Stress Exercise Testing and Interpretation

Dr. Ravinder Narwal

Type of CPX
1. Max. Execise test 2. Submaximal exercise testing 1. In this strategy, the patients exercise enough to achieve 70% of maximum predicted heart rate for their age (ie, 70% of 220 minus age in years). 2. This test is commonly performed prior to discharge and is followed by maximal exercise testing 6-8 weeks later (when patients aim to achieve 90% of maximum predicted heart rate) 3. Symptom-limited exercise testing 1. The patients exercise soon after a cardiac event. 2. A representative schedule might begin exercise at intervals, such as 7-21 days following uncomplicated acute myocardial infarction (MI), 3-10 days following angioplasty, or 14-28 days after bypass surgery.

Indications for CPX

General indications
Assessment of general fitness Evaluation of dyspnea

Evaluation of certain pulmonary disorders

COPD, including EIA Interstitial lung disease

Indications for CPX

Evaluation of certain cardiovascular disorders Pulmonary vascular disorders Coronary artery disease Other vascular disorders Other general disorders Neuromuscular disorders Obesity Anxiety induced hyperventilation

Exercise Testing

Best used for :

Patients w/ signs & symptoms who are probably + for CAD Persons w/ multiple risk factors but who are asymptomatic

Contraindications for CPX

General contraindications
Limiting neurological disorders Limiting neuromuscular disorders Limiting orthopedic disorders

Contraindications for CPX

Cardiovascular contraindications
Acute pericarditis CHF Recent MI (<4 weeks) 2nd or 3rd degree H block Significant atrial or ventricular tachyarrhymias

Contraindications for CPX

Uncontrolled hypertension Unstable angina Recent systemic or pulmonary embolism Severe aortic stenosis Thrombophlebitis or intracardiac thrombi

Complication of CPX
Cardiac Bradyarrhythmias Sinus Atrioventricular junctional Ventricular Atrioventricular block Asystole Sudden death (ventricular tachycardia/fibrillation) Myocardial infarction Heart failure Hypotension and shock Noncardiac Musculoskeletal trauma Ill-defined and miscellaneous Severe fatigue sometimes persisting for days, dizziness, fainting, body aches, delayed feelings of illness

Key Points of Exercise Testing

Manual SBP measurement (not automated) most important for safety Adjust to clinical history No Age predicted Heart Rate Targets The BORG Scale of Perceived Exertion METs Fit protocol to patient (RAMP) Use standard ECG analysis/ 3 minute recovery/ use scores Heart rate recovery Expired Gas Analysis?

6 7 8 9 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very, very hard 20

Very, very light Very light

Perceived Exertion Scale (CR 10) Adapted from Borg (1998)

0 0.5 1 2 3 4 5 6 7 8 9 10 *

No exertion at all Extremely light Very light Light Somewhat hard Hard Very hard

(just noticeable)

(heavy)

Extremely hard Maximal exertion

(almost maximal)

Symptom-Sign Limited Testing Endpoints When to stop!

Dyspnea, fatigue, chest pain

Systolic blood pressure drop ECG--ST changes, arrhythmias Physician Assessment Borg Scale (17 or greater)

Target Heart Rate

Approximates the actual heart rate at an oxygen consumption of 65 to 75% of the predicted vo2max

How to read an Exercise ECG

Good skin prep Not one beat Three consistent complexes Averages can help Three minute recovery

Types of Exercise

Isometric (Static) weight-lifting pressure work for heart, limited cardiac output, proportional to effort Isotonic (Dynamic) walking, running, swimming, cycling Flow work for heart, proportional to external work Mixed

Problems with Age-Predicted Maximal Heart Rate

Which Regression Formula? (220 - ..5 x Age) Confounded by Beta Blockers A percent value target will be maximal for some and sub-max for others Borg scale is better for evaluating Effort Do Not Use Target Heart Rate to Terminate the Test or as the Only Indicator of Effort or adequacy of test

Information Obtained From CPX

Monitor The Patient on CPX

HR & BP Anginal Scale Dyspnea Scale Borgs RPE Scale EKG monitoring - Leads I, II, V5 Patients subjective symptomatology

Information Obtained From CPX

Lung function RR Vt and VE Spo2 Oxygen uptake or consumption (VO2 and vo2max Carbon dioxide production (VCO2) Respiratory quotient (RQ)

Information Obtained From CPX

Cardiovascular function Hr B/p ECG O2 pulse (O2 consumption per beat) Cardiac output HR reserve ( 1-[HRmax Hrrest/ Hrpred.Max Hrrest]

Information Obtained From CPX

Metabolic equivalents of energy expenditure (METS) 1 MET equals +/- 3.5 ml O2 consumption per kg of body weight per minute (at rest, all pts are at 1 MET) Anaerobic threshold (AT) VD/VT Breathing reserve (1 [VEmax/MVV]

Oxygen Consumption During Dynamic Exercise Testing

There are Two Types to Consider:

Myocardial (MO2) Internal, Cardiac

Ventilatory (VO2) External, Total Body

Myocardial (MO2)

Systolic Blood Pressure x HR

SBP should rise > 40 mmHg

Drops are ominous (Exertional Hypotension)

Diastolic BP should decline

Ventilatory (VO2)

Cardiac Output x a-VO2 Difference VE x (% Inspired Air Oxygen Content - Expired Air Oxygen Content)

External Work Performed

****Direct relationship with Myocardial O2 demand and Work is altered by beta-blockers, training,...

VO2
THE FICK EQUATION
VO2 = C.O. x C(a-v)O2

Equipment and Personnel

Equipment and Personnel

Equipment Metabolic cart (breath by breath analysis) Spirometer with computer Pulse oximeter Ergometer and/or treadmill ECG recorder and monitor B/P cuff (automated if possible) Crash cart

Equipment
Treadmill tests Upper arm ergometry Repetitive lifting/weight carrying test

Devices Used for Exercise

Ergometer (stationary bicycle)
Pros
Pt. Is seated Work load is independent of patient weight or size

Cons
Slightly longer learning curve

Devices Used for Exercise

Treadmill Pros Minimal learning curve Cons Workload dependant upon pt size and weight Workload varies with handgrip Can be dangerous

WORK
TREADMILL

WORK TIME

WORK TIME

Why Ramp?
Individualized test Using Prior Test, history or Questionnaire Linear increase in heart rate Improved prediction of METs Nine-minute duration for most patients Requires special Treadmill controller or manual control by operator

Types Of Testing protocols

Types Of Tests protocols

Treadmill tests

Bruce or Ellestad - good for young folks because the between-stage graduations of grade and speed are more aggressive USAFSAM or Naughton - good for older folks because of the more gradual between-stage progressions of grade and speed

Bruce Protocol GXT

Stage I II III IV V VI Speed Grade 1.7 mph 10 % 2.5 mph 12 % 3.4 mph 14 % 4.2 mph 16 % 5.0 mph 18 % 5.5 mph 20 % Dur. 3 min 3 min 3 min 3 min 3 min 3 min

Modified Bruce
Stage I II III IV V VI VII Speed Grade 1.7 mph 0 % 1.7 mph 5 % 1.7 mph 10 % 2.5 mph 12 % 3.4 mph 14 % 4.2 mph 16 % 5.0 mph 18 % Dur. 3 min 3 min 3 min 3 min 3 min 3 min 3 min

USAFSAM GXT
Stage I II III IV V VI Speed Grade 2.0 mph 0 % 3.3 mph 0 % 3.3 mph 5 % 3.3 mph 10% 3.3 mph 15% 3.3 mph 20% Dur. 3 min 3 min 3 min 3 min 3 min 3 min

Reasons To Stop The Test

Drop in BP with increases in workload Moderate to severe angina Ataxia, dizziness, syncope Dysrhythmias ST segment elevations and depressions Hypertensive responses

CPX Testing significance HRR

Should Heart Rate Recovery be added to ET?

Long known as a indicator of fitness: perhaps better for assessing physical activity than METs Recently found to be a predictor of prognosis after clinical treadmill testing Studies to date have used all-cause mortality

Heart Rate Drop in Recovery

Probably not more predictive than Duke Treadmill Score or METs Should be calculated along with Scores as part of all treadmill tests

RPP =SBP(MAX) HR(MAX)

RPP =SBP(MAX) HR(MAX)

What is a MET?

What is a MET?
Metabolic Equivalent Term
consumption to stay alive = 3.5 ml O2 /Kg/min

1 MET = "Basal" aerobic oxygen

Actually differs with thyroid status, post

exercise, obesity, disease states by 3.5

But by convention just divide ml O2/Kg/min

Key MET Values (part 1)

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; limit immediate post MI; cost of basic activities of daily living

Key MET Values (part 2)

10 METs = As good a prognosis with medical therapy as CABS

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

METs(Report Exercise Capacity in METs)

Optimize Test by Individualizing for Patient

Adjust test to 8-10 minute duration (aerobic capacity--not endurance) Use prognostic power of METs

Estimated vs Measured METs

All Clinical Applications based on Estimated Estimated Affected by:
Habituation (Serial Testing) Deconditioning and Disease State

Measured Requires a Mouthpiece and Delicate Equipment Measured More Accurate and Permits measurement of Gas Exchange Anaerobic Threshold and Other Mxments (VE/VCO2)

CARDIAC RISK vs METs

Diagnosis vs Prognosis

METs
10 to 15% increase in survival per MET Can be increased by 25% by a training program

Duke Treadmill Score (uneven lines, elderly?)

Single measurement of steady state heart rate Can use step or bicycle ergometer Nomogram is for age 25 years Need to adjust for older and younger (for which standard table available)

All-comers prognostic score

SCORE = (1=yes, 0=no)

METs<5 + Age>65 + History of CHF + History of MI or Q wave a=0, b=1, c=2, d=more than 2

Interpretation
Parameters at Max Poor conditioning exercise VO2max METS VEmax/MVV O2 saturation VD/VT HRmax/workload O2 pulse Pulmonary disorders Cardiovascular disorders

Low Low Low N

Low Low High Low

Low Low Low N

N
High N

N or High
N N

N
High Low

SUMMARY METs

Diagnosis vs Prognosis

CPX Testing Procedure and INDICATION

CPX Testing
Steps in testing After filling of Consent form Patient prepratation
Baseline READING OR RESTING Resting EKG Baseline B/P

AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing

Diagnosis CAD Prognosis with symptoms/CAD After MI Using Ventilatory Gas Analysis Special Groups

AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing Special Groups:
Pre- and Post-Revascularization Women Asymptomatic Pre-surgery Valvular Heart Disease Cardiac Rhythm Disorders

AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing

Diagnosis

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.

Diagnostic Use, continued:

Class IIb (Maybe appropriate)
Patients taking Digoxin with less than 1 mm resting ST depression. Patients with ECG criteria for left ventricular hypertrophy with less than 1 mm ST depression. Patients with a high pre-test probability of coronary artery disease by age, symptoms and gender. Patients with a low pre-test probability of CAD by age, symptoms and gender.

Diagnostic Use, continued:

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

2. To use the ST segment response in the

diagnosis of coronary artery disease in MI patients

Comparison of Tests for Diagnosis of CAD

Grouping Standard ET ET Scores Score Strategy Thallium Scint SPECT Adenosine SPECT Exercise ECHO Dobutamine ECHO Dobutamine Scint Electron 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 Predictive Accuracy 68% 77% 73% 85% 85% 88% 89% 84% 88% 88% 60% 92% 85% 72% 80% 75% 84% 74% 70%

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

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 Age Angina History

1-2mm =15 > 2mm =25 >55 yrs =20 40 to 55 yrs = 12 Definite/Typical = 5 Probable/atypical =3 Non-cardiac pain =1

Hypercholesterolemia? Diabetes? Exercise test induced Angina

Yes=5 Yes=5 Occurred =3 Reason for stopping =5

Total Score:

Maximal Heart Rate (x4)

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

(x5)

1-2mm =6 (x2) > 2mm =10 >65 yrs =25 50 to 65 yrs = 15

Angina History (x2)

Definite/Typical = 10
Probable/atypical =6 Non-cardiac pain =2

Smoking? (x2) Diabetes? (x2) Exercise test induced Angina (x3) Estrogen Status

Yes=10

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

Total Score

AHA/ACC Exercise Testing Guidelines: Recommendations for Exercise Testing

Prognosis with symptoms/CAD

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

Indications for Exercise Testing to Assess Risk and prognosis in patients with symptoms or a prior history of coronary artery disease:
Patients undergoing initial evaluation with suspected or known CAD. Specific exceptions are noted below in Class IIb. Patients with suspected or known CAD previously evaluated with significant change in clinical status.

Class I. Should be used:

Prognostic Use, continued:

Class IIb. Maybe Appropriate for:
Patients who demonstrate the following ECG
abnormalities: Pre-excitation (WPW) syndrome; Electronically paced ventricular rhythm; More than one millimeter of resting ST depression; and LBBB. Patients with a stable clinical course who undergo periodic monitoring to guide management

Prognostic Use, continued:

Class IIa. Probably Appropriate:
None

Class III. Should not be used for prognostication:

Patients with severe co-morbidity likely to limit life and/or consideration for revascularization procedures

CPX Testing significance Prognostic

Problems with max tests in average/less fit subjects

1. May not be accustomed to exercise at severe levels, so may not reach maximum 2. On a bike, need strong quads, so lightly built subjects, possibly most female subjects, will lack strength to reach VO2max 3. Can use treadmill, but significant minority find treadmill disorienting or have balance problems

Submaximal exercise tests

Most follow this pattern: Subjects does standardised work schedule Heart rate is measured Work capacity at age-predicted heart rate max is calculated Oxygen consumption at work rate calculated for HRmax is estimated from average relation between VO2 and work rate for the test could use a short ramp test

Drawbacks of submaximal tests:

Assume reliable HR-VO2 relation across subjects (1 point tests) or linearity of HR relation for multi-point tests

Depend on estimating age-related HRmax.(error +/- 10%)

Assume same VO2-work relation in all subjects, i.e. constant efficiency Are subject to error from fluctuations in HR due to time of day, eating patterns, uncontrolled stressors. McArdle estimates a typical submax test can only give VO2max estimates to within +/- 16%

Field Tests
12 min run
VO2 = 3.126 (meters in 12 min) - 11.3

1.5 mile run

VO2 = 3.5 + 483/(time in minutes)

Rockport Walking Test (1 mile walk)

VO2 = 132.853 - 0.1692 (BW in kg) - 0.3877 (age in y) + 6.315 (gender) - 3.2649 (time in min) - 0.1565 (HR) 0 for female; 1 for male; HR at end of walk

Non-exercise methods 1.
Use Exercise heart rate variability.

Non-exercise methods 1.
Use Exercise heart rate variability.

Heart rate variability during exercise

Best by beat variability falls during exercise. This is due to reduction in vagal (parasympathetic) drive to the heart. Part of the way heart rate is increased (NB other factors are increased sympathetic drive and circulating adrenaline)

Instantaneous heart rate, min-1

180 160 140 120 100 80 60 40 20 0 0 50 100 150 200 250 300 350 400 450

Time , se c

Resting
75 70 65 60 55 50 160 170 180 190 200 210 220 230
150 145 140 135 130 125

Moderate-hard exercise

320

330

340

350

360

370

Time, sec

Time, sec

Non-exercise methods 2.
Use just age, gender, level of physical activity, perceived functional ablility (latter two from simple questionnaires). Claimed can estimate fitness to within +/- 3.4 ml/min.kg (SEE, standard error of estimate, so 5% confidence limit about 7 ml/min.kg). This appears better than any of the real tests, so some doubt that comparisons are being made in a fair way.
.

Monitoring change in fitness

Submax exercise tests are much more reliable on repeat testing in the same individual. So for following the effect of an exercise for health individual programme, they are fine. But in this situation may be better to forget VO2max altogether. Simply follow trend in final heart rate for a standard exercise, e.g. short step test or timed walk test.

Summary
Fitness levels vary markedly between individuals and are highly predictive of future health. Need simple methods to monitor fitness in individuals and in populations Various sub-max tests are suitable for this purpose. However, because of inherent non-linearities in the underlying physiology, will have low accuracy. For reliable VO2max estimates in a performance context or clinically, need a maximum test.

Key Points of Exercise Testing

Key Points of Exercise Testing

Manual SBP measurement (not automated) most important for safety Adjust to clinical history No Age predicted Heart Rate Targets The BORG Scale of Perceived Exertion METs not Minutes Fit protocol to patient (RAMP) Use standard ECG analysis/ 3 minute recovery/ use scores Heart rate recovery Expired Gas Analysis?

Question 1
What is the most important prognostic measurement from the exercise test? 1. 2. 3. 4. BORG scale estimate ST depression Exercise time Exercise capacity

Question 2
What is the most appropriate indicator of a maximal effort? 1. 2. 3. 4. BORG scale ST depression Heart rate Exercise capacity

Thank you