Interpreting The Exercise Test

Dyna Evalina Syahlul, BMedSci, SpJP

RSPAD Gatot Soebroto - DITKESAD

Indications
1.
2.
3.
4.
5.
6.

To diagnose the presence or absence of heart disease

To determine the prognosis and severity of the disease
To evaluate the effect of medical and surgical therapy
Risk stratification
To evaluate functional capacity
To develop an exercise prescription or evaluate an
individual training program.

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

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

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.

Absolute contraindications to test

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

A recent significant change in resting ECG suggestive significant

ischemia
Recent MI within 2 days or other acute cardiac event
Unstable angina
Uncontrolled cardiac arrhythmias
Known severe left main disease
Uncompensated HF
Acute pulmonary embolus or pulmonary infarction (within 3 months)
Suspected or confirmed dissecting aneurysm
Hyperthyroidsm
Acute myocarditis or pericarditis
Uncooperative patient

Relative contraindications to test

Known left main artery stenosis
2.
Moderately stenostic valvular heart disease
3.
Electrolyte abnormalities
4.
Severe arterial hypertension ( SBP > 200 mmHg or DBP > 110 mmHg )
5.
Assymetrical septal hypertrophy
6.
HCM or other forms of outflow tract obstruction
7.
Compensated heart failure
8.
Ventricular aneurysm
9.
Uncontrolled metabolic disease ( DM, Thyrotoxicosis )
10. High degree AV block
11. Tachy or bradyarhytmias
12. Mental or physical impairment leading to inability to exercise adequately.
1.

Equipment and Protocols

Equipment:

Treadmill
Cycle
Arm Ergometery
Monitor and EKG Recorder
Thallium, Echocardiography

Protocol:
Maximal:
Bruce Protocol is the most commonly used test. Vigorous with the
first stage commencing at 5 METs. Speed and grade is increased
every three min. Generally symptom-limited; adequate tests reach
85% of MHR.

Sub-Maximal:
Tests that involve termination at a pre-determined heart rate. PostMI patients generally are set at 60% of MHR, 5 METs or 120 bpm.

Performing the Test

Preparing

the Patient
Monitoring the Patient
Terminating the Test
Recovery of the
Patient

Preparing the Patient

Instructions:
No eating two hours before test; no
consumption of alcohol, caffeine, or
tobacco three hrs before.
Comfortable clothing.
Medications determined by functional vs.
diagnostic testing.

Skin Preparation
Hair shaved; abrasive rub; tap test.

Appropriate Blood Pressure cuff.

Consent.

Preparing the Patient

Pre-Test

Checklist

Equipment and safety check

Informed Consent
Pre-test history and physical
examination
Electrode skin preparation
Resting ECG reviewed
Standing ECG and BP
Patient Demonstration
Patient Questions

Monitoring the Patient

Borg RPE Scale

Pre-Test
12 lead ECG supine and standing.
BP supine and standing.

Exercise
12 lead last 15 sec of each stage.
BP and RPE at the end of each stage.

Post-Test
12 lead ECG immediately after exercise,
then every 1 to 2 minutes until return to
baseline.
BP: immediately after exercise, then every
1 to 2 minutes until return to baseline.
Follow symptoms.

6
7 Very, very light
8
9 Very light
10
11 Fairly light
12
13 Somewhat hard
14
15 Hard
16
17 Very hard
18
19 Very, very hard
20

Terminating the Test

All treadmill stress tests should be

completed to a symptom-limited
endpoint, if possible.
85% of maximal predicted heart rate
is required to identify a test as
adequate.

Recovery of the Patient

Have the patient lie down and continuously

observe.
Auscultate for abnormal heart and lung
sounds.
Monitor until clinically stable and
electrocardiogram has returned to normal.
ECG changes in recovery just as ominous as
those occurring during exercise.

What needs to be evaluated

1.
2.
3.
4.
5.
6.

The HR and BP response

The presence or absence of symptoms
The presence or absence of arrythmias
The aerobic capacity
The presence of myocardial ischemia
A statement about patients risk for coronary disease or
future coronary events.

SIGNS OF ISCHEMIA ( ECG CHANGES )

Normal response :

Shortening PR segment
P wave becomes taller
Repolarization wave of the atria (Ta wave) increases
Downsloping PR segment
Depression PQ junction
Depression J point, Rapid upsloping ST segment
Shortening QT interval

BASELINE : PR segment ~ usually downsloping

PQ junction (end of PR segment and beginning QRS )
J point as reference point (60 or 80 msec after J point )

Exercise Stress Test Essentials

Diagnostic of Myocardial Ischemia

Upsloping ST segment that is 1.5 mm at 80 msec past the J
point.
Horizontal or downsloping ST segment depression 1 mm at 60
msec past the J point.
ST segment elevation (and J point elevation) of 1 mm or more at
80 msec past the J point.
ST segment elevation in AVR ~
reliable as horizontal ST segment
depression.

Normal

Rapid
Upsloping

Minor ST
Depression

Slow Upsloping

Horizontal

Downsloping

Elevation (non
Q lead)

Elevation (Q
wave lead)

Criteria to define a NORMAL exercise test

Normal : reaching 85% of maximal predicted HR.

Adequate : reaches 80% of maximal HR, stops due to
fatigue and describes a high rate of perceived exertion.
Inadequate : No abnormal responses, but pt achieves <
85% of max HR and a low level perceived exertion.

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

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 (BBlocker??)

Exercise Test Report

Five main responses :
The presence of myocardial ischemia
The heart rate and blood pressure response
Symptoms
Dysrhythmias
Maximal aerobic capacity

Function is Everything!

Thank
You