Download Treadmill Stress Testing for the Primary Care Physician

Majelle L. Gagtan
 Definition
 Indications/Contraindications
 Running the Exercise Test
 Protocols
 Non-invasive procedure providing information about
changes in rate, rhythm, conductionn and ventricular
repolarization as the heart responds to exertion
 Exposes the heart to the stress of exercise thus unmasking
s/sx of heart disease, and the ECG may produce
characteristic abnormalities
 Patients with s/sx suggestive of CAD
 Patients with significant risk factors for CAD
 To evaluate exercise tolerance in patients with
unexplained fatigue and shortness of breath
 To evaluate BP response to exercise in patients with
borderline hypertension
 To look for exercise-induced serious irregular heart beats
 Recent acute MI
 Severe aortic stenosis
 Unstable angina
 Active myocarditis
 Ventricular tachycardia
 Thrombophlebitis or
 Dissecting aortic
intracardiac thrombi
 Recent pulmonary embolus
 Acute infection
aneurysm
 Acute CHF
 Uncontrolled severe
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 Complex ventricular ectopy
hypertension
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Moderate aortic stenosis
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Severe subaortic stenosis
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Supraventricular dysrhythmias 
Ventricular aneurysm
Cardiomyopathy
Uncontrolled metabolic disease
Recurrent infectious disease
Complicated pregnancy
 HR and BP are recorded at rest
 12L ECG is recorded
 Start at a relatively slow “warm up” speed then its speed and
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inclination are increased every 3 mins. according to a
preprogrammed protocol
BP is recorded every minute
Stopped when the patient achieves target HR, or if he develops
chest discomfort, dyspnea, dizziness etc., or if the ECG showed
significant changes
It may also be stopped if BP rises or falls beyond acceptable
limits
Maximum HR = 220 – age of patient
BRUCE Protocol

multi stage maximal treadmill protocol with 3-min periods
to allow achievement of steady state before workload is
increased
Modified BRUCE Protocol
 2 3-min warm-up stages at 1.7mph and 0% grade and
1.7mph and 5% grade
 For older individuals or those with exercise capacity is
limited by cardiac disease
Naughton and Weber protocols
• 1 2-min stages with 1 MET increments between stages
• More suitable for patients with limited exercise tolerance
Asymptomatic Cardiac Ishemia Pilot Trial (ACIP) and
modified ACIP protocols
• For pxs with established CAD
• Results in linear increase in HR and VO2
• Modified ACIP – similar aerobic demand; well suited for
short or elderly who can’t keep up with a walking speed of
3mph
 ST Depression
 → or ↓ ≥ 1mm at
60msec
 ↑ ≥ 1.5mm at 80msec
 ST Elevation
 ≥ 1mm at 60msec
 No change
 ST depression doesn’t fulfill
no.2
 T wave inversion w/o ST
segment changes
 ST elevatoin in a Q wave
lead
Dyspnea, fatigue, chest pain
Systolic blood pressure drop
Technical difficulties
ECG--ST changes, arrhythmias
Signs of poor perfusion (cyanosis/pallor)
Px’s desire to stop
Achievement of maximal exercise