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Cardiovascular Risk Factors. Non-modifiable Age Gender Family History. Modifiable Hypertension Smoking Diabetes Hyperlipedemia Other: Homocystine levels CRP levels Sedentary life style obesity. Cardiovascular Evaluation. History Blood Pressure Pulse Auscultation CXR EKG

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cardiovascular risk factors
Cardiovascular Risk Factors
  • Non-modifiable
    • Age
    • Gender
    • Family History
  • Modifiable
    • Hypertension
    • Smoking
    • Diabetes
    • Hyperlipedemia
    • Other:
      • Homocystine levels
      • CRP levels
      • Sedentary life style
      • obesity
cardiovascular evaluation
Cardiovascular Evaluation
  • History
  • Blood Pressure
  • Pulse
  • Auscultation
  • CXR
  • EKG
  • Stress EKG
  • Scintigraphy – Thallium
  • Echocardiograms
  • Angiography
exercise stress testing
Exercise Stress Testing
  • Pathophysiology:
    • At rest, there may be adequate coronary blood flow, with exercise, supply may not keep up with demand leading to characteristic ST segment changes and other end points due to obstruction.
    • At least a 70-80%occlucions is needed before coronary stenosis (obstruction) is reliably detected by this test.
    • Significant coronary artery disease can exist with a negative Exercise Stress Test.
indications for stress testing
Indications for Stress Testing
  • Evaluation of patients with suspected coronary artery disease (CAD).
    • Typical Angina Pectoris
    • Atypical Angina Pectoris
  • Evaluation of patients with known coronary artery disease (CAD).
    • After myocardial infarction
    • After intervention
  • Evaluation of exercise capacity
  • Evaluation of cardiac rhythm disorders
preparation for stress testing
Preparation for Stress Testing
  • History
    • Type, character, durations, radiation, position of chest pain
    • Factors that increase or decrease chest pain
    • Associated symptoms i.e. SOB, Diaphoresis, leg pain, etc
    • Other illnesses:

- HTN, DM, COPD, >lipids, CNS disease, Physical Limitations

    • Medications
    • General Activity level
preparation for stress testing1
Preparation for Stress Testing
  • Physical Examination
    • General appearance, gait and mobility
    • Cardiac auscultation and palpation
    • Pulmonary Exam
    • Vascular- bruits, pulses
    • Musculoskeletal – limb strength and mobility
  • Laboratory Studies
    • Screening chemistry and hematologic profiles
    • Resting ECG
contraindications to stress testing
Contraindications to Stress Testing
  • Acute myocardial infarction or unstable angina
  • Acute cardiac inflammation, pericarditis, endocarditis, or myocarditis
  • Severe congestive heart failure
  • Uncontrolled sustained ventricular arrhythmias, symptomatic supraventricular arrhythmias or high-grade block
  • Hemodynamically significant aortic stenosis
contraindications to stress testing1
Contraindications to Stress Testing
  • Severe hypertension (>200/>100)
  • Active thromboembolic processes within past 3 months
    • Pulmonary embolism
    • Deep vein thrombosis
  • Poor candidate for exercise
  • Extreme obesity, i.e. Exceeds equipment capacity, usually can’t do over 350 lb.
  • Severe mental or physical disabilities
possible contraindications to stress testing based on resting ecg
Possible Contraindications to Stress Testing based on Resting ECG
  • ST-segment changes 1 mm or greater, either depression or elevation
  • Ventricular strain patterns or hypertrophy
  • T-wave inversions
  • Left bundle branch block
  • Right bundle branch block, if significant
  • Prolonged QT interval
equipment for stress testing
Equipment for Stress Testing
  • Treadmill or bicycle or steps
  • ECG machine
  • Blood Pressure Cuff
  • Computer is a ‘nice to have’
  • ACLS Certification
  • Exit Strategy
  • Good Help* (it takes two to test)
normal response to stress testing
Normal Response to Stress Testing
  • Heart rate increases
  • Blood pressure increases
  • Cardiac output increases
  • Total peripheral resistance decreases
  • Dysrhythmias – isolated unifocal PVC’s and PAC’s not of concern, usually suppressed at increased heart rate
  • Oxygen consumption increases

(1MET = 3.5 ml O2/Kg./min =

1 metabolic equivalent)

abnormal response to stress testing
Abnormal Response to Stress Testing
  • Heart rate fails to rise above 120 or unable to attain target heart rate of 85% of max
  • Blood pressure shows a drop in systolic
  • Patient physically unable to complete test
  • Marked hypertension, >260/115
  • Chest Pain and/or unusual shortness of breath
normal response of ecg to stress testing
Normal Response of ECG to Stress Testing
  • ECG Changes
    • QRS complex decreases in size
    • J point depresses, resulting in up sloping of ST segment
    • ST segment returns to baseline by 80 milliseconds
    • PR segment may down slope – thus baseline is defined as PQ junction
    • R amplitude may decreaseat rates that go above 130
    • T wave decreases
abnormal response of ecg to stress testing
Abnormal Response of ECG to Stress Testing
  • ECG Changes
    • Horizontal or down sloping ST segments
    • ST segment depressed or elevated
    • ST segment does not return to baseline by 80 milliseconds
    • U or T wave inversion
    • Dysrhythmias – rate dependent blocks above first degree, WPW appears, Atrial fib/flutter, multiform and/or increasing PVC’s, V-tach occurs
protocols
Protocols
  • EST’s utilize standard protocols to progressively increase cardiovascular work load in a uniform and reproducible manner.
  • Work load is expressed in METS (1 MET = 3.5ml O2 /Kg/min).
    • 1 MET (3.5 ml) = basal O2 requirement
    • 5 METS (17.5 ml) = activities of daily life
    • 13 METS (45.5 ml) = good work out and excellent prognosis
  • Myocardial O2 consumption is estimated by multiplying HR by BP to obtain the ‘double product’.
    • Double product < 20,000 is low heart work load
    • Double product > 29,000 indicates high heart work load
reasons to terminate test
Reasons to Terminate Test
  • Absolute
    • Patient requests to stop
    • Technical/mechanical difficulties
    • Suspected MI
    • CNS symptoms
    • Serious dysrhythmias
    • Drop in systolic BP
    • Severe Angina
    • ST elevation > 1mm
    • Poor perfusion
  • Relative
    • > 2mm of ST depression
    • Increasing chest pain
    • Tired or SOB
    • Wheezing
    • Claudication
    • SVT
    • SBP>260, DBP>115
    • Exercise induced BBB
    • 85% of max predicted HR
    • > 15 METS
    • > 30,000 double product