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Treadmill Stress Testing for the Primary Care Physician. Francis G. O’Connor, MD, FACSM Primary Care Sports Medicine. Objectives. Review essential Exercise Test Terminology Describe the Performance of the Exercise Stress Test Discuss Interpretation of the Exercise Stress Test

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Treadmill stress testing for the primary care physician l.jpg

Treadmill Stress Testingfor the Primary Care Physician

Francis G. O’Connor, MD, FACSM

Primary Care Sports Medicine


Objectives l.jpg

Objectives

  • Review essential Exercise Test Terminology

  • Describe the Performance of the Exercise Stress Test

  • Discuss Interpretation of the Exercise Stress Test

  • Discuss Special Considerations in Athletes

  • Review Indications for “would-be” Athletes


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Boring?.....


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Playford

Dietche

Howe

Gonzales


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Exercise Test Terminology

  • The Electrocardiogram

  • VO2max

  • METs

  • Myocardial Oxygen Consumption


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The Electrocardiogram


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The Electrocardiographic Response


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What is

VO2max?


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Maximal Oxygen Uptake (VO2max)

  • Greatest amount of oxygen an individual utilizes with maximal exercise (ml O2 per kilogram per minute)

  • “Gold Standard” for cardiorespiratory fitness

  • Fick Equation

    • VO2max = (HRmax x SVmax) x (CaO2max - CvO2max)


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Diffusion

Ventilation

Perfusion

FICK EQUATION

(220 - Age)

Sinus Node Dysfunction

Drugs (e.g., B - blockers)

PaO2

Hgb [ ]

SaO2

  • Skeletal Muscles

    • Aerobic Enzymes

    • Fiber Type

    • Muscle Disease

  • Capillary Density

Genetic Factors (Heart Size)

Conditioning Factors Contractility/Afterload/Preload

Disease Factors

Wall Motion/Ventricular Fxn Valve Stenosis or Regurgitation

VO2max = (HRmax X SVmax) X (CaO2max - CvO2max)


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The MET

METS


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Metabolic Equivalents (METs)

  • 1 MET = 3.5 ml O2 per kilogram of body weight per minute


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Key MET Values (part 1)

  • 1 MET = "Basal" = 3.5 ml O2 /Kg/min

  • 2 METs = 2 mph on level

  • 4 METs = 4 mph on level

  • < 5METs = Poor prognosis if < 65;

    • limit immediate post MI;

    • cost of basic activities of daily living


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Key MET Values (part 2)

  • 10 METs = As good a prognosis with medical therapy as CABS

  • 13 METs = Excellent prognosis, regardless of other exercise responses

  • 16 METs = Aerobic master athlete

  • 20 METs = Ooh lah lah Aerobic athlete


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Myocardial (MO2)

  • Accurate measurement requires cardiac catheterization

    • Coronary Flow x Coronary a - VO2 difference

  • Wall Tension (Pressure x Volume, Contractility, Stroke Work, HR)

  • Systolic Blood Pressure x HR

    • Angina and ST Depression usually occurs at same Double Product in an individual** Direct relationship to VO2 is altered by beta-blockers, training,...


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    Myocardial Oxygen Consumption

    • Indirectly measured as the “Double Product”

    • “Double Product” = HR x systolic blood pressure

    • A normal value is greater than 20,000 – 25,000


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    Objectives

    • Review essential Exercise Test Terminology

    • Describe the Performance of the Exercise Stress Test

    • Discuss Interpretation of the Exercise Stress Test

    • Discuss Special Considerations in Athletes

    • Review Indications for “would-be” Athletes


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    Performance of the Exercise Stress Test

    • Indications/Contraindications

    • Running the Exercise Test

    • Physician Responsibilities


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    ACSM’s Guidelines for Exercise Testing and Prescription

    ACSM. Lippincott, Williams & Wilkins

    6th Edition 2000


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    Indications for Exercise Testing

    • Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

    • Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

      • II a: weight of evidence is in favor of usefulness/efficacy.

      • II b: usefulness is less well established by the evidence.

    • Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.


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    Class I Indications for Performing an Exercise Test

    • Diagnosis of CAD in adults with intermediate pretest probability of disease

    • Assess functional capacity and prognosis of patients with:

      • Known CAD

      • Recent uncomplicated myocardial infarction

    • Evaluate symptoms of recurrent, exercise-induced arrhythmias


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    Class II Indications for Performing an Exercise Test

    • 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.


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    Class III Indications for Performing an Exercise Test

    • 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.


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    Pre Test Probability of Coronary Disease by Symptoms, Gender and Age


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    Recent acute MI

    Unstable angina

    Ventricular tachycardia

    Dissecting aortic aneurysm

    Acute CHF

    Severe aortic stenosis

    Active myocarditis

    Thrombophlebitis or intracardiac thrombi

    Recent pulmonary embolus

    Acute infection

    Contraindications to GXT Testing: Absolute


    Contraindications to gxt testing relative l.jpg

    Uncontrolled severe hypertension

    Moderate aortic stenosis

    Severe subaortic stenosis

    Supraventricular dysrhythmias

    Ventricular aneurysm

    Complex ventricular ectopy

    Cardiomyopathy

    Uncontrolled metabolic disease

    Recurrent infectious disease

    Complicated pregnancy

    Contraindications to GXT Testing: Relative


    So what do you do l.jpg

    So What Do You Do….

    • 39 yo female with risk factors and a squirrelly story….


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    Comparison of Tests for Diagnosis of CAD


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    Which Protocol?

    • Vast Majority (82+%) use BRUCE

    • So, why not you?


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    How to read an Exercise ECG

    • Good skin prep

    • PR isoelectric line

    • Not one beat

    • Three consistent complexes

    • Averages can help

    • Garbage in, garbage out

    • Why watch during recovery?


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    Symptom-Sign Limited Testing Endpoints – When to stop!

    • Dyspnea, fatigue, chest pain

    • Systolic blood pressure drop

    • ECG--ST changes, arrhythmias

    • Physician Assessment

    • Borg Scale (17 or greater)

    MHR=220-age...


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    Problems with Age-Predicted Maximal Heart Rate

    • Which Regression Formula? (2YY - .Y x Age)

    • Big scatter around the regression line

      • poor correlation [-0.4 to -0.6]

      • One SD is plus/minus 12 bpm

    • A percent value target will be maximal for some and sub-max for others

    • Confounded by Beta Blockers

    • Borg scale is better for evaluating Effort

    • Target Heart Rate does have a place as an Indicator of Effort or adequacy of test


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    The MET

    METS


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    Heart Rate Drop in Recovery vs METs

    • 10 to 15% increase in survival per MET

    • METS can be increased by 25% by a training program

    • What about Heart Rate Recovery???


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    Heart Rate Recovery and Treadmill Exercise Score as Predictors of Mortality in Patients Referred for Exercise ECG

    Nishime EO, et al: JAMA, September 20, 2000.

    Vo 284, No 11, 2000.


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    • Following the GXT, patients walked for 2 minutes at 1.5 mph and at a grade of 2.5%.

    • Heart rate recovery was the difference in heart rate at peak exercise and one minute into recovery; 12/min or less was considered abnormal.

    • 9454 patients were followed for a median of 5 years; 20 % had abnormal heart rate recovery; they represented 8% of deaths vs. 2%; hazard ratio of 4.16.

    • Heart rate recovery is an independent predictor of mortality.


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    Should Heart Rate Drop in Recovery be added to ET?

    • Long known as a indicator of fitness: perhaps better for assessing physical activity than METs

    • Recently found to be a predictor of prognosis after clinical treadmill testing

    • Does not predict angiographic CAD

    • Studies to date have used all-cause mortality and failed to censor


    Heart rate drop in recovery l.jpg

    Heart Rate Drop in Recovery

    • Probably not more predictive than Duke Treadmill Score or METs

    • Studies including censoring and CV mortality needed


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    Objectives

    • Review essential Exercise Test Terminology

    • Describe the Performance of the Exercise Stress Test

    • Discuss Interpretation of the Exercise Stress Test

    • Discuss Special Considerations in Athletes

    • Review Indications for “would-be” Athletes


    Interpretation of the exercise stress test l.jpg

    Interpretation of the Exercise Stress Test

    Must Contain Following Elements:

    • Exercise Capacity

    • Hemodynamic

    • Clinical

    • Electrocardiographic

    • Optional Other Stuff…..


    Positive vs suggestive l.jpg

    ST Depression

    → or ↓ ≥ 1mm at 60msec

    ↑ ≥ 1.5mm at 80msec

    ST Elevation

    ≥ 1mm at 60msec

    ST Depression

    → or ↓ 0.5 - 1mm at 60msec

    ↑ 0.7 - 1.5mm at 80msec

    ST Elevation

    0.5 – 1mm at 60msec

    Positive vs Suggestive


    Negative vs inconclusive l.jpg

    Above criteria not met and pt exercised to at least 85% MPHR

    Pt did not reach 85% MPHR, but no evidence of ischemia (B-Blocker??)

    Negative vs Inconclusive


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    DUKE Treadmill Score for Stable CAD

    METs - 5 X [mm E-I ST Depression] - 4 X [Treadmill Angina Index]

    ******Nomogram*******

    E-I = Exercise Induced


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    Duke Treadmill Score (uneven lines, elderly?)


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    But Can Physicians do as well as the Scores?

    954 patients - clinical/ETT reports

    Sent to 44 expert cardiologists, 40 cardiologists and 30 internists

    Scores did better than all three but was most similar to the experts


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    Objectives

    • Review essential Exercise Test Terminology

    • Describe the Performance of the Exercise Stress Test

    • Discuss Interpretation of the Exercise Stress Test

    • Discuss Special Considerations in Athletes

    • Review Indications for “would-be” Athletes


    Special considerations in athletes l.jpg

    Special Considerations in Athletes

    • Indications

    • Athletic Heart Syndrome

    • Test Interpretation


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    Objectives

    • Review essential Exercise Test Terminology

    • Describe the Performance of the Exercise Stress Test

    • Discuss Interpretation of the Exercise Stress Test

    • Discuss Special Considerations in Athletes

    • Review Indications for “would-be” Athletes


    Does the patient need a gxt l.jpg

    Does the patient need a GXT?

    • Controversial

    • ACSM- Must be able to distinguish:

      • Moderate vs. vigorous exercise

      • Apparently healthy vs. higher risk

      • Older vs. younger


    Acsm recommendations for medical examination and exercise testing prior to participation l.jpg

    Low Risk

    Mod Risk

    High Risk

    Moderate

    Exercise

    Not

    Necessary

    Recommend

    Not

    Necessary

    Vigorous Exercise

    Recommend

    Recommend

    Not

    Necessary

    ACSM Recommendations for Medical Examination and Exercise Testing Prior to Participation


    Acsm initial risk stratification by age and cardiac risk l.jpg

    ACSM Initial Risk Stratification by Age and Cardiac Risk

    • Moderate Risk

      • “Older” individuals

      •  2 risk factors

    • Low Risk

      • Men < 45, Women <55

      • No cardiac symptoms

      • 1 risk factor

    • Cardiac Risk Factors

    • Cigarette smoking

    • Fam Hx. of early CAD

    • LDL >130)

    • Hypertension

    • Impaired fasting gluc

    • (>110mg/dL)

    • Obesity (BMI >30)

    • Sedentary lifestyle

    “Positive” Risk Factor: High serum HDL (>60)

    “Positive” Risk Factor:

    “Positive” Risk Factor:


    Acsm initial risk stratification by age and cardiac risk56 l.jpg

    ACSM Initial Risk Stratification by Age and Cardiac Risk

    • Low Risk

      • Men < 45, Women <55

      • No cardiac symptoms

      • 1 risk factor

    • Moderate Risk

      • “Older” individuals

      •  2 risk factors

    • High Risk

      • Signs or Symptoms of cardiac dz

      • Known cardiac, pulmonary or metabolic (DM) disease.

    • Signs/Sx. CV Disease

    • Chest pain or anginal equiv

    • Dyspnea w/ mild exertion

    • Dizziness or syncope

    • Orthopnea/PND

    • Ankle edema

    • Palpitations or tachycardia

    • Intermittent claudication

    • Fatigue w/ normal activities


    Who needs a gxt l.jpg

    Not

    Necessary

    Not

    Necessary

    Who Needs a GXT?

    • Athlete with known CAD

    • Anyone with symptoms of CAD

    • Moderate risk patient for vigorous exercise

    • Anyone with known medical disease


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    Questions???


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    Chris

    “It’s My

    Fault”

    Chris

    “Papa

    Teet”

    Thaddeus

    Flateus

    Chris

    “Don’t Call

    Me Lt”


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