1.2 -1.6
0.1 0.1 0.5 0.1 -0.3 0.3 1.2 -0.4
Conclusions
III aVF V3 V6 III aVF V3 V6
0.2 0.3 0.6 0.3 -1.6 -1.9 0.2 -1.4
-0.2 -0.1 0.5 0.0 -0.6 -0.5 1.0 -0.4
Unconfirmed Date:13-APR-2017
8.0.1 CASE V6.73-0.0 SID: 0000542668 EID:9100 EDT: 15:21 13-APR-2017 ORDER: ACCOUNT: 28597681Duke Score • 4 - 5 (2) - 4 (2) = -14 • High Risk
Elements of a report • Patient name • Referring provider • Indication for test • Date performed • Protocol performed • Duration of exercise
Elements of a report
• Baseline and Max HR, BP Workload.
• Description of abnormal HR or BP response
• Symptoms - when and what. Specifically mention presence or
absence of chest pain.
• Reason for Stopping
• ECG changes - baseline, peak, and when significant
• Arrhythmias - rest and stress
• Comparison to age matched controlsSummary
• “Positive”, “Negative” or “Equivocal”
• “Normal”, “Abnormal” or “Non-diagnostic”
• For detection of ischemia a reasonable RPP
must be achieved. (10th percentile 25,000, 90th
40,000)
• THR = 85% max age predicted (220-age)Weight: 0 lb Race: --
Study Date: 13-Apr-2017 Referring Physician: GENEVIEVE MORTERA
Test Type: Treadmill Stress Attending Physician: TECH CLINIC
Protocol: BRUCE Technician: LINDA BOURBONNAIS
Medications:
TECTA , rosuvastatin
Medical History:
Report
Reason for Exercise Test:
Screening for CAD
• Mr. Bob Smith
Exercise Test Summary
• Referred by: Dr. S. Ramer
Phase
Name
Stage
Name
Time
in Stage
Speed
(mph)
Grade
(%)
HR
(bpm)
BP
(mmHg)
Comment
PRETEST STANDING 05:43 1.0 0.0 63 130/80
Exercise STAGE 1 03:00 1.7 10.0 100 164/82
• Indication: Exertional chest pain, ? ischemia
STAGE 2 01:39 2.5 12.0 112 160/84 03:04 chest discomfort
starting into right shoulder
04:16 Chest Discomfort
Increasing 3/10
Recovery 1 Minute 01:00 0.0 0.0 83 158/84 00:55 discomforrt easing
• Date: April 24, 2020
2 Minute
3 minute
4 minute
01:00
01:00
00:55
0.0
0.0
0.0
0.0
0.0
0.0
63
62
61
158/84
148/80 03:37 chest and right
shoulder discomfort gone
The patient exercised according to the BRUCE for 04:39 min:s, achieving a work level of Max.
METS: 6.5. The resting heart rate of 60 bpm rose to a maximal heart rate of 112 bpm. This value
represents 66 % of the maximal, age-predicted heart rate. The resting blood pressure of 130/80 mmHg
, rose to a maximum blood pressure of 164/82 mmHg. The exercise test was stopped due to usual
chest, right shoulder discomfort increasing.
Interpretation
Summary: Functional Capacity: Class II.
Chest Pain: limiting.
ST Changes: Depression horizontal.
Overall Impression: Positive stress test typical of ischemia.Report
• Decreased exercise capacity (FC II) with endpoint of chest
discomfort. Usual CP developed at 4:30 at a HR of 100 beats per
minute.
• Blunted HR response to exercise - target HR not achieved
• BP response to exercise - normal resting BP, normal BP response
to exercise
• Arrhythmias - none
• ECG changes - Normal resting ECG. Diagnostic ST depression at
4 minutes in the protocol. At peak exercise there is 2 mm ST
segment depression, downsloping.Summary
• Positive Stress test, typical of ischemia at a FCII
workload.
• High risk based on a Duke score of -14.Important definitions
Normal HR response to
exercise
• Increase of 10 beats per min per MET
• Expect less if beta blocked
• Chronotropic incompetence can cause
symptoms and correlates with poorer prognosis.Abnormal BP response to
exercise
• Hypertensive increase in SBP >60 for men, >50
for women or increase to above the 90th
percentile (>210 in men and >190 in women).
DBP increase >10 mmHg or absolute value
>90mmHg.
• Blunted = an increase of less than 20-25 mmHg.
• Hypotensive = drops below resting value or
rises initially and then drops by >/= 10 mmHg.Oral Scenario
• A 62 year old man presents for outpatient
exercise stress testing for evaluation of chest
pain. His resting ECG is normal. After 4 minutes
on a Bruce Protocol he develops 2 mm of ST
elevation in the anterior leads associated with
his usual chest pain (retrosternal heaviness).How to Manage this Patient?
Summary
• Exercise stress testing is ‘bread and butter’
cardiology.
• There will be stress testing on your exam - could
be in any section of the exam.
• Know your Duke Score!Thank you!
You can also read
