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ACSM’s Guidelines For Exercise Testing & Prescription PowerPoint PPT Presentation

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ACSM’s Guidelines For Exercise Testing & Prescription. Chapter 6 Interpretation Of Clinical Test Data. World Health Organization : - PowerPoint PPT Presentation

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ACSM’s Guidelines For Exercise Testing & Prescription

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ACSM’s Guidelines For Exercise Testing & Prescription

Chapter 6

Interpretation Of Clinical Test Data

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World Health Organization :

“The primary purpose of an exercise test is to determine the responses of the individual to [exercise] efforts at given levels and from this information to estimate probable performance in specific life and occupational situations.”

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  • Bayes Theorem states :

    “The post-test probability of a patient having disease is determined by the disease probability before the test and by the probability that the test will provide a true result.”

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  • Bayes Theorem speaks to the issue that an exercise test must have two qualities : sensitivity and specificity.

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  • Sensitivity refers to the percent of patients tested who have CAD and who demonstrate a positive (abnormal) test outcome - i.e. - how often the test will identify a sick individual (~ 70%).

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  • Specificity refers to the percent of healthy people without CAD who also demonstrate a negative (normal) stress test - i.e. - how often the test is able to identify a healthy individual (~80%).

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False Negative Tests

  • Failure to reach ischemic threshold

  • Monitoring an insufficient # of leads

  • Failure to recognize non-EKG signs & symptoms associated w/ CAD

  • Collateralization that masks angiographically significant CAD

  • Technical & observer error

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False Positive Tests

  • Drugs - digitalis preparations

  • Wolff-Parkinson-White syndrome

  • Left Bundle Branch Block

  • Cardiac hypertrophy

  • Hypokalemia

  • Mitral valve prolapse

  • Coronary spasm - Prinzmetal angina

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Predictive Value

  • The predictive value of exercise testing is a measure of how accurately a test result correctly identifies the presence or absence of CAD in the test population.

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  • Using exercise tests to screen large numbers of asymptomatic people is of questionable value.

  • Testing individuals with symptoms is a much more practical reason for an exercise test.

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  • Symptoms which make Bayesian senseand which increase the predictive value of an exercise test would be :

    • Angina, chest discomfort/pressure

    • Anginal equivalents

    • Recurrent palpitations w/ exercise

    • SOB w/ exertion that is unexpected

    • Dizziness, syncope, vertigo, diplopia w/ ex.

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Imaging Stress Tests

  • Generally speaking, echocardiogaphic studies will slightly improve the sensitivity & specificity of simple GXT’s .

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  • Exercise GXT’s with technetium-Tc99m sestamibi imaging or thallium chloride-201 imaging tend to improve the sensitivity and specificity of the test to ~ 85+%.

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  • The sensitivity and specificity of any test is improved by the number of diseased vessels.

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