Exercise Treadmill Testing

Dr Vikrant V Vijan

Overview
Basic EKG Review Introduction to Treadmill Test
Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Exercise Testing to Diagnose Obstructive Coronary Artery Disease

Rationale and Guidelines Pretest Probability ST-Segment Interpretation Confounders of Stress ECG Interpretation

Result Reporting

Basic EKG Review

Simple Method of EKG Interpretation

Rate Rhythm Axis Hypertrophy Infarction and Ischemia

Rate

Rhythm
Identify basic rhythm
then scan entire tracing for pauses, premature beats, irregularity, and abnormal waves.

Always:
Check for:
P before each QRS. QRS after each P.

Axis

Hypertrophy

Infarction and Ischemia

Normal EKG

Atrial Fibrillation with Rapid Ventricular Response

Inferior Acute MI and RBBB

Anterior Acute MI

Left Ventricular Hypertrophy

Ventricular Fibrillation

Overview
Basic EKG Review Introduction to Treadmill Test
Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Exercise Testing to Diagnose Obstructive Coronary Artery Disease

Rationale and Guidelines Pretest Probability ST-Segment Interpretation Confounders of Stress ECG Interpretation

Result Reporting

Indications and Safety

Generally a safe procedure, but both myocardial infarction and death have been reported and can be expected to occur at a rate of up to 1 per 2500 tests. Good clinical judgment should therefore be used in deciding which patients should undergo exercise testing. Exercise testing should be supervised by an appropriately trained physician. The electrocardiogram (ECG), heart rate, and blood pressure should be monitored carefully and recorded during each stage of exercise and during ST-segment abnormalities and chest pain.

Indications for Exercise Testing:

Diagnosis of Coronary Artery Disease Assessment of Prognosis in Coronary Artery Disease Evaluation of Functional Capacity Evaluation of Therapy for Coronary Disease Determination of Exercise Prescription

Equipment and Protocols

Both treadmill and cycle ergometer devices are available for exercise testing. Much of the published data are based on the Bruce protocol, there are clear advantages to customizing the protocol to the individual patient to allow 6 to 12 minutes of exercise. Exercise capacity should be reported in estimated metabolic equivalents (METs) of exercise.

Exercise Endpoints
Commonly terminated when subjects reach an arbitrary percentage of predicted maximum heart rate. Other end points (summarized next slide) are strongly preferred. The use of rating of perceived exertion scales, such as the Borg scale is often helpful in assessment of patient fatigue.

The Modified Borg Scale

SCALE 0 0.5 1 2 SEVERITY No Breathlessness* At All Very Very Slight (Just Noticeable) Very Slight Slight Breathlessness

3
4 5 6 7 8 9

Moderate
Somewhat Severe Severe Breathlessness Very Severe Breathlessness Very Very Severe (Almost Maximum)

10

Maximum

Basics of Interpretation of the Exercise Treadmill Test

Interpretation of the exercise test should include exercise capacity and clinical, hemodynamic, and electrocardiographic response. The occurrence of ischemic chest pain consistent with angina is important, particularly if it forces termination of the test. The most important electrocardiographic findings are ST depression and elevation. Positive exercise test result is greater than or equal to 1 mm of horizontal or downsloping ST-segment depression or elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS complex

Overview
Basic EKG Review Introduction to Treadmill Test
Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Exercise Testing to Diagnose Obstructive Coronary Artery Disease

Rationale and Guidelines Pretest Probability ST-Segment Interpretation Confounders of Stress ECG Interpretation

Result Reporting

Rationale for Using ETT to Diagnose Obstructive CAD

Most predictive clinical finding is a history of chest pain or discomfort. Myocardial ischemia is the most important cause of chest pain and is most commonly a consequence of underlying coronary disease. CAD that has not resulted in sufficient luminal occlusion to cause ischemia during stress can still lead to ischemic events through spasm, plaque rupture, and thrombosis, but most catastrophic events are associated with extensive atherosclerosis. These nonobstructive lesions explain some of the events that occur after a normal exercise test. Although the coronary angiogram has obvious limitations, angiographic lesions remain the clinical gold standard.

The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test
Class I (Definitely appropriate) - Adult males

or females (including RBBB or < 1mm resting ST depression) with an intermediate pre-test probability of coronary artery disease based on gender, age and symptoms (specific exceptions are noted under Class II and III below). Class IIa (Probably appropriate) - Patients with vasospastic angina.

The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test

Class IIb (maybe appropriate)

Patients with a high pretest probability of CAD by age, symptoms, and gender. Patients with a low pretest probability of CAD by age, symptoms, and gender. Patients with less than 1 mm of baseline ST depression and taking digoxin. Patients with electrocardiographic criteria for left ventricular hypertrophy (LVH) and less than 1 mm of baseline ST depression.

The ACC/AHA Guidelines for the Diagnostic Use of the Standard Exercise Test, contd

Class III (Not appropriate) -

1. To use the ST segment response in the diagnosis of coronary

artery disease in patients who demonstrate the following baseline ECG abnormalities:

2. To use the ST segment response in the

artery disease in
MI patients

pre-excitation (WPW) syndrome; electronically paced ventricular rhythm; more than one millimeter of resting ST depression; LBBB
diagnosis of coronary

Pretest Probability
Based on the patient's history (including age, gender, and chest pain characteristics), physical examination and initial testing, and the clinician's experience with this type of problem. Typical or definite angina makes the pretest probability of disease so high that the test result does not dramatically change the probability. Atypical or probable angina in a 50-year-old man or a 60year-old woman is associated with approximately a 50% probability of CAD. Diagnostic testing is most valuable in this intermediate pretest probability category, because the test result has the largest potential effect on diagnostic outcome. Typical or definite angina can be defined as 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin.

Pre Test Probability of Coronary Disease by Symptoms, Gender and Age

Ae g Gne e dr Tp aDfne A p aP bb y i l ei i c/ t t i l r al yc/ o e Ag a et rs Ag a et rs ni Pcoi n ni Pcoi n I t r eia n m t e d e I t r eia n m t e d e H h >0 ) ig ( 9% I t r eia n m t e d e H h >0 ) ig ( 9% I t r eia n m t e d e Hh ig Hh ig I t r eia n m t e d e Vr Lw<% ey o ( 5 ) I t r eia n m t e d e Lw o I t r eia n m t e d e I t r eia n m t e d e I t r eia n m t e d e I t r eia n m t e d e Nn oAy p m i sm o a c t t Ag a ni l n CetPi hs a n lo ( 1% Vr lo ( 5 ) w<0 ) ey w<% Vr lo ey w I t r eia n m t e d e Vr lo ey w I t r eia n m t e d e Lw o I t r eia n m t e d e I t r eia n m t e d e Vr lo ey w lo w Vr lo ey w Lw o Vr lo ey w Lw o Lw o

3- 9 03 3- 9 03 4- 9 04 4- 9 04 5- 9 05 5- 9 05 6- 9 06 6- 9 06

M s a le Fm s ea le M s a le Fm s ea le M s a le Fm s ea le M s a le Fm s ea le H h >0 ig = 9%

I t r eia = 09% n m t 1- 0 e d e Vr Lw <% ey o = 5

Lw <0 o = 1%

ST Segment Interpretation
Computer summaries can help find possible areas of ischemia then review raw data carefully! Determine PQ junction, J point, ST80, and estimate slope Elevation Depression
Upsloping Horizontal Downsloping

Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with a relatively stable baseline are selected. The PQ junction (1) and J point (2) are determined; the ST 80 (3) is determined at 80 msec after the J point. In this example, average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The average slope measurement from the J point to ST 80 is 1.1 mV/sec.

Normal

Rapid Upsloping

Minor ST Depression

Slow Upsloping

Horizontal

Downsloping

Elevation (non Q lead)

Elevation (Q wave lead)

Upsloping

J point depression of 2 to 3 mm in leads V4 to V6 with rapid upsloping ST segments depressed approximately 1 mm 80 msec after the J point. The ST segment slope in leads V4 and V5 is 3.0 mV/sec. This response should not be considered abnormal.

 In lead V4 , the exercise ECG result is abnormal early in the test, reaching 0.3 mV (3 mm) of horizontal ST segment depression at the end of exercise. Consistent with a severe ischemic response.

The J point at peak exertion is depressed 2.5 mm, the ST segment slope is 1.5 mV/sec, and the ST segment level at 80 msec after the J point is depressed 1.6 mm. This slow upsloping ST segment at peak exercise indicates an ischemic pattern in patients with a high coronary disease prevalence pretest. A typical ischemic pattern is seen at 3 minutes of the recovery phase when the ST segment is horizontal and 5 minutes after exertion when the ST segment is downsloping.

Becomes abnormal at 9:30 minutes (horizontal arrow right) of a 12minute exercise test and resolves in the immediate recovery phase. This ECG pattern in which the ST segment becomes abnormal only at high exercise workloads and returns to baseline in the immediate recovery phase may indicate a false-positive result in an asymptomatic individual without atherosclerotic risk factors.

A 48-year-old man with several atherosclerotic risk factors and a normal rest ECG result developed marked ST segment elevation (4 mm [arrows]) in leads V2 and V3 with lesser degrees of ST segment elevation in leads V1 and V4 and J point depression with upsloping ST segments in lead II, associated with angina. This type of ECG pattern is usually associated with a full-thickness, reversible myocardial perfusion defect in the corresponding left ventricular myocardial segments and high-grade intraluminal narrowing at coronary angiography. Rarely, coronary vasospasm produces this result in the absence of significant intraluminal atherosclerotic narrowing.(

Confounders of Exercise Treadmill Test Interpretation

Digoxin
Produces an abnormal ST-segment response to exercise. This abnormal ST depression occurs in 25% to 40% of healthy subjects studied and is directly related to age.

Left Ventricular Hypertrophy

Decreased specificity of exercise testing, but sensitivity is unaffected. Therefore, a standard exercise test may still be the first test, with referrals for additional tests only indicated in patients with an abnormal test result.

Resting ST Depression
Resting ST-segment depression has been identified as a marker for adverse cardiac events in patients with and without known CAD.

Left Bundle-Branch Block

Exercise-induced ST depression usually occurs with left bundle-branch block and has no association with ischemia. Even up to 1 cm of ST depression can occur in healthy normal subjects. There is no level of ST-segment depression that confers diagnostic significance in left bundle-branch block.

Right Bundle-Branch Block

The presence of right bundle-branch block does not appear to reduce the sensitivity, specificity, or predictive value of the stress ECG for the diagnosis of ischemia.

Beta Blocker Therapy

For routine exercise testing, it appears unnecessary for physicians to accept the risk of stopping beta-blockers before testing when a patient exhibits possible symptoms of ischemia or has hypertension. However, exercise testing in patients taking beta-blockers may have reduced diagnostic or prognostic value because of inadequate heart rate response.

Overview
Basic EKG Review Introduction to Treadmill Test
Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Exercise Testing to Diagnose Obstructive Coronary Artery Disease

Rationale and Guidelines Pretest Probability ST-Segment Interpretation Confounders of Stress ECG Interpretation

Result Reporting

Comparison of Tests for Diagnosis of CAD

Grouping

Standard ET ET Scores Score S trategy Thallium Scint SPECT Adenosine SPECT Exercise ECHO Dobutamine ECHO Dobutamine Scint E lectron Beam Tomography (EBCT)

# of Total # Studies Patients 147 24,047 24 11,788 2 >1000 59 6,038 16+14 5,272 10+4 2,137 58 5, 000 5 <1000 20 1014 16 3,683

Sens Spec 68% 77% 85% 85% 88% 89% 84% 88% 88% 60% 92% 85% 72% 80% 75% 84% 74% 70%

Predictive Accuracy

73% 80% 88% 85% 80% 85% 80% 86% 81% 65%

Results Reporting
Hope Medical Group Exercise Treadmill Test Results Report rev. 11/04 Patient Name: Chart Number: Reason for Test: ________________________________________________________________________ Digoxin? _______ Beta blocker? ________ Resting EKG interpretation: ________________________________________________________________________ ________________________________________________________________________ LVH? ___________ LBBB? __________ RBBB? ___________ Resting ST Depression? _________ Cardiac Risk Factors (circle) Age Hypercholesterolem ia Gender Smoker Diabetes Sedentary/Obese HTN Total Number: Date of Test:

Estimate pretest probability use table for reference (very low, low, intermediate, high, very high): _______________________________________________________________________ Reason for test if pretest probability not intermediate: _______________________________________________________________________

1. Exercise Capacity Results Reporting Page METS achieved: _______________ Minutes exercised: _______________ 2. Clinical response to exercise Chest pain during test? ___________ Chest pain reason for stopping test? __________ Perceived exertion scale (BORG scale reached 6 to 20): _________ Reason for stopping test:_____________ 3. Electrocardiographic response to exercise ST elevation (yes/no) ? ____________ ST depression (yes/no)? ____________ (positive = 1 mm of horizontal or downsloping ST-segment depression or elevation for at least 60 to 80 milliseconds (ms) after the end of the QRS complex) What leads? ___________ ST quality (upsloping, horizontal, downsloping):_______________ ST depression amount (mm): ___________ Dysrhythmia? _____________ Other: ____________________________________________________ 4. Hemodynamic response to exercise Systolic BP response: ______________ Diastolic BP response: ______________ Maximum heart rate achieved: ________________ 2 minute heart rate recovery (should be at least 22 bpm by 2 minutes): ______________

What is a MET?
Metabolic Equivalent Term 1 MET = "Basal" aerobic oxygen
consumption to stay alive = 3.5 ml O2 /Kg/min

Actually differs with thyroid status, post

exercise, obesity, disease states

Key MET Values

1 MET = "Basal" = 3.5 ml O2 /Kg/min
2 METs = 2 mph on level

4 METs = 4 mph on level

< 5METs = Poor prognosis if < 65;

Key MET Values (part 2)

10 METs = As good a prognosis with medical therapy as CABG 13 METs = Excellent prognosis, regardless of other exercise responses 16 METs = Aerobic master athlete 20 METs = Aerobic athlete

Calculation of METs on the Treadmill

METs = Speed x [0.1 + (Grade x 1.8)] + 3.5 3.5 Calculated automatically by Device!
Note: Speed in meters/minute conversion = MPH x 26.8 Grade expressed as a fraction

Results Reporting Page 3

5. Duke treadmill scores (see nomogram or use calculator): 5-year survival _______ Average annual mortality __________ 1. VA treadmill score: _________ 1. Final conclusions and recommendation for follow-up: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

Duke treadmill score = duration of exercise in minutes on the Bruce protocol - (minus) 5x maximal mm ST deviation - (minus) 4x treadmill angina index Treadmill Angina Index: 0 if no angina. 1 if non-limiting angina. 2 if limiting angina.

High Risk = treadmill score < -10 79% 4-year survival Moderate Risk = treadmill score -10 to +4 95% 4-year survival Low Risk = treadmill score >+5 99% 4-year survival

Duke Nomogram for 2 mm depression, non-limiting chest pain at 5 METS.

Variable
Maximal Heart Rate

Circle response
Less than 100 bpm = 30 100 to 129 bpm = 24 130 to 159 bpm =18 160 to 189 bpm =12 190 to 220 bpm =6

Sum

Males
Choose only one per group
<40=low prob 40-60= intermediate probability >60=high probability

Exercise ST Depression

1-2mm =15 > 2mm =25

Age

>55 yrs =20 40 to 55 yrs = 12

Angina History

Definite/Typical = 5 Probable/atypical =3 Non-cardiac pain =1

Maximal Heart Rate

Variable

Circle response
Less than 100 bpm = 20 100 to 129 bpm = 16 130 to 159 bpm =12 160 to 189 bpm =8 190 to 220 bpm =4

Sum

Women
Choose only one per group
<37=low prob 37-57= intermediate probability >57=high probability

Exercise ST Depression Age Angina History

1-2mm =6 > 2mm =10 >65 yrs =25 50 to 65 yrs = 15 Definite/Typical = 10 Probable/atypical =6 Non-cardiac pain =2

Smoking? Diabetes? Exercise test induced Angina Estrogen Status

Yes=10 Yes=10 Occurred =9 Reason for stopping =15 Positive=-5, Negative=5

Total Score

Review
Basic EKG Review Introduction to Treadmill Test
Indications and Safety Equipment and Protocols Exercise End Points Basics of Interpretation of the Exercise Test

Exercise Testing to Diagnose Obstructive Coronary Artery Disease

Rationale and Guidelines Pretest Probability ST-Segment Interpretation Confounders of Stress ECG Interpretation

Result Reporting