STRESS

TESTING
WEEK 4: SPDX
 WHOA!
Exercise testing is a form of cardiovascular stress testing that uses exercise with
electrocardiography (ECG) and blood pressure monitoring. This form of stress testing is
usually performed with exercise protocols using either a treadmill or bicycle.
 TABLE OF CONTENT

01. 02. 03.

HISTORY CLINICAL MAIN TYPES
SIGNIFICANCE
01. The “cornerstone” of modern stress testing was
the recognition of the importance of ST segment
changes to predict the presence of coronary
HISTORY artery disease (CAD)
 HISTORICAL
ST changes during exercise
HIGHLIGHTS
(sit-ups) are associated with ST depression is present in
chest pain and decreased only 75% of patients with
cardiac flow. (Feil & Siegel) angina during exercise.
1928 1932

1918 1929
ST depression first noted Master’s Step test, first
during angina “standard” exercise
protocol-submaximal with
EKG (Master)
 HISTORICAL
Continuous EKG monitoring,
HIGHLIGHTS
depression > 1.0 mm is The Harvard Step Test used to
clinically significant assess fitness from HR during
(Riseman et al.) recovery (Johnson et al.)
1940 1950

1938 1941
First to use maximal exercise EKG changes after exercise
testing to test for CAD can be useful to detect
climbing stairs (Missal) CAD (Master & Jaffe)
 HISTORICAL
HIGHLIGHTS
Refined interpretation of ST
Cycle tests used to predict changes (V5 or CM5 most
fitness (Astrand) sensitive leads) (Blackburn et al.)
1954 1950

1952 1956
Treadmill testing used with set criteria to Bruce established the
screen for CAD (Yu et al.) guidelines used today:
• ST depression > 1.0 mm treadmill, with EKG, during
• Change in T wave (upright - inverted) exercise
• Increase T wave amplitude & Q-T duration
 EXERCISE PHYSIOLOGY
The hemodynamic response
Several studies have depends on the amount of
reported that the muscle mass involved,
coronaries dilate exercise intensity, and
during exercise. overall conditioning.

Skeletal muscle blood flow

The increase in myocardial increase and peripheral resistance
oxygen demand and coronary decrease leading to an increase in
vasodilation allows for systolic blood pressure (SBP),
increased oxygen delivery mean arterial pressure (MAP), and
which is crucial to myocardial pulse pressure. Diastolic blood
perfusion thereby preventing pressure (DBP) may remain
ischemia. unchanged, slightly increase or
Due to sympathetic stimulation and slightly decrease.
vagal inhibition, stroke volume, heart
The age-predicted maximum
rate, and cardiac output increase.
heart rate is a useful
Alveolar ventilation and venous return
measurement for estimating the
also increase as a consequence of
adequacy of stress on the heart to
selective vasoconstriction
induce ischemia.
 02.
CLINICAL
SIGNIFICANCE
 Treadmill exercise testing is helpful as part of the
diagnostic evaluation of patients with known or
suspected coronary disease, and it provides
significant prognostic information for patients with
CLINICAL known disease. Exercise stress testing without an
imaging modality has a sensitivity and specificity of
SIGNIFICANCE about 70% and 75%, respectively.

Patients with abnormal stress testing may or may not

have coronary artery disease depending upon the
diagnostic accuracy of the test performed and the
pretest likelihood of each patient. The ACC/AHA
guidelines suggest that exercise radionuclide
myocardial perfusion imaging or exercise
echocardiography has potential use as a follow-up test
in patients with intermediate or high risk.
 INDICATIONS
Indications for treadmill testing include:
● Symptoms suggesting myocardial ischemia
●Acute chest pain in patients excluded for acute coronary
syndrome (ACS)
● Recent ACS treated without coronary angiography or
incomplete revascularization
● Known CAD with worsening symptoms
● Prior coronary revascularization (patients 5 years or longer
after Coronary artery bypass grafting [CABG] or 2 years or less
after percutaneous coronary intervention [PCI])
● Valvular heart disease (to assess exercise capacity and need
for surgical intervention)
● Certain cardiac arrhythmias to assess chronotropic
competence
● Newly diagnosed heart failure or cardiomyopathy
 CONTRAINDICTIONS
Contraindications for treadmill testing include::
1. Acute myocardial infarction within 2 to 3 days
2. Unstable angina not previously stabilized by medical therapy
3. Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
4. Symptomatic severe aortic stenosis.
5. Uncontrolled symptomatic heart failure
6. Acute pulmonary embolus or pulmonary infarction
7. Acute myocarditis or pericarditis or endocarditis
8. Acute aortic dissection
9. High-grade AV blocks
10. Severe hypertension (SBP greater than 200 mm Hg, DBP greater than 110 mm Hg, or both)
11. Inability to exercise given extreme obesity or other physical/mental impairment
 PREPARATIONS:
Exercise stress testing is generally safe. Complications are rare, and the frequency of serious
adverse cardiac events (i.e., myocardial infarction, sustained ventricular arrhythmia, and death)
has been estimated to be approximately 1 in 10,000 patients.

All persons conducting exercise stress test should be trained on how to diagnosis and manage
complications, should they arise. Emergency resuscitation equipment and drugs should also be
readily available.
Exercise stress testing is performed in a designated lab,
supervised by a trained healthcare personnel.

Electrodes are placed on the chest, which is attached to

an ECG machine that is recording the electrical activity
PREPARATIONS
of the heart. Your resting ECG, heart rate, and blood
pressure are obtained prior to starting the exercise
regimen.

Once it is determined that there are no limiting factors

based on baseline ECG, the patient is placed on a
treadmill with a designed protocol that increases in
intervals as you exercise.
 The most common protocol used during treadmill
exercise stress testing is the Bruce protocol. This protocol
is divided into successive 3-minute stages, each of which
requires the patient to walk faster and at a steeper grade.
The testing protocol could be adjusted to a patient’s
tolerance, aiming for 6 to 12 minutes of exercise duration.

There is a modified Bruce protocol for those who cannot

PREPARATIONS
exercise vigorously, which adds two lower workload
stages to the beginning of the standard Bruce protocol,
both of which require less effort than Stage 1. .

During the exercise test, data about heart rate, blood

pressure and ECG changes should be obtained at the
end of each stage and at any time an abnormality is
detected with cardiac monitoring.
 In general, heart rate and systolic blood pressure should rise
with each stage of exercise until a peak is achieved. Patients
should be questioned about any symptoms they experience
during exercise.

All patients should be monitored closely during the recovery

period until heart rate, and ECG are back to baseline, as
PREPARATIONS
arrhythmias and ECG changes can still develop. At the
conclusion of testing, a report should be included

This report should outline the baseline ECG interpretation,

baseline heart rate, and blood pressure, ECG changes during
exercise including the presence of arrhythmia/ectopy and the
onset of such changes, maximal heart rate, and blood pressure
during exercise, estimated exercise capacity in METs, exercise
duration and Stage completed, symptoms experienced during
A Duke Treadmill Score (DTS) is a validated scoring system that
can assist with the risk assessment of a patient who has
undergone an exercise stress test. The DTS was developed to
provide accurate diagnostic and prognostic information for the
evaluation of patients with suspected coronary artery disease.

The DTS uses three exercise parameters: exercise time, ST

segment deviation (depression or elevation) and exertional
PREPARATIONS
angina to determine if patients are at a low, intermediate or
high risk for ischemic heart disease.

The typical range is from +15 to -25. If patient’s score greater

than or equal to 5, they are considered low risk while those
who score less than or equal to -11 are considered high risk.
This scoring system predicts 5-year mortality, where low-risk
scores have a 5-year survival of 97%, intermediate risk scores
have a 5-year survival of 90%, and high-risk scores indicate a 5-
COMPLICATIONS:
Patients should be instructed not to eat, drink, or smoke for at least three hours before the
examination, as this allows for maximal exercise capacity. The patient should bring comfortable
exercise clothing and walking shoes to the testing facility. The healthcare professional perming the
test should explain benefits the risks, benefits and possible complications to the patient before
testing and patient is given an informed consent form to review and sign.

Medications should be discussed with the patient beforehand, as some medications such as beta
blockers, calcium-channel blockers, digoxin, and anti-arrhythmic medications can affect maximal
heart rate achieved. An ischemic response can also be affected if patients are taking nitrates. A
thorough history and physical examination should be performed in all patients before referral for
exercise stress testing.
MAIN TYPES OF
STRESS TEST
PHARMACOLOGICAL STRESS TEST
Exercise stress testing is also not very helpful in patients with an insufficient hemodynamic
response to exercise due to abnormalities involving the respiratory system, and having ongoing
issues involving muscles, bones, and vessels in the peripheral system.

Pharmacological stress testing is a highly supervised procedure conducted under expert medical
personnel supervision either in clinic or hospital. During the procedure, the patient will have
electrodes attached to their chest, and also their vital signs are continuously monitored. The stress
agent is injected through a peripheral intravenous line, which will increase blood flow through the
coronary vasculature and mimic a response similar to exercise stress testing.
 Vasodilator agents currently approved by the Food and
Drug Administration (FDA) include:
• Adenosine
• Dipyridamole
• Regadenoson

Vasodilators do not really stress the heart and create a

coronary steal phenomenon by temporarily increasing
PREPARATIONS
blood flow to non-diseased vessels of the coronary
vasculature at the expense of diseased vessels that can
be visualized on nuclear imaging.

Regadenoson is a newer vasodilator agent approved by

the FDA in 2008 and most routinely used today due to
its selective action on A2A receptors and lesser side-
effects.
 Patients who are unable to tolerate exercise stress test
due to abnormalities involving the respiratory system
(severe chronic obstructive pulmonary disease (COPD)),
provoked angina, hypotension during exercise,
chronotropic incompetence. These patients are suitable
candidates for testing involving pharmacologic agents.

Patients who have baseline abnormal electrocardiogram

which include the presence of left bundle branch block
INDICATIONS
at baseline, left ventricular hypertrophy, paced rhythm,
Wolf Parkinson White syndrome, and greater than 1 mm
ST-segment depression. These patients can have false-
positive results on an exercise stress test.

Symptomatic aortic stenosis.

Caffeine and methylxanthines intake within 12
hours prior to stress testing with vasodilator
stress agents.

Beta-blockers taken in the last 24 hours if the

INTERFERING
patient is going for dobutamine stress testing. FACTORS
NUCLEAR STRESS TEST
A nuclear stress test uses radioactive dye and an imaging machine to create pictures showing the
blood flow to your heart. The test measures blood flow while you are at rest and are exerting
yourself, showing areas with poor blood flow or damage in your heart.

The test usually involves injecting radioactive dye, then taking two sets of images of your heart —
one while you're at rest and another after exertion.

A nuclear stress test is one of several types of stress tests that may be performed alone or in
combination. Compared with an exercise stress test, a nuclear stress test can help better
determine your risk of a heart attack or other cardiac event if your doctor knows or suspects that
you have coronary artery disease.
 You may need a nuclear stress test if a routine stress
test didn't pinpoint the cause of symptoms such as
chest pain or shortness of breath. A nuclear stress test
may also be used to guide your treatment if you've
been diagnosed with a heart condition. Your doctor
may recommend a nuclear stress test to:

Diagnose coronary artery disease. Your coronary arteries

are the major blood vessels that supply your heart with
WHY IT IS DONE?
blood, oxygen and nutrients. Coronary artery disease
develops when these arteries become damaged or
diseased — usually due to a buildup of deposits
containing cholesterol and other substances (plaques).
Guide treatment of heart disorders. If you've been
diagnosed with coronary artery disease, a nuclear stress
test can help your doctor find out how well treatment is
working. It may also be used to help establish the right
treatment plan for you by determining how much
exercise your heart can handle.
RISKS:
A nuclear stress test is generally safe, and complications are rare. As with any medical
procedure, there is a risk of complications, including:
● Allergic reaction. Though rare, you could be allergic to the radioactive dye that's injected
during a nuclear stress test.
● Abnormal heart rhythms (arrhythmias). Arrhythmias brought on during a stress test usually
go away shortly after you stop exercising or the medication wears off. Life-threatening
arrhythmias are rare.
● Heart attack (myocardial infarction). Although extremely rare, it's possible that a nuclear
stress test could cause a heart attack.
● Dizziness or chest pain. These symptoms can occur during a stress test. Other possible signs
and symptoms include nausea, shakiness, headache, flushing, shortness of breath and
anxiety. These signs and symptoms are usually mild and brief, but tell your doctor if they
occur.
● Low blood pressure. Blood pressure may drop during or immediately after exercise, possibly
causing you to feel dizzy or faint. The problem should go away after you stop exercising.
WHAT TO EXPECT?
A nuclear stress test may be performed in combination with an exercise stress test, in which you
walk on a treadmill. If you aren't able to exercise, you'll receive a drug through an IV that mimics
exercise by increasing blood flow to your heart. A nuclear stress test can take two or more
hours, depending on the radioactive material and imaging tests used.
● Before a nuclear stress test: First, your doctor will ask you some questions about your
medical history and how often and strenuously you exercise. This helps determine the
amount of exercise that's appropriate for you during the test. Your doctor will also listen to
your heart and lungs for any abnormalities that might affect your test results.
● During a nuclear stress test: Before you start the test, a technician inserts an intravenous
(IV) line into your arm and injects a radioactive dye (radiopharmaceutical or radiotracer).
The radiotracer may feel cold when it's first injected into your arm. It takes about 20 to 40
minutes for your heart cells to absorb the radiotracer. Then, you'll lie still on a table and
have your first set of images taken while your heart is at rest. A nurse or technician will place
sticky patches (electrodes) on your chest, legs and arms. Some areas may need to be shaved
to help them stick. The electrodes have wires connected to an electrocardiogram machine,
which records the electrical signals that trigger your heartbeats. A cuff on your arm checks
your blood pressure during the test. You may be asked to breathe into a tube during the test
to show how well you're able to breathe during exercise.
 WHAT TO EXPECT?
● During a nuclear stress test: You'll have another injection of radiotracer when your heart rate
peaks. About 20 to 40 minutes later, you'll lie still on a table and have a second set of images
made of your heart muscle. The dye shows any areas of your heart receiving inadequate blood
flow. Your doctor will use the two sets of images to compare the blood flow through your heart
while you're at rest and under stress.
● After a nuclear stress test: After you stop exercising, you might be asked to stand still for
several seconds and then lie down for a period of time with the monitors in place. Your doctor
can watch for any abnormalities as your heart rate and breathing return to normal. When the
test is complete, you may return to normal activities unless your doctor tells you otherwise.
The radioactive material will naturally leave your body in your urine or stool. Drink plenty of
water to help flush the dye out of your system.
 RESULT:
Your doctor will discuss your nuclear stress test results with you. Your results could show:

● Normal blood flow during exercise and rest. You may not need further tests.
● Normal blood flow during rest, but not during exercise. Part of your heart isn't receiving
enough blood when you're exerting yourself. This might mean that you have one or more
blocked arteries (coronary artery disease).
● Low blood flow during rest and exercise. Part of your heart isn't getting enough blood at all
times, which could be due to severe coronary artery disease or a previous heart attack.
● Lack of radioactive dye in parts of your heart. Areas of your heart that don't show the
radioactive dye have tissue damage from a heart attack.

If you don't have enough blood flow through your heart, you may need to undergo coronary
angiography. This test looks directly at the blood vessels supplying your heart. If you have severe
blockages, you may need a coronary intervention (angioplasty and stent placement) or open-heart
surgery (coronary artery bypass).
 THANKS
Do you have any questions?

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