Exercise Treadmill Testing

Introduction to Treadmill Test

Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Generally safe, but myocardial infarction and death up to 1 per 2500 test. should be supervised by physician. ECG, heart rate, and blood pressure to be monitored carefully and recorded during each stage of exercise and during ST-segment abnormalities and chest pain.

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.

 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.

 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.

Absolute Acute myocardial infarction (within 2 days) High-risk unstable angin Uncontrolled cardiac arrhythmias Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Acute aortic dissection

Relative  Left main coronary stenosis  Moderate stenotic valvular heart disease  Electrolyte abnormalities  Severe arterial hypertension  Tachy or Brady arrhythmias  HOCM and other outflow obstructions  Mental or physical impairment  High-degree atrio-ventricular block

Bicycle Ergo meter

Treadmill Test

Bruce stage Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6

Speed and Gradient 1.7 mph + 10% Gradient 2.4 mph + 12% Gradient 3.1 mph + 14% Gradient 3.8 mph + 16% Gradient 4.6 mph + 18% Gradient 5.5 mph + 20% Gradient

Minutes 3 6 9 12 15 18

METs 5 7 10 13 17 20

Lead V5 alone consistently outperforms other leads. Exercise-induced ST-segment only in inferior leads is not significant for CAD. Down sloping or horizontal ST-segment is a stronger predictor of CAD but not up sloping ST

Electrocardiographic Max ST L and STK ST sloping down, up or  No. of leads showing ST change ST duration into recovery ST/HR Index, Time to onset

Hemodynamic Max ETT Heart Rate Max ETT - SBP Max ETT Double product Exercise hypotension Exercise in METs, minutes

Symptomatic Exercise Angina Exercise limiting Sympt. Time to onset of angina Exercise up to stage IV

ETT induced ventricular arrhythmia Chronotropic failure

Only Manual SBP measurement for safety Age predicted Heart Rate Targets The BORG Scale of Perceived Exertion METs - not Minutes have to be used Use standard ECG analysis + 3 minute recovery Use scores, Heart rate recovery ST segment changes alone will not suffice

o 1 MET = "Basal" = 3.5 ml O2 /Kg/min o 2 METs = 2 mph on level o 4 METs = 4 mph on level o < 5METs = Poor prognosis if < 65 years o10 METs = Medical Rx as good as CABG o 13 METs = Excellent prognosis o 16 METs = Aerobic master athlete o 20 METs = Super athlete

Duke treadmill score = duration of exercise in minutes on the Bruce protocol - (minus) 5x maximal mm ST deviation - (minus) 4x treadmill angina index Treadmill Angina Index: 0 if no angina. 1 if non-limiting angina. 2 if limiting angina. High Risk = treadmill score < -10 79% 4-year survival Moderate Risk = treadmill score -10 to +4 95% 4-year survival Low Risk = treadmill score >+5 99% 4-year survival

SCALE 0 0.5 1 2 3 4 5 6 7 8 9 10

SEVERITY No Breathlessness* At All Very Very Slight (Just Noticeable) Very Slight Slight Breathlessness Moderate Somewhat Severe Severe Breathlessness Very Severe Breathlessness Very Very Severe (Almost Maximum) Maximum

Absolute indications
Drop

in SBP of >10 mm Hg from baseline BP with accompanying evidence of ischemia Moderate to severe angina Increasing nervous system symptoms ataxia, dizziness Signs of poor perfusion (cyanosis or pallor) Technical difficulties in monitoring ECG or SBP Subjects desire to stop; Sustained ventricular tachycardia ST elevation (1.0 mm) in leads without diagnostic Q

Relative indications
Drop

in SBP of 10 mm Hg BP without ischemia ST or QRS changes - ST depression (>2 mm of horizontal or down sloping ST-segment ) or axis shift Arrhythmias VT, multifocal PVCs, triplets of PVCs, SVT, Heart block or brady arrhythmias, BBB or IVCD Fatigue, shortness of breath, wheezing, leg cramps, IC Increasing chest pain; Hypertensive response > 250/115

1.

2.

3.

4.

Exercise Capacity METS achieved: _______________ Minutes exercised: _______________ Clinical response to exercise Chest pain during test? ___________ Chest pain reason for stopping test? __________ Perceived exertion scale (BORG scale reached 6 to 20): _________ Reason for stopping test:_____________ Electrocardiographic response to exercise ST elevation (yes/no) ? ____________ ST depression (yes/no)? ____________ (positive = 1 mm of horizontal or downsloping ST-segment depression or elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS complex) What leads? ___________ ST quality (upsloping, horizontal, downsloping):_______________ ST depression amount (mm): ___________ Dysrhythmia? _____________ Other: ____________________________________________________ Hemodynamic response to exercise Systolic BP response: ______________ Diastolic BP response: ______________ Maximum heart rate achieved: ________________ 2 minute heart rate recovery (should be at least 22 bpm by 2 minutes): ______________

5. Duke treadmill scores (see nomogram or use calculator): 5-year survival _______ Average annual mortality __________ 6. VA treadmill score: _________ 7. Final conclusions and recommendation for follow-up: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Duke Nomogram for 2 mm depression, non-limiting chest pain at 5 METS.