Download Chapter 11 PPT

Electrocardiography for
Healthcare Professionals
Kathryn A. Booth
Thomas O’Brien
Chapter 11: Exercise
Electrocardiography
© 2016 McGraw-Hill Education. All Rights Reserved.
Learning Outcomes
11.1 Describe exercise electrocardiography and identify its
other names.
11.2 Identify uses of exercise electrocardiography.
11.3 Describe variations of exercise electrocardiography.
11.4 Prepare a patient for exercise electrocardiography.
11.5 Summarize safety measures that are used before,
during, and after exercise electrocardiography.
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Learning Outcomes (Cont.)
11.6 Explain the responsibilities of a healthcare
professional during exercise electrocardiography.
11.7 Compare common protocols followed in exercise
electrocardiography.
11.8 Explain the responsibilities of a healthcare
professional after exercise electrocardiography.
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11.1 What Is Exercise
Electrocardiography?
Key Term

Noninvasive
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11.1 What Is Exercise
Electrocardiography?
Known as:

Exercise tolerance test

Treadmill stress test

Cardiac stress test

Stress ECG

Exercise treadmill test
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11.1 What Is Exercise
Electrocardiography? (Cont.)


Noninvasive procedure performed in presence of
cardiologist or physician
Usually involves an exercise treadmill
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11.1 Responsibilities during Exercise
Electrocardiography

Provide for safety.

Prepare patient prior to procedure.

Attach electrodes properly.

Instruct patient to report symptoms.

Monitor patient:
 Blood
pressure
 ECG
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11.1 Apply Your Knowledge
Why is exercise electrocardiography considered
noninvasive?
ANSWER: It does not require entrance into a body
cavity, tissue, or blood vessel.
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11.2 Why Is Exercise
Electrocardiography Used?
Key Terms

Angina

Coronary vascular disease (CVD)
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11.2 Why Is Exercise
Electrocardiography Used?

Evaluate how the heart and blood vessels respond to
physical activity

Performed when physician suspects coronary vascular
disease

Determine problems that do not show up on resting ECG
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11.2 Why Is Exercise
Electrocardiography Used?

Reveal signs of narrowed
or obstructed arteries
 ST segment depression
 Angina
 Shortness of breath
 Palpitations
 Dizziness
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11.2 Why Is Exercise
Electrocardiography Used?

Determine patient risk for MI

Diagnose causes of chest pain

After surgery or MI to determine function

Screens for asymptomatic heart disease

Sets limitations for exercise programs

Identify dysrhythmias that occur during exercise

Evaluate effectiveness of cardiac drugs
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11.2 Apply Your Knowledge
A treadmill stress test is typically performed for what
type of disease?
ANSWER: Coronary vascular disease
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11.3 Variations of Exercise
Electrocardiography
Key Terms

Cardiologist

Echocardiogram

Chemical stress
echocardiogram

Nuclear stress test

Radiologist

Stress echocardiogram

Chemical stress test

Gamma camera

Gate
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11.3 Chemical Stress Test

Used when patient is unable to perform physical
exercise

Performed under guidance of cardiologist or radiologist

Heart is stressed using chemicals:
 Adenosine
 Persantine
 Dobutamine
 Lexiscan
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11.3 Nuclear Stress Test

Stressing chemical injected first

Radioactive tracer injected before completion of
stressing cycle

Patient scanned with gamma camera

Study is gated using 3-lead ECG
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11.3 Echocardiogram

Uses sound to study heart, heart valves, and major
blood vessels surrounding heart

Stress echocardiogram
 Combines
stress test with
echocardiogram
 Assesses
left ventricular wall
motion

Chemical stress echocardiogram
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11.3 Apply Your Knowledge
What type of diagnostic test uses both a chemical
stressor and sound?
ANSWER: Chemical stress echocardiogram
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11.4 Preparing the Patient for Exercise
Electrocardiography
Key Term

Beta blockers
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11.4 Preparing the Patient for Exercise
Electrocardiography

Describe the procedure and what to expect
 Before
the procedure
 During
the procedure/day of appointment
 After
the procedure

Obtain informed consent

Test may take 45 minutes to 3 hours, depending on test
being performed
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11.4 Patient Instructions

Do not use tobacco products or consume alcohol or
caffeine three hours prior to test.

Do not eat two hours prior to test.

Wear comfortable clothes and shoes.

Certain medications should not be taken—check
physician’s order.
 Beta
blockers
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11.4 Day of Appointment

Verify that equipment is working, including crash cart.

Gather supplies.

Verify physician’s order.

Make sure paperwork is complete.
 Medical
history
 Informed

consent
Verify that patient has complied with instructions.
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11.4 Day of Appointment (cont.)

Provide privacy or assist patient to change into gown.

Assist patient to exam table.

Obtain ECGs and blood pressure as required by facility.

Explain stress test protocol.

Inform physician patient is ready.

Assist during treadmill stress test.

Assist patient to chair after test is complete.
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11.4 Posttest Duties

Cooldown period:
 Monitor
 Obtain

and observe patient’s condition.
blood pressure and ECGs, per facility.
After cooldown period:
 Remove
 Allow
patient to dress.
 Provide
 File
cables and electrodes.
posttest instructions.
report per facility protocol.
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11.4 Apply Your Knowledge
True or False: Informed consent may not be necessary
before performing exercise electrocardiography,
depending on facility policy.
ANSWER: False; informed consent is always
required before performing exercise
electrocardiography.
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11.4 Apply Your Knowledge
Which substances should the patient avoid 3 hours
prior to the procedure?
ANSWER: Tobacco, alcohol, and caffeine
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11.5 Providing Safety
Key Terms

Congestive heart failure (CHF)

Hypertension

Hyperventilation
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11.5 Providing Safety

Exercise electrocardiography patients are already at risk.

Some risk of MI or CVA during the procedure

Follow rules to provide for safety:
 Physician
should always be present during procedure.
 Emergency
equipment nearby, including crash cart.
 Monitor
patient at all times.
 Patient
must know to report symptoms.
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11.5 Patients Who Should Not Have
Exercise Electrocardiography

Change in resting ECG

Uncontrolled hypertension

Abnormal heart rhythms

Cardiovascular conditions

Recent MI or unstable
angina

CHF

Acute infection

Psychosis

Pericarditis or myocarditis
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11.5 Safety and Infection Control

Patients having exercise electrocardiography may have
cardiac or vascular disease.

Increased chance of:
 Dizziness
 Syncopal

episode
Monitor patient’s carefully during position changes and
hyperventilation.
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11.5 Apply Your Knowledge
What two medical emergencies is a patient at risk for
while undergoing an exercise electrocardiography?
ANSWER: Myocardial infarction (MI) and
cerebrovascular accident (CVA)
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11.6 Performing Exercise
Electrocardiography
Key Term

Skin rasp
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11.6 Gather Materials
Prior to patient’s arrival,
prepare and assemble:



Blood pressure
equipment
Shaving equipment,
abrasive cleaner, skin
rasp
Skin prep solution

2x2 or 4x4 gauze

Chest electrodes

Stress test unit

Lead wires

Treadmill/cycle ergometer

Adhesive tape belt

Crash cart
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11.6 Verify Patient Details

Verify that patient has followed instructions.

Confirm complete medical history.

Verify that informed consent form is signed.

Prepare electrode sites:
 Dry
 Rub
shave skin, if necessary
site with skin prep, let dry
 Abrade
skin
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11.6 Performing Exercise
Electrocardiography

Attach blood pressure cuff and electrodes.

Check and set artifact filters.

Perform pre-test blood
pressures and 12-lead ECGs.
 Supine
 Sitting
 Hyperventilating
 Standing
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11.6 Apply Your Knowledge
Why is a baseline ECG often performed after asking
the patient to hyperventilate?
ANSWER: An ECG performed after hyperventilation
helps identify changes on the ECG that result from
changes in the patient’s breathing pattern.
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11.7 Common Protocols
Key Terms

Maximal exercise

Rate pressure product (RPP)

Submaximal exercise

Target heart rate
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11.7 Common Protocols

Test is divided into stages of 2 to 3 minutes each.
 At
end of each stage, blood pressure is checked and
ECG is repeated.
 Level
of exercise is then increased.

Physician determines which protocol to use.

Exercise period may last up to 15 minutes.
 Depends
on patient’s cardiac risk factor and ability
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11.7 Common Protocols (Cont.)

Goal of test is target heart rate (THR) without symptoms
or complications.
THR = 220 – patient’s age x (60-85%)
Percentage used depends on the testing protocol.

Patient should not exceed THR during test.
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11.7 Bruce Protocol

Most commonly used protocol

3-minute stages

Speed starts at 1.7 mph

Grade starts at 10%

Speed and grade increase with each stage.
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11.7 Modified Bruce Protocol

Most commonly used for older patients and patients with
cardiac disease.

3-minute stages

Speed starts at 1.7 mph

Grade starts at 0%

Grade increases with each stage.

Speed increases beginning at fourth stage.
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11.7 Naughton Protocol

Better suited for sicker patients

2-minute stages

Speed stays at 2 mph throughout test

Grade starts at 0%

Grade increases more gradually than in other protocols.
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11.7 During the Procedure
Monitor the following:
 Blood pressure
 Pulse
 Signs of cardiac distress
You may also monitor:
 Blood oxygen level
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11.7 During the Procedure (Cont.)

Watch patient closely, including:
 Skin
color
 Breathing
 Amount
 Facial

pattern
of perspiration
expressions
If you suspect a problem:
 Ask
the patient
 Report
suspicion to physician.
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11.7 Rate Pressure Product (RPP)

Also called double product

Systolic blood pressure × heart rate

Used to estimate:
 Oxygen
utilization
 Myocardial
 Heart’s
work
response to workload
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11.7 Apply Your Knowledge
What two checks are performed near the end of each
stage of the exercise electrocardiography procedure?
ANSWER: Blood pressure and ECG
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11.8 After Exercise Electrocardiography
Key Term

False positive
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11.8 After Exercise Electrocardiography

Monitor patient for 10 to 15 minutes after test (cooling-off
period).
6
to 15 minutes
 Stay
with patient
 Monitor

for changes
If patient asks about test results, refer patient to
physician.
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11.8 Factors Used to Interpret Results
of Exercise ECG

ECG changes and symptoms (most important)

Heart rate and rhythm

Blood pressure

Changes in oxygen saturation
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11.8 Inconclusive Tests

Test does not verify or exclude abnormality.

Additional testing required.
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11.8 Instructions for
Patient after Exercise ECG

Rest for several hours.

Avoid extreme temperature changes.

Avoid stimulants (caffeine, tobacco, alcohol) for at least
3 hours.

No bath or shower for 2 hours.

Know when to expect test results.

Discuss results with physician.
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11.8 False Positive Result

Occurs in approximately 5% of adults.
 More
common in females

Can cause unnecessary fears and additional testing.

Physician is responsible for providing information.
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11.8 Apply Your Knowledge
For how many minutes should the patient be monitored
following an exercise ECG?
ANSWER: 6 to 15 minutes, depending on facility
protocol and physician preference
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Chapter Summary

Exercise electrocardiography is a noninvasive test that
monitors the patient during exercise to diagnose
problems that do not occur during resting tests.

Exercise electrocardiography is known by many names,
including treadmill stress test, cardiac stress test, and
stress ECG.

Exercise electrocardiography is used to evaluate the
heart’s response to physical activity, blood pressure
during exercise, exercise-induced symptoms, risk of MI,
or effectiveness of cardiac medications.
54
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Chapter Summary (Cont.)

A chemical stress test is used when a patient is unable
to perform the exercise due to age, injury, or physical
defect.

An echocardiogram uses sound to study the heart, its
valves, and the major blood vessels surrounding the
heart.

Educate the patient about how to prepare for the
procedure, its complications, and what to report during
the procedure itself.
55
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Chapter Summary (Cont.)

Safety measures must always be followed because most
patients having exercise electrocardiography are already
at risk.

It is your responsibility to assemble all equipment and
prepare the patient for the test, including running
baseline blood pressures and 12-lead ECGs.

Common exercise electrocardiography protocols include
the Bruce, modified Bruce, and Naughton protocols.
56
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Chapter Summary (Cont.)

Your responsibilities after the test include monitoring the
patient and providing posttest instructions to the patient.
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