Exercise Testing

ACC/AHA PRACTICE GUIDELINES

Gibbons et al. 2002
 The evaluation of chest pain
can be very difficult.

 It is possible to have a normal resting

ECG with considerable narrowing of the
coronary arteries.

 Exercise testing was developed in the

1950s with the Bruce protocol published in
1963. It is now a well established
technique.
 Definition
 exercise testing is a cardiovascular
stress test that uses treadmill or bicycle
exercise and electrocardiographic and
blood pressure monitoring.

 is used for testing in the diagnosis and

treatment of patients with known or
suspected cardiovascular disease.
 Indications and Safety
 exercise testing is generally a safe procedure
 the 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
 the patient should be monitored continuously for transient rhythm
disturbances, ST-segment changes, and other electrocardiographic
manifestations of myocardial ischemia
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.
 Protocols

The Bruce protocol is very widely used and has been extensively validated.
There are 7 stages of 3 minutes each so that a complete test takes 21 minutes.
The level of exercise is estimated in METs.
1 MET or metabolic equivalent test is the amount of energy expended at rest
or 3.5 ml oxygen per kilogram per minute.
≥ 7 METs – NYHA I
5-7 METs – NYHA II
3-5 METs – NYHA III
< 2 METs – NYHA IV
A modified Bruce protocol is used for exercise testing within one week
of myocardial infarction and for those who are old and frail or
expected to have poor exercise tolerance for other reasons.

It starts at a lower work level and so takes longer to achieve the required heart rate.
Ideally, for an adequate test the patient should achieve 85% of maximum heart rate.
Maximum heart rate is calculated as 220- age in years for men and 210-age for women.
Beta blockers are usually stopped the day before if possible as they can prevent
an adequate heart rate being achieved. Not everyone insists in this.
Digoxin is stopped a week before as the effect on the ST segment can make
interpretation difficult.
treadmill

Equipment
cycle ergometer

Equipment
 Exercise ECG testing can be used in
the following circumstances:

 Assessing a clinical diagnosis of angina

 Risk stratification after myocardial infarction

 Risk stratification in patients with hypertrophic cardiomyopathy

 Evaluation of revascularisation procedures or drug treatment

 Evaluation of exercise tolerance and cardiac function

 Assessment of cardiopulmonary function in patients with

dilated cardiomyopathy or heart failure

 Assessment of treatment for arrhythmia

 Assessment of asymptomatic people in

high risk occupations like airline pilots
Value of exercise testing

 Exercise testing has a sensitivity of 78% and a

specificity of 70% in detecting coronary artery disease.

 Hence a negative test does not adequately rule out disease.

 A positive test is much more likely to be false in a young

person than an older person unless there is a very good history
as they are at much lower risk.

 A positive test at a low workload is a poor prognostic sign

and it indicates the need for urgent treatment.
The test

 The patient is connected to the exercise ECG machine and

a standard resting ECG is performed.
 This is repeated with the patient standing as some changes
such as T wave inversion can occur simply on standing.
 A record during hyperventilation may also be made to note changes
purely from hyperventilation.
 During the test the machine provides a continuous record of the heart rate
and the 12 lead ECG is recorded intermittently.
 Blood pressure is measured before starting and
at the end of each stage of exercise.
 Blood pressure may fall or be stable during the early stages.
 Systolic blood pressure should increase as the exercise level rises.
Up to 225mmHg is normal, although athletes can have higher levels.
 Diastolic pressure usually falls slightly.
 The aim of the exercise is for the patient to achieve
the target heart rate of 85% of maximum.
Clinical context for exercise testing for patients
with suspected ischemic heart disease
Patient with stable chest pain
or low-risk or intermediate-risk unstable angina
or previous MI
or post-revascularization

CAD Need for Need to

yes no guide medical no
diagnosis risk/prognostic
certain? assessment? management

no yes
yes

Contraindications yes
to Consider coronary angiogram Continue/initiate/modify
stress testing? medical rx

no

Symptoms yes
warranting
angiography?

no
 no
Can patient
Pharmacologic imaging study
exercise?

yes

Is no
resting ECG Exercise imaging study
interpretable*?

yes

Exercise test

Is test yes Consider coronary

result high
angiography/revascularization
risk?**

no
Consider imaging
no study/angiography
Is diagnosis
and prognosis
certain?
yes Continue/initiate/modify
rx as appropriate
Contraindications to Exercise Testing

Absolute
• Acute myocardial infarction (within 2 d)
• High-risk unstable angina
• Uncontrolled cardiac arrhythmias causing
symptoms or hemodynamic compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Acute aortic dissection
Relative
• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities
• Severe arterial hypertension systolic blood
pressure of >200 mm Hg and/or diastolic blood
pressure of >110 mm Hg
• Tachyarrhythmias or bradyarrhythmias
• Hypertrophic cardiomyopathy and other forms
of outflow tract obstruction
• Mental or physical impairment leading to
inability to exercise adequately
• High-degree atrioventricular block
Stopping the test

Patients rarely exercise for the full 21 minutes

of the Bruce protocol but completion
of 9 to12 minutes of exercise or reaching 85%
of the maximum predicted heart rate is usually
satisfactory.
Exercise Endpoints
 Commonly terminated when subjects
reach an arbitrary percentage of
predicted maximum heart rate.
 Other end points (summarized next
slides) are strongly preferred.
 The use of rating of perceived
exertion scales, such as the Borg
scale is often helpful in assessment of
patient fatigue.
 Indications for Terminating Exercise Testing
Absolute indications

• Moderate to severe angina

• Increasing nervous system symptoms (e.g., ataxia, dizziness, or

near-syncope)

• Signs of poor perfusion (cyanosis or pallor)

• Technical difficulties in monitoring ECG or systolic blood pressure

• Subject’s desire to stop

• Sustained ventricular tachycardia

• ST elevation (≥1.0 mm) in leads without diagnostic Q-waves

(other than V1 or aVR)
Relative indications
• Drop in systolic blood pressure of ≥10 mm Hg from baseline
blood pressure despite an increase in workload, in the absence of
other evidence of ischemia

• ST or QRS changes such as excessive ST depression (>2 mm of

horizontal or downsloping ST-segment depression) or marked
axis shift

• Arrhythmias other than sustained ventricular tachycardia, including

multifocal PVCs, triplets of PVCs, supraventricular tachycardia,
heart block, or bradyarrhythmias

• Fatigue, shortness of breath, wheezing, leg cramps, or claudication

• Development of bundle-branch block or IVCD that cannot be

distinguished from ventricular tachycardia

• Increasing chest pain

• Hypertensive response* *In the absence of definitive evidence, the committee suggests
systolic blood pressure of >250 mm Hg and/or a diastolic blood
pressure of >115 mm Hg. ECG indicates electrocardiogram; PVCs,
premature ventricular contractions; ICD, implantable cardioverter-
defibrillator discharge; and IVCD, intraventricular conduction delay.
The Modified Borg Scale
SCALE SEVERITY
0 No Breathlessness* At All
0.5 Very Very Slight (Just Noticeable)
1 Very Slight
2 Slight Breathlessness
3 Moderate
4 Somewhat Severe
5 Severe Breathlessness
6  
7 Very Severe Breathlessness
8  
9 Very Very Severe (Almost Maximum)
10 Maximum
Complications

The incidence of serious complications including

death or acute myocardial infarction is low if patients
are adequately selected.
Ventricular tachycardia or ventricular fibrillation
may occur in about 1 in 5,000.
Full CPR equipment must be present and
test supervisors must be properly trained
in resuscitation.
 The test is terminated when diagnostic
criteria have been met or when the
patient's condition prevents continuation.

 After the exercise has ended the recording

continues for up to 15 minutes.

 ST segment changes or arrhythmias may occur

during the recovery period even if they were
not present during exercise.

 These changes usually carry the same significance

as those occurring during exercise.
 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
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, cont’d

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
 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 60-
year-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
Age Gender Typical/Definite Atypical/Probable Non- Asymptomatic
Angina Pectoris Angina Pectoris Anginal
Chest Pain
30-39 Males Intermediate Intermediate low (<10%) Very low (<5%)
30-39 Females Intermediate Very Low (<5%) Very low Very low
40-49 Males High (>90%) Intermediate Intermediate low
40-49 Females Intermediate Low Very low Very low
50-59 Males High (>90%) Intermediate Intermediate Low
50-59 Females Intermediate Intermediate Low Very low
60-69 Males High Intermediate Intermediate Low

60-69 Females High Intermediate Intermediate Low

High = >90% Intermediate = 10-90% Low = <10%

Very Low = <5%
 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 12-
minute 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.(
The following findings suggest high probability
of coronary artery disease:

 Horizontal ST segment depression of <2mm

 Down-sloping ST segment depression
 Early positive findings within 6 minutes
 Persistence of ST depression for more than 6 minutes
after stopping
 ST segment depression in 5 or more leads
 Hypotension with exercise
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.
 Results Reporting
Hope Medical Group
Exercise Treadmill Test
Results Report – rev. 11/04

Patient Name: Date of Test:

Chart Number:
Reason for Test:
________________________________________________________________________
Digoxin? _______
Beta blocker? ________
Resting EKG interpretation:
________________________________________________________________________
________________________________________________________________________
LVH? ___________
LBBB? __________
RBBB? ___________
Resting ST Depression? _________
Cardiac Risk Factors (circle)

Age Gender Diabetes HTN

Hypercholesterolemia Smoker Sedentary/Obese Total Number:

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
METS achieved: _______________
Minutes exercised: _______________
Results Reporting – Page 2
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):
______________
Results Reporting – Page 3

5. Duke treadmill scores (see nomogram or use calculator):

5-year survival _______

Average annual mortality __________

6. VA treadmill score: _________

7. 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 Circle response Sum
Maximal Heart Rate Less than 100 bpm = 30 Males
100 to 129 bpm = 24
130 to 159 bpm =18
160 to 189 bpm =12 Choose
190 to 220 bpm =6 only one
Exercise ST Depression 1-2mm =15
per
group
> 2mm =25

Age >55 yrs =20

40 to 55 yrs = 12

Angina History Definite/Typical = 5

Probable/atypical =3 <40=low prob

Non-cardiac pain =1 40-60=
Hypercholesterolemia? Yes=5 intermediate
Diabetes? Yes=5 probability
Exercise test Occurred =3
>60=high
induced Angina Reason for stopping =5 probability
Total Score:
 Women
Variable Circle response Sum
Maximal Heart Less than 100 bpm = 20
Rate 100 to 129 bpm = 16
130 to 159 bpm =12

160 to 189 bpm =8 Choose

190 to 220 bpm =4
only one
Exercise ST 1-2mm =6
Depression > 2mm =10 per
Age >65 yrs =25 group
50 to 65 yrs = 15
Angina History Definite/Typical = 10
Probable/atypical =6
Non-cardiac pain =2 <37=low prob
Smoking? Yes=10
37-57=
Diabetes? Yes=10
intermediate
Exercise test Occurred =9
probability
Reason for stopping =15
induced Angina
Estrogen Status

Positive=-5, Negative=5
Total Score
>57=high
probability
Thank you