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Treadmill Exercise Stress Echocardiography Procedure Policy and Procedure Purpose: To provide guidelines and information to ensure best practice. Procedure: Pre test Prior to study date, patient will be notified by phone or mail with the date and time of test, instructions to wear comfortable clothing and shoes, and a reminder to have someone available to drive them home. On arrival, after introductions and patient identification confirmed, patient will receive a full explanation of the test procedure and potential risks, with the opportunity to ask questions A verbal and/ written consent must be obtained to continue Test Patient will be required to disrobe from the waist up and don a gown open in the front 12-lead ECG hook up is attached ensuring a good signal with appropriate prep to the skin The Technologist will take standing and supine ECGs at rest for baseline Documentation of patient height, weight, age, resting B/P and current medications A cardiac history is taken and recorded for the reading Cardiologist Ensure patient is wearing comfortable shoes to walk in Use tissue harmonics (reduces near field artifact, improves resolution, enhances myocardium, and improves endocardial border definition) Decide early the need for a contrast agent, used with each acquisition The Sonographer acquires digital loops of the imaging views Apical 4ch, 2ch, ALAX, PLAX and PSAX at rest. The machine preset should have a continuous capture or stacking function. Choose either the Bruce or the Modified protocol Reinforce instructions and explanation of treadmill format just before starting test Remind patient to speak up if having any symptoms or concerns while on the treadmill Remind patient of increase in incline and speed about 10 seconds before it occurs Encourage patient to stay on treadmill to reach or surpass the target heart rate Check patient B/P each stage and document Continually watch 12-lead ECG for arrhythmias and ST changes Stop treadmill when test end point has been reached Get patient back onto bed in a left lateral position so the Sonographer can acquire peak images while heart rate is at its maximum Continue to monitor B/P and any symptoms Complete the test with post imaging when heart rate is below 100 beats/minute and document. Test End Points Reached or surpassed target heart rate Drop in systolic blood pressure from baseline despite an increase in workload ST segment or QRS changes such as excessive ST depression (> 2 mm of horizontal or down-sloping) S-T elevation > 1 mm in leads without diagnostic Q waves (other than V1 or AVR) Arrhythmias: ventricular tachycardia, multifocal frequent PVCs, heart block Severe symptoms: moderate to severe angina, presyncope, ataxia, pallor with unwell feelings Machine technical difficulties—patient safety is a priority Patient refuses to continue Policy Respect patient’s modesty by draping throughout the test Respect patient’s right to refuse test or stop upon request Ensure proper test supervision by Physician, location and availability prior to starting the test Patients ability to walk on treadmill should be assessed by staff as early as patient walking down the hall. Need to change test type should be discussed and approved by the supervising Physician. Ensure requisition filled out and appropriateness of test indication Confidentiality: test results not to be given to patient in a preliminary format Use of contrast if unable to see any of the walls of the myocardium to ensure a complete study Sonographer must have a strong knowledge base of coronary artery anatomy and distribution, and what LV walls are affected Technologist must have a strong knowledge base for reading 12 lead ECGs (i.e. arrhythmias, S-T changes) and be able to monitor B/P and symptoms for the Sonographer Medications and equipment available to treat and monitor if patient has symptoms Crash cart is in close proximity and staff aware of emergency response protocols Appropriate room size and current equipment, to ensure patient safety in an emergency situation Preprinted order forms preferred for the use of contrast, oxygen, nitroglycerine and written instructions for administration Treatment of Symptoms Moderate or severe angina: stop test, return patient to the bed, do an immediate blood pressure, apply oxygen--if supervising Physician is nearby, have someone bring him into the room for assessment of 12 lead ECG and vitals, and give Nitroglycerine if ordered S-T depression of > 2 mm or elevation > 1 mm: stop test and return to bed doing immediate images and monitoring vitals and symptoms Arrhythmias as listed: stop test and return to the bed monitoring 12 lead ECG until settled; if sustained life threatening arrhythmias – call a code Presyncope, dizziness, unwell feeling: stop test, return to bed and monitor vitals