DYNAMIC PROTOCOLS FOR E.C.

G
BY

MINJU

DEFINITION
: To induce chest pain or discomfort under controlled conditions in the laboratories, that can be done by certain protocols .This is known as dynamic protocols.

PURPOSES
Using controlled and carefully supervised exercise to increase myocardial oxygen demand . To evaluate the coronary arteries ability to meet the increased demand successfully. To determine the typical and atypical chest pain.

PRINCIPLES
Skeletal muscle function should be proper. Blood vessels should be patent. Cardiac function should be normal. Myocardial function should be good. Coronary perfusion should be clear.

TYPES OF DYNAMIC PROTOCOLS

. 24 hours monitoring E.C.G. or ambulatory E.C.G. . Radio Telemetry. . Holter Monitoring. . Masters Double step technique. . Bicycle Ergometry. . Stress Test or Tread Mill Test (T.M.T.)

24 Hours E.C.G. monitoring

We use 3 modified chest leads usually.
Neutral lead placed just below the clavicle. V1 or V2. Apical.

PROCEDURE
> Place the electrodes over the chest and connect the patient to a transmitter. > Ask the patient to perform an activity. > It will show variations in E.C.G. if there is any demand-supply mismatch. > It can perform in I.C.U. only.

RADIO TELEMETRY
#. A Transmitter is connected to the patient with modified chest leads. #. Ask the patient to go for a brisk walk of a radius of 2 kms. #. Continuous communication and monitoring of the patient that will enable to monitor the E.C.G. for any abnormalities.

HOLTER MONITORING
A Holter monitor is connected to the patient .

Ask the patient to go home and allow him to do his daily activities. Patient should maintain a dairy of daily activities related with time.

Patient should come back to the hospital after 24 hours. By correlating the patients activity and abnormal complexes, helps in identifying coronary insufficiency.

MASTERS DOUBLE STEP

Ask the client to climb-up and down in a two step and do it vigorously,so exertion is done. It will be monitored and able to evaluate the demand-mismatch supply.

Disadvantage
It is very uncommonly performed because client can take his own time.

BICYCLE ERGOMETRY
Ask the client to ride a stationary bicycle and go on. When examiner increase the resistance for peddling, as a result of that, the demand of oxygen and heart work load also be increased. If heart is able to meet the demand, the heart function will be normal.

STRESS TEST OR TREAD MILL TEST

DEFINITION:

Disease of the heart frequently are best evaluated during an altered state of physiologic stress of the cardiovascular system.

The most common method of creating that altered cardiovascular state is an exercise stress test or tread mill test.

OBJECTIVES
For the evaluation of chest pain.

To assess the signs and symptoms of coronary artery disease.

INDICATIONS
To evaluate the physiologic response of post-MI. To evaluate the post revascularisation patients to

exercise.
To evaluate functional capacity for the purpose of

exercise prescription .

 To evaluate exercise capacity for the purpose of work classification (disability evaluation) and risk stratification (prognosis). To evaluate the efficacy of medical,surgical,or pharmacological treatment. To evaluate the presence and severity of arrhythmias. The know the preoperative physiological status. To evaluate intermittent claudication.

CONTRAINDICATIONS There are 2 types. 1.Absolute contraindication. 2.Relative contraindication.

ABSOLUTE
A recent change in the resting electrocardiogram suggesting infarction or other acute cardiac event.

Recent complicated myocardial infarction.

Unstable angina.

Uncontrolled ventricular arrhythmia.

Uncontrolled atrial arrhythmia that compromises

cardiac function. Third-degree atrioventricular heart block. Severe aortic stenosis.

Suspected or unknown Dissecting aneurysm.

Acute or suspected myocarditis or pericarditis. Thrombophlebitis or intracardiac thrombi. Recent systemic or pulmonary embolus. Acute infection. Significant emotional distress(psychosis).

RELATIVE
Resting diastolic B.P.> 115 mm of Hg or

Resting systolic B.P.> 200 mm of Hg.

Moderate valvular heart disease. Known electrolyte abnormalities (Hypokalemia).

 Fixed rate pacemaker.

Frequent or complex ectopy. Ventricular Aneursym. Uncontrolled metabolic disease. Neuromuscular, musculoskeletal or rheumatoid disorders that exacerbated by exercise. Advanced or complicated pregnancy.

PRE-TEST PREPARATIONS
Take a complete medical history and physical examination. Provide a detailed verbal and written instructions to withhold ingestion of food,alcohol and caffeine or using tobacco within 3 hours of testing.

 Patient should be well rested and avoid vigorous

activity the day of the rest.

Wear non-constrictive and comfortable clothing. Wear rubber-soled, supportive shoes during testing. Inform the client of the purposes and risks of exercise testing and obtain a signed consent.

Record the patients B.P. and pulse.

Record standard 12 lead resting E.C.G.

Obtain a drug history of the patient.

COMMON DRUGS AND IMPACT ON STRESS TEST

Drug
Beta blockers

Heart Rate
Rest : Exercise:

B.P.
Rest : Exercise: Rest : Exercise:

E.C.G.
signs of ischemia signs of ischemia signs of ischemia

: Ca channel Rest Exercise: blockers Digoxin No change

Rest : Exercise:

PROCEDURE
There are 3 phases.
1. Preparatory phase. 2. Performance phase.

3. Post exercise recovery period.

1.PREPARATORY PHASE
Proper skin preparation. Careful placing of electrodes in proper location with tape or a belt. Examiner must take a baseline resting E.C.G. before the test.

 Drape lead wires,cables and B.P. cuff to allow

maximum freedom of movement.

Record the patients pulse, B.P. before the test. Emergency drugs and resuscitation equipments should be kept ready.

Target heart rate should be evaluated before test.

TARGET HEART RATE = 220 - AGE OF PATIENT.

2. PERFORMANCE PHASE
Tread Mill is a motorized device that has an

adjustable conveyer belt. It has a maximum speed of 1 to 10 miles/hr. The conveyer belt can be adjusted from a horizontal position to 22% gradient. It allows the client to walk or run on slopes at all different stages.

TREAD MILL TEST

 Total duration of T.M.T is 18 mins which includes 6 stages of 3 mins. Normal speed of T.M.T is 4 km/hr.

Maximum speed of T.M.T is 7 km/hr. T.M.T starts with a speed of 2 km/hr.

PROTOCOLS
: It means that a written plan specifying the

procedures to be followed in giving a particular test.

There are 3 protocols. 1. Elstends protocol.

2. Balke & Naughton protocol.

3. Modified Bruse protocol.

ELSTENDS PROTOCOL Gradient remains constant &

speed increase in every 3 mins.

BALKE & NAUGHTON PROTOCOL

Speed remains constant

&
gradient increase in every 3 mins.

MODIFIED BRUCE PROTOCOL

Both angle of inclination and speed

increase in every 3mins.

 Record the clients B.P, heart rate, rhythm strip

and activity level at specified intervals.

Monitor the client for chest pain, arrhythmias, ST segment changes and changes in B.P. Make frequent observation throughout testing for any cardiac symptoms include extreme dyspnea, claudication and vertigo.

REASON FOR TERMINATION OF TEST

Chest pain.

Severe fatigue. Greatly increased heart rate a(age related).

20-29 yrs. = 170 Bpm. 30-39 yrs. = 160 Bpm. 40-49 yrs. = 150 Bpm. 50-59 yrs. = 140 Bpm. 60-69 yrs. = 130 Bpm.

 Untoward signs and symptoms of myocardial

ischemia or heart failure. Failure of systolic B.P. to rise or a drop in B.P. (below resting levels). Sudden development of bradycardia. Severe hypertension. Severe dyspnea.

 ST segment depression (>2-4cm).

A sudden loss of co-ordination(cerebral ischemia).

Serious cardiac dysrhythmia.

POST- EXERCISE RECOVERY PERIOD

After the procedure, assist the client to a chair or

bed for recovery. Periodically monitor the clients B.P, heart rate and rhythm strip for at least 15 mins. After test completion or until the E.C.G. returns to base line.

Ask the patient to inform if he experience any cardiovascular symptoms ( chest pain, shortness of breath or dizziness). Restrict the patient from taking a hot shower for 1 to 2 hrs. following the test.
Patient should be told that they may experience

fatigue and muscle soreness and to avoid heavy exertion that day.

DOBUTAMINE STRESS TEST

DEFINITION :This is also known as chemical stress test which

includes Chemically exercising the heart with controlled Infusion of dobutamine. :This is indicated for the patients who is not able to Perform physical stress test.