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Symptom-Sign Limited Testing Endpoints – When to stop
Symptom-Sign Limited Testing Endpoints – When to stop
Should Heart Rate Drop in Recovery be added to ET
Should Heart Rate Drop in Recovery be added to ET
How to Perform and Interpret an Exercise Test
How to Perform and Interpret an Exercise Test
How to Perform and Interpret an Exercise Test
How to Perform and Interpret an Exercise Test
Duke Treadmill Score (uneven lines, elderly
Duke Treadmill Score (uneven lines, elderly
“All-comers” prognostic score
“All-comers” prognostic score
Thank you
Thank you
Thank you
Thank you
Thank you
Thank you
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How to Perform and Interpret an Exercise Test

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1How to Perform and Interpret an 23What about Heart Rate Recovery???
Exercise Test. V. Froelicher, MD Professor 24
of Medicine Stanford University VA Palo 25
Alto HCS. 26Maximal Heart Rate vs METs. Diagnosis
2Key Points of Exercise Testing. Manual vs Prognosis.
SBP measurement (not automated) most 27Diagnosis CAD Prognosis with
important for safety Adjust to clinical symptoms/CAD After MI Using Ventilatory
history (couch potatoes) No Age predicted Gas Analysis Special Groups. AHA/ACC
Heart Rate Targets The BORG Scale of Exercise Testing Guidelines:
Perceived Exertion METs not Minutes Fit Recommendations for Exercise Testing.
protocol to patient (RAMP) Avoid HV and 28AHA/ACC Exercise Testing Guidelines:
cool down walk Use standard ECG analysis/ Recommendations for Exercise Testing.
3 minute recovery/ use scores Heart rate Special Groups: Pre- and
recovery Expired Gas Analysis? Post-Revascularization Women Asymptomatic
3BORG SCALE. Very, very light. Very Pre-surgery Valvular Heart Disease Cardiac
light. Fairly light. Somewhat hard. Hard. Rhythm Disorders.
Very hard. Very, very hard. 6. 7. 8. 9. 29The ACC/AHA Guidelines for the
10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Diagnostic Use of the Standard Exercise
20. Test. Class I (Definitely appropriate) -
4Symptom-Sign Limited Testing Endpoints Adult males or females (including RBBB or
– When to stop! Dyspnea, fatigue, chest < 1mm resting ST depression) with an
pain Systolic blood pressure drop ECG--ST intermediate pre-test probability of
changes, arrhythmias Physician Assessment coronary artery disease based on gender,
Borg Scale (17 or greater). age and symptoms (specific exceptions are
5How to read an Exercise ECG. Good skin noted under Class II and III below). Class
prep PR isoelectric line Not one beat IIa (Probably appropriate) - Patients with
Three consistent complexes Averages can vasospastic angina.
help Garbage in, garbage out Three minute 30Pre Test Probability of Coronary
recovery. Disease by Symptoms, Gender and Age.
6Types of Exercise. Isometric (Static) 31Diagnostic Use, continued: Class IIb
weight-lifting pressure work for heart, (Maybe appropriate) – Patients taking
limited cardiac output, proportional to Digoxin with less than 1 mm resting ST
effort Isotonic (Dynamic) walking, depression. Patients with ECG criteria for
running, swimming, cycling Flow work for left ventricular hypertrophy with less
heart, proportional to external work than 1 mm ST depression. Patients with a
Mixed. high pre-test probability of coronary
7There are Two Types to Consider: artery disease by age, symptoms and
Myocardial (MO2) Internal, Cardiac gender. Patients with a low pre-test
Ventilatory (VO2) External, Total Body. probability of CAD by age, symptoms and
Oxygen Consumption During Dynamic Exercise gender.
Testing. 32Diagnostic Use, continued: Class III
8Myocardial (MO2). Coronary Flow x (Not appropriate) - 1. To use the ST
Coronary a - VO2 difference Wall Tension segment response in the diagnosis of
(Pressure x Volume, Contractility, Stroke coronary artery disease in patients who
Work, HR) Systolic Blood Pressure x HR demonstrate the following baseline ECG
Angina and ST Depression usually occurs at abnormalities: pre-excitation (WPW)
same Double Product in an individual ** syndrome; electronically paced ventricular
Direct relationship to VO2 is altered by rhythm; more than one millimeter of
beta-blockers, training,... resting ST depression; LBBB 2. To use the
9Problems with Age-Predicted Maximal ST segment response in the diagnosis of
Heart Rate. Which Regression Formula? (2YY coronary artery disease in MI patients.
- .Y x Age) Big scatter around the 33Comparison of Tests for Diagnosis of
regression line poor correlation [-0.4 to CAD.
-0.6] One SD is plus/minus 12 bpm 34Males. Choose only one per group.
Confounded by Beta Blockers A percent Variable. Circle response. Sum. <40=low
value target will be maximal for some and prob 40-60= intermediate probability
sub-max for others Borg scale is better >60=high probability. Maximal Heart
for evaluating Effort Do Not Use Target Rate. Exercise ST Depression. Age. Angina
Heart Rate to Terminate the Test or as the History. Hypercholesterolemia? Diabetes?
Only Indicator of Effort or adequacy of Exercise test. induced Angina. Total
test. Score: Less than 100 bpm = 30. 100 to 129
10Myocardial (MO2). Systolic Blood bpm = 24. 130 to 159 bpm =18. 160 to 189
Pressure x HR SBP should rise > 40 mmHg bpm =12. 190 to 220 bpm =6. 1-2mm =15.
Drops are ominous (Exertional Hypotension) > 2mm =25. >55 yrs =20. 40 to 55 yrs
Diastolic BP should decline. = 12. Definite/Typical = 5.
11Ventilatory (VO2). Cardiac Output x Probable/atypical =3. Non-cardiac pain =1.
a-VO2 Difference VE x (% Inspired Air Yes=5. Yes=5. Occurred =3. Reason for
Oxygen Content - Expired Air Oxygen stopping =5.
Content) External Work Performed 35Women. Choose only one per group.
****Direct relationship with Myocardial O2 <37=low prob 37-57= intermediate
demand and Work is altered by probability >57=high probability.
beta-blockers, training,... 36Indications for Exercise Testing to
12VO2 THE FICK EQUATION VO2 = C.O. x Assess Risk and prognosis in patients with
C(a-v)O2 C(a-v)O2 ~ k then, VO2 ~ C.O. symptoms or a prior history of coronary
13What is a MET? Metabolic Equivalent artery disease: Class I. Should be used:
Term 1 MET = "Basal" aerobic Patients undergoing initial evaluation
oxygen consumption to stay alive = 3.5 ml with suspected or known CAD. Specific
O2 /Kg/min Actually differs with thyroid exceptions are noted below in Class IIb.
status, post exercise, obesity, disease Patients with suspected or known CAD
states But by convention just divide ml previously evaluated with significant
O2/Kg/min by 3.5. change in clinical status. The ACC/AHA
14Key MET Values (part 1). 1 MET = Guidelines for the Prognostic Use of the
"Basal" = 3.5 ml O2 /Kg/min 2 Standard Exercise Test.
METs = 2 mph on level 4 METs = 4 mph on 37Prognostic Use, continued: Class IIb.
level < 5METs = Poor prognosis if < Maybe Appropriate for: Patients who
65; limit immediate post MI; cost of basic demonstrate the following ECG
activities of daily living. abnormalities: Pre-excitation (WPW)
15Key MET Values (part 2). 10 METs = As syndrome; Electronically paced ventricular
good a prognosis with medical therapy as rhythm; More than one millimeter of
CABS 13 METs = Excellent prognosis, resting ST depression; and LBBB. Patients
regardless of other exercise responses 16 with a stable clinical course who undergo
METs = Aerobic master athlete 20 METs = periodic monitoring to guide management.
Aerobic athlete. 38Prognostic Use, continued: Class IIa.
16Calculation of METs on the Treadmill. Probably Appropriate: None Class III.
METs = Speed x [0.1 + (Grade x 1.8)] + 3.5 Should not be used for prognostication:
3.5 Calculated automatically by Device! Patients with severe comorbidity likely to
Note: Speed in meters/minute conversion = limit life and/or consideration for
MPH x 26.8 Grade expressed as a fraction. revascularization procedures.
17METs---not Minutes (Report Exercise 39Endpoints for Prediction of Prognosis.
Capacity in METs). Can compare results Why is this even an issue?? Confusion
from any mode or Testing Protocol Can All-cause certainly best for
Optimize Test by Individualizing for interventional studies CV mortality more
Patient Can adjust test to 8-10 minute appropriate outcome for CV tests.
duration (aerobic capacity--not endurance) 40DUKE Treadmill Score for Stable CAD.
Can use prognostic power of METs. METs - 5 X [mm E-I ST Depression] - 4 X
18Estimated vs Measured METs. All [Treadmill Angina Index]
Clinical Applications based on Estimated ******Nomogram*******. E-I = Exercise
Estimated Affected by: Habituation (Serial Induced.
Testing) Holding on Deconditioning and 41Duke Treadmill Score (uneven lines,
Disease State Measured Requires a elderly?).
Mouthpiece and Delicate Equipment Measured 42“All-comers” prognostic score. SCORE =
More Accurate and Permits measurement of (1=yes, 0=no) METs<5 + Age>65 +
Gas Exchange Anaerobic Threshold and Other History of CHF + History of MI or Q wave
Mxments (VE/VCO2) Prognostic in CHF and a=0, b=1, c=2, d=more than 2.
Transplantation. 43But Can Physicians do as well as the
19WORK TREADMILL. RAMP. WORK. WORK. Scores? 954 patients - clinical/TMT
TIME. TIME. reports Sent to 44 expert cardiologists,
20Why Ramp? Started with Research for AT 40 cardiologists and 30 internists Scores
and ST/HR but clinicaly helpful did better than all three but was most
Individualized test Using Prior Test, similar to the experts.
history or Questionnaire Linear increase 44Key Points of Exercise Testing. Manual
in heart rate Improved prediction of METs SBP measurement (not automated) most
Nine-minute duration for most patients important for safety Adjust to clinical
Requires special Treadmill controller or history (couch potatoes) No Age predicted
manual control by operator. Heart Rate Targets The BORG Scale of
21Should Heart Rate Drop in Recovery be Perceived Exertion METs not Minutes Fit
added to ET? Long known as a indicator of protocol to patient (RAMP) Avoid HV and
fitness: perhaps better for assessing cool down walk Use standard ECG analysis/
physical activity than METs Recently found 3 minute recovery/ use scores Heart rate
to be a predictor of prognosis after recovery Expired Gas Analysis?
clinical treadmill testing Does not 45Question 1. What is the most important
predict angiographic CAD Studies to date prognostic measurement from the exercise
have used all-cause mortality and failed test? 1. BORG scale estimate 2. ST
to censor. depression 3. Exercise time 4. Exercise
22Heart Rate Drop in Recovery. Probably capacity.
not more predictive than Duke Treadmill 46Question 2. What is the most
Score or METs Studies including censoring appropriate indicator of a maximal effort?
and CV mortality needed Should be 1. BORG scale 2. ST depression 3. Heart
calculated along with Scores as part of rate 4. Exercise capacity.
all treadmill tests. 47All references are available as pdf
23Heart Rate Drop in Recovery vs METs. files on www.cardiology.org along with
10 to 15% increase in survival per MET Can scores and sample report generator.
be increased by 25% by a training program 48Thank you.
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How to Perform and Interpret an Exercise Test

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