Download Bicycle Stress Echocardiography Protocol

Bicycle Stress Echocardiography Protocol
Equipment:
 Recumbent bicycle attached to an echo bed with cut outs for imaging
 12-lead ECG monitoring unit that connects to an echo machine
 Prep materials for skin – alcohol, gauze, razor and abrasive tape
 Electrodes
 Automatic blood pressure unit
 IV and contrast supplies
 Pre-printed bike stress worksheets
Staff:
 Sonographer
 ECG technologist
 Supervising physician
Pre Test:
 Reminder notice sent to patient before the day of the procedure to wear comfortable
clothing and shoes.
 No eating or drinking 2 hours before the test.
 Personal medications are taken as prescribed unless otherwise instructed by physician.
 On day of test: introductions, patient ID confirmed, test explanation and time for
questions to be answered.
 Written consent to proceed with test.
 If client is an inpatient, check ID band.
 If the staff determines the patient will not be able to pedal the bike on their side the
supervising physician must assess and change the test accordingly.
 If the supervising physician is not available, the test is postponed until the patient is
reassessed.
 Have patient undress from the waist up and put on a gown.
 Skin prep and application of 12-lead ECG electrodes ensuring a good ECG signal on both
machines.
 Baseline ECG supine and standing.
 Baseline blood pressure.
 Height, weight and BSA.
 Cardiac history, allergies and a list of current medications – if patient is taking beta
blocker, patient may not reach a high enough maximum heart rate.
 Harness patient to the bed comfortably, put on shoe covers and place feet in footholds,
then tilt bed for preliminary images.
 Ensure the patient’s legs are not over or under extended: important the patient is
comfortable while pedaling.
 Choose the continuous capture stress package.
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Store the resting images as required - example apical 4, apical 2, PLAX, PSAX - decide at
this time whether contrast will be needed.
Do measurements and EF at rest.
Return patient to a supine position - explain about the pedaling, the stages, lights and a
quick practice pedal before starting.
Exercise Test:
 Have patient pedal until green light comes on.
 Start ECG timer and bike timer at the same time.
 Do a blood pressure every 2 minutes and multiply the systolic blood pressure number by
the heart rate at each stage for the RPP (Rate Pressure Product).
 A minimum RPP of 20,000 is required to make it a readable test.
 Monitor for symptoms and arrhythmias throughout test.
 If the patient is having symptoms or arrhythmias or any other problem - the supervising
physician must be notified and assess patient to determine if test should continue.
 Each stage is 2 minutes long as preset into the ECG monitor and ultrasound machine.
 Have patient continue pedaling each stage until they reach an end point.
 Tilt bed again for peak images - decrease workload by 2 stages; have patient continue
pedaling while peak images are being acquired.
 When images have been acquired, patient can stop pedaling.
 Start the recovery phase on the treadmill.
 Document length of time biked, watts, RPP, symptoms, vitals, and any arrhythmias.
Post Test:
 When heart rate below 100 beats/ min post images can be taken.
 Position patient back in a supine position, remove feet from pedal boots and remove
harness.
 Clean gel from patient’s chest, assist with dressing if needed.
 Sanitize the echo bed, harness, ECG leads, blood pressure cuff, transducer and pillow
after each patient.
End Points:
 Moderate or severe angina.
 ST elevation > than 1 mm or depression > 2 mm.
 Nausea and other symptoms with an abrupt change in vital signs.
 Frequent serious arrhythmias - VT, heart block, rapid sustained SVT.
 Technical difficulties with equipment.
 Patient refuses to continue test.
 Regional wall motion seen.
Contraindications:
 Acute cardiac events or ECG changes - uncontrolled arrhythmias at rest.
 Recent MI.
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Unstable angina.
Severe pathology found in pre images - aortic stenosis, intracardiac mass, pericardial
effusion - all pathology must be reviewed by the supervising physician.
Severe hypertension - systolic > 225 and diastolic > 110 mm Hg.
Patient refuses the test after explanation and questions have been completed.
Bike Exercise Stress Worksheet:
Should include the following columns: Sample
Bike Protocol
Watts
Heart Rate
Blood
Pressure
Rest
Stage 1 ( 0-2 min)
Stage 2 ( 2-4 min )
xx
10
30
60
82
100
130/70
148/66
160/80
Stage 3 ( 4-6 min )
60
121
186/90
Stage 4 ( 6-8 min )
90
155
194/92
Recovery
Exercise time 7 min
12 sec
Mets
8.60
RPP 194 x 155
= 30,070
Symptoms and comments
mild dyspnea
dyspnea
legs sore, burning in chest,
dyspnea
stopped chest pains - oxygen
and nitro given
Interpretation of Bicycle Stress Echocardiography:
 Due to the limitations of the bike stress echo, this test is not indicated for everyone.
Patients should be assessed prior to performing the test.
 Conditions such as fibromyalgia, rheumatoid arthritis, peripheral vascular disease may
affect the test RPP making it inconclusive for CAD.
Criteria for Reporting:
 Negative test: All segments that were active and augmenting at baseline and remain
active with exercise, plus a decrease in overall cavity size and improvement in overall
contractility.
 Positive test: Two or more adjacent segments—which demonstrated normal thickening
at baseline but decreased or absent thickening with stress—in at least 2 imaging planes.
 Indeterminate test: All other responses, with an explanatory note.