EXERCISE ECG TESTING

INTRODUCTION:

 The exercise ECG test is a popular, well-established, inexpensive

procedure for answering important clinical questions related to
exercise tolerance and heart disease.
 It is often included as a diagnostic service in the primary care setting as
well as in the offices of cardiovascular specialists.
 The exercise ECG test indirectly detects myocardial ischemia, which is
the physiologic consequence of coronary obstruction.
 The sensitivity and specificity of this test have been derived from
studies correlating the ECG response to exercise with coronary
angiographic data (to document the anatomic abnormality).
 Important determinants of the pretest probability of coronary heart
disease and therefore of the diagnostic accuracy of exercise ECG
testing are:
1. Patient gender.
2. Age.
3. Coronary risk factors.
4. Characteristics of the chest pain.

TEST LIMITATIONS:

 There are two limitations to exercise ECG testing for the diagnosis of
CHD:
1. Exclusion of subsets of patients from the test.
2. Limited sensitivity and specificity compared to coronary
angiography.
Patient selection:

 One of the principal limitations of exercise ECG testing is that two

groups of patients are excluded from conventional testing:
1. Patients who are unable to exercise sufficiently due to:
a. leg claudication.
b. Arthritis.
c. Deconditioning,.
d. Associated pulmonary disease.
2. Patients with ECG changes at rest that can interfere with
interpretation of the exercise test,these abnormalities include:
a. Preexcitation (Wolff-Parkinson-White) syndrome.
b. A paced ventricular rhythm.
c. more than 1 mm of ST depression at rest.
d. Complete left bundle branch block.
e. Patients taking digoxin.
f. Patients with ECG criteria for left ventricular hypertrophy, even
if they have less than 1 mm of baseline ST depression.
 On the other hand, patients with:
1. right bundle branch block.
or
2. those with less than 1 mm of ST depression at rest.
are candidates for diagnostic exercise ECG testing in the
appropriate clinical setting.
 Pharmacologic stress testing with radionuclide myocardial perfusion
imaging or echocardiography should be performed in patients who
cannot exercise, exercise testing with radionuclide myocardial
perfusion imaging or echocardiography should be performed in
patients with resting ECG abnormalities, and an imaging study should
be performed to localize ischemia or assess myocardial viability.
Test accuracy:

 The sensitivity of exercise ECG testing is higher in patients with three

vessel or left main disease and lower in those with one vessel
disease.However, exercise test indices do not necessarily correlate
with the extent or severity of CHD.
 Perhaps the best way to increase the diagnostic accuracy of exercise
ECG testing is to consider the test to be an extension of the clinical
and risk factor evaluation.
 If the patient still has an intermediate probability of CHD after exercise
ECG testing, another independent noninvasive test that does not rely
on electrocardiographic criteria (such as a stress cardiac imaging
procedure) can be utilized to further increase or reduce the risk of
CHD.
 Another approach is to consider the efficacy of exercise ECG testing in
terms of the clinically important variable of outcome rather than
simply the presence of disease as determined by angiography.
 Despite the lower diagnostic accuracy of exercise ECG testing
compared to angiography and to other forms of stress testing, it
remains widely used because it effectively identifies patients at low
and high clinical risk.
INDICATIONS:

 Class I indications:
1. Adult patients (including those with complete right bundle branch
block or less than 1 mm of resting ST-segment depression) with an
intermediate pretest probability of CAD on the basis of gender, age,
and symptoms (specific exceptions are noted under Classes II and
III, below)
 Class IIa indications:
1. Suspected variant (vasospastic) angina.
 Class IIb indications:

1 Patients with a high pretest probability of CAD by age, symptoms, and

gender
2 Patients with a low pretest probability of CAD by age, symptoms, and
gender
3 Patients with less than 1 mm of baseline ST-segment depression and
taking digoxin
4 Patients with electrocardiographic criteria for left ventricular
hypertrophy and less than 1 mm of baseline ST-segment depression

 Class III indications:

1. Patients with the following baseline ECG abnormalities:
a. Preexcitation (Wolff-Parkinson-White) syndrome.
b. Electronically paced ventricular rhythm.
c. More than 1 mm of ST segment depression at rest.
d. Complete left bundle branch block.
2. Patients with a documented myocardial infarction or prior coronary
angiography demonstrating significant disease who have an
established diagnosis of CAD; however, ischemia and risk can be
determined by testing.

CONTRA-INDICATIONS:
Absolute contraindications:

1. Acute myocardial infarction (within two days).

2. Unstable angina pectoris.
3. Uncontrolled arrhythmias causing symptoms of hemodynamic
compromise.
4. Symptomatic severe aortic stenosis.
5. Uncontrolled symptomatic heart failure.
6. Active endocarditis.
7. Acute myocarditis.
8. Acute pericarditis.
9. Acute aortic dissection.
10. Acute pulmonary or systemic embolism.
11. Acute noncardiac disorders that may affect exercise
performance or may be aggravated by exercise.

Relative contraindications: (can be superseded if benefits outweigh risks

of exercise).

1. Left main coronary stenosis or its equivalent.

2. Moderate stenotic valvular heart disease.
3. Electrolyte abnormalities.
4. Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg).
5. Tachyarrhythmias or bradyarrhythmias, including atrial fibrillation with
uncontrolled ventricular rate.
6. Hypertrophic cardiomyopathy and other forms of outflow tract
obstruction.
7. Mental or physical impairment leading to inability to cooperate .
8. High-degree atrioventricular block.

CHOICE OF EXERCISE DEVICE:

  The two most common modalities for clinical exercise testing are:
1. The motor-driven treadmill.
2. The stationary bicycle ergometer.
 Arm-crank ergometry is an alternative exercise device for individuals
with lower extremity disabilities,including:
1. Paraplegics.
2. Amputees.
3. Patients with peripheral vascular disease.

ECG LEAD SYSTEMS:

 The most popular lead system for exercise ECG testing is a simple
modification of the standard 12-lead ECG with the arm and leg
electrodes moved to the torso.
 It is important that the arm electrodes be placed at the base of the
shoulder just inside the border of the deltoid muscles and 1 to 2 cm
below the clavicles.
 More medially placed electrodes are associated with false positive and
false negative diagnostic errors for myocardial infarction.
 The leg electrodes should be positioned below the umbilicus and
above the anterior superior iliac crest.
 The precordial leads, V1 to V6, are located in their standard positions.
 Twelve-lead ECGs are usually obtained at rest (both supine and
standing), during the various stages of exercise, and during recovery.

EXERCISE TEST PROTOCOLS:

 Most clinical indications for exercise testing require an incremental
protocol, which progresses from low workloads to higher workloads
until either a predetermined end point is reached (target heart rate or
workload) or signs or symptoms develop that preclude further
exercise.
 The most efficient protocols for treadmill or bicycle testing are patient
specific as the protocol is chosen to match the physical working
capacity of the individual so that a maximal effort is reached in 6 to 12
minutes.
 Protocols that are either too short or too long in duration may not
truly reflect the patient's functional capacity.
 The protocol is usually determined from the patient's expected
functional capacity using information derived from the clinical history
and exercise habits.

A. Treadmill testing:
The specific speed and grade parameters for three standard
treadmill testing protocols along with estimated oxygen costs for
each workload are shown on Table 8 (show table 8).

1. Bruce protocol:
 is generally preferred for office-based exercise testing largely because
it has been carefully validated.
 is divided into successive three minute stages, each of which requires
the patient to walk faster and at a steeper grade.
A. Stage I has at an incline of 10 percent and a speed of 1.7 miles per
hours.
B. stage II progresses to an incline of 12 percent and a speed of 2.5
miles per hour.
 The initial work load in stage I may occur too suddenly for some
individuals, and an optional stage 1/2, in which the work load is lower
than the usual first stage of the Bruce protocol, may be added at the
beginning.

 The modified Bruce protocol can be used for risk stratification of

patients after an acute coronary syndrome (myocardial infarction or
unstable angina) and in sedentary patients in whom the standard
Bruce protocol may be too strenuous.

 The modified protocol adds two low-workload stages, both of which

require less effort than Stage 1, to the beginning of the standard Bruce
protocol.

2. Cornell protocol:
 was developed for use with computerized ST/HR slope determination,
a possibly improved method of quantitative exercise
electrocardiography.
 In the Cornell protocol, each stage of the Bruce protocol is divided into
two smaller and shorter stages.

3. Naughton protocol:
 is often used in post-MI exercise testing to classify patients into high-
risk and low-risk categories and to determine optimal treatment
strategies.
 is also used for functional exercise testing with gas analysis techniques
to measure oxygen uptake and VO2max.

B. Bicycle testing :
  Exercise should begin with the patient pedaling against minimal
resistance for several minutes.
 The work rate should then be increased in increments of 15 to 25
watts (90 to 150 kpm [kilopond meters/min]) every one to two
minutes depending upon the subject's heart rate response.
 The goal is a test duration of 8 to 12 minutes.
 Extremely sedentary or debilitated subjects may require even smaller
increments.

EXERCISE TEST PROCEDURE:

  Patients should be instructed not to eat, drink, or smoke for two hours
prior to the examination, but they can take their scheduled
medications unless specifically requested not to.
 The patients should bring comfortable exercise clothing and walking
shoes to the testing facility.
 Before testing, the patient should read and sign an informed consent
form, which describes the benefits and occasional risks of exercise
testing.

Patient interview and examination:

 If the patient is being tested for a known or suspected heart problem,

a brief interview by a physician or qualified health professional is
necessary to rule out contraindications to testing and to gather
information that will facilitate interpreting the test.
 All patient medications must be identified.
1. Certain drugs will reduce the maximal heart rate that is achieved
(eg, beta blockers, verapamil, diltiazem, and amiodarone)
2. While other drugs, particularly digoxin, are associated with a false
positive ECG response to exercise.
3. In addition, diuretic-induced hypokalemia can interfere with the
interpretation of the ST segment and T waves.
4. Recent use of nitrates can minimize the ischemic response to
exercise in patients with coronary disease.
5. Patients undergoing exercise testing for diagnostic purposes should
not take antiischemic medications or drugs that slow the heart
rate.However, antiischemic medications should be continued if the
purpose of the test is to establish prognosis.

 A limited cardiac examination should be performed, with attention

given to detecting heart murmurs and gallops:
 1. Severe aortic stenosis, for example, is a contraindication to
maximal exercise testing.
2. Detecting mitral valve prolapse is also important, since this valve
lesion may be associated with a false positive ECG response to
exercise.
 The presence of an arrhythmia, confirmed by the resting ECG, should
be documented since it may have an impact on exercise.
 The blood pressure (BP) should be measured at rest (supine and
standing) and during the last minute of each exercise stage.
*** Exertional hypotension:
defined as a fall in systolic blood pressure below that measured
standing at rest, is often indicative of severe heart failure or
multivessel coronary disease and the test should be stopped when
detected.
*** Hypotension after exercise is sometimes seen in normal
individuals as well as patients with heart disease.
1. In normal persons: the hypotension is usually due to venous
pooling in the lower extremities if the patient is left standing on the
treadmill, especially immediately after maximal exercise & placing
the patient supine or in the Trendelenburg position will correct this
situation in a few minutes.
2. In patients with heart disease: hypotension after exercise may be
due to a severe ischemic response that impairs cardiac output or,
rarely, a tachyarrhythmia.
*** Exertional hypertension :
Some patients develop exercise-induced hypertension, defined as a
peak systolic blood pressure ≥ 210 mmHg in men and ≥ 190 mmHg in
women. A hypertensive response during exercise is not associated
with increased mortality,but a delayed decline during recovery may be
an adverse prognostic finding.
  Chest discomfort:
**The patient should be carefully observed for symptoms and other
physical signs during exercise.
**The development of chest discomfort is an important finding,
especially if the patient is undergoing diagnostic testing.
**Careful observation of:
1. Patient's facial expression and color.
2. ECG.
3. BP.
enable the chest discomfort to be classified as anginal or
nonanginal.
**It is not necessary to stop exercise at the onset of chest discomfort
if the intensity is mild, the BP is stable or rising, and the ECG does not
show significant ST segment abnormalities.
**Indications for terminating the test include:
1. Increasing pain intensity.
2. A fall in systolic pressure.
3. Marked ST segment depression or elevation.
4. Increasing ventricular ectopy.

Test end points:

 The decision to stop an exercise test can be:
1. patient-determined:
a. Patient wants to stop
b. Significant chest discomfort
c. Marked fatigue or severe dyspnea
d. Other limiting symptoms (dizziness, leg cramps, joint discomfort,
etc)
2. protocol-determined:
a. Heart rate determined (eg, 120 to 140 bpm)
b. Workload determined (eg, 5 METs)
3. physician-determined:
a. Patient does not look well (eg, ataxia, confusion, pallor, cyanosis,
etc)
b. Exertional hypotension (systolic BP below standing at rest
systolic BP)
c. Systolic BP >250 mmHg
d. Diastolic BP >120 mmHg
e. Equipment failure
4. ECG endpoints:
a. Marked ST segment depression
b. New bundle branch block or AV heart block
c. Ventricular tachycardia or fibrillation
d. Increasing frequency of ventricular arrhythmia (premature
beats, couplets or nonsustained ventricular tachycardia),
especially if ischemia present
e. Onset of supraventricular tachyarrhythmias.
  The maximal HR decreases as a function of age, and traditionally has
been predicted by the following equation:

Maximal HR = 220 - age (in years)

 The following equation was more accurate for predicting maximal HR

in healthy adults:

Maximal HR = 208 - 0.7 x age (in years)

Submaximal testing:
  Stable patients with an acute coronary syndrome (myocardial
infarction or unstable angina) often undergo a submaximal exercise
test prior to discharge unless they have undergone percutaneous
coronary intervention or coronary artery bypass graft surgery and
been fully revascularized (eg, single vessel disease successfully treated
with percutaneous coronary intervention).

 The submaximal exercise test uses one of the following end points:

1. A peak heart rate of 120 to 130 beats per minute.

2. 70 % of the maximal predicted heart rate for age.
3. A peak work level of 5 METs.
4. Mild angina or dyspnea.
5. ≥ 2 mm of ST segment depression.
6. Exertional hypotension.
7. ≥ 3 consecutive ventricular premature beats.

Procedures after exercise:

  The ECG should be recorded after a brief cool-down, while the patient
is still on the treadmill or sitting on the bicycle.

***If significant ECG abnormalities did not develop during exercise, and the
test is being done to diagnose ischemia, the patient should return to the
supine position for the remainder of the recovery period.

***The increased venous return in the supine position may precipitate

ischemic abnormalities not seen when upright on the treadmill.

***ST segment changes limited to the recovery period are as predictive of

underlying coronary disease as changes seen during exercise.

***If, however, the patient develops ischemic ECG abnormalities during

exercise, it may be safer to have the patient sit during recovery to minimize
the risk of increasing ischemia and ventricular arrhythmias.

 The ECG should be recorded every two minutes for 7 to 10 minutes

until the heart rate falls below 100 beats per minute or the ECG
waveform returns to the control baseline pattern.

***These ECGs should be compared with the resting ECG in the same
position (supine or standing).

***In addition, continuous monitoring of the ECG waveform in selected

leads should be performed during recovery to assess cardiac rate, rhythm,
and ST segment responses.

 Ventricular arrhythmias can occur during the recovery period, and are
associated with an increased risk of death during follow-up.
 Other abnormalities that occur during recovery also have prognostic
importance:

1. A slower than expected fall in HR at one minute (≤ 12 to ≤ 18 bpm).

2. A delayed fall in systolic pressure.
3. The development of frequent ventricular ectopy.
Life-threatening complications:

 for every 10,000 tests there were approximately:

1. 3.5 myocardial infarctions.
2. 4.8 serious arrhythmias.
3. 0.5 deaths.

The exercise test summary report:

 At the conclusion of an exercise test, a summary report should be

prepared.
 This is usually done by exercise test personnel and reviewed by the
supervising physician.
 The summary report can be placed in the patient's medical record,
sent to the referring physician (if any), and a copy given to the patient
for his or her medical records.