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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

Treadmill Stress Testingfor the Primary Care Physician

Francis G. O’Connor, MD, FACSM

Primary Care Sports Medicine

objectives
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
slide5

Playford

Dietche

Howe

Gonzales

exercise test terminology
Exercise Test Terminology
  • The Electrocardiogram
  • VO2max
  • METs
  • Myocardial Oxygen Consumption
slide10

What is

VO2max?

maximal oxygen uptake vo2max
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)
slide12

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)

metabolic equivalents mets
Metabolic Equivalents (METs)
  • 1 MET = 3.5 ml O2 per kilogram of body weight per minute
key met values part 1
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
key met values part 2
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
myocardial mo 2
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,...
myocardial oxygen consumption
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
objectives19
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
performance of the exercise stress test
Performance of the Exercise Stress Test
  • Indications/Contraindications
  • Running the Exercise Test
  • Physician Responsibilities
acsm s guidelines for exercise testing and prescription

ACSM’s Guidelines for Exercise Testing and Prescription

ACSM. Lippincott, Williams & Wilkins

6th Edition 2000

indications for exercise testing
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.
class i indications for performing an exercise test
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
class ii indications for performing an exercise test
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.
class iii indications for performing an exercise test
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.
contraindications to gxt testing absolute
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
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
So What Do You Do….
  • 39 yo female with risk factors and a squirrelly story….
which protocol
Which Protocol?
  • Vast Majority (82+%) use BRUCE
  • So, why not you?
how to read an exercise ecg
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?
symptom sign limited testing endpoints when to stop
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...

problems with age predicted maximal heart rate
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
heart rate drop in recovery vs mets
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???
slide37

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.

slide38
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.
should heart rate drop in recovery be added to et
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
Heart Rate Drop in Recovery
  • Probably not more predictive than Duke Treadmill Score or METs
  • Studies including censoring and CV mortality needed
objectives43
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
Interpretation of the Exercise Stress Test

Must Contain Following Elements:

  • Exercise Capacity
  • Hemodynamic
  • Clinical
  • Electrocardiographic
  • Optional Other Stuff…..
positive vs suggestive
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
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
duke treadmill score for stable cad
DUKE Treadmill Score for Stable CAD

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

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

E-I = Exercise Induced

but can physicians do as well as the scores

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

objectives50
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
Special Considerations in Athletes
  • Indications
  • Athletic Heart Syndrome
  • Test Interpretation
objectives52
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
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

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
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
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

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
slide59

Chris

“It’s My

Fault”

Chris

“Papa

Teet”

Thaddeus

Flateus

Chris

“Don’t Call

Me Lt”