1. CLINICAL EXERCISE TESTING To evaluate person’s ability to tolerate increasing levels of work output parameters measured include but are not limited to ECG hemodynamic response symptomatic ischemia electrical abnomralities exertion related problems

2. APPLICATIONS Diagnostic, Prognostic and Therapeutic Exercise Prescription Occupation Activities of daily living

3. DIAGNOSTIC TESTING Not appropriate for the general population Age, gender, risk factors, symptoms and vigor of exercise will determine test necessity Geared toward individuals with a higher probability of disease

4. TESTING FOR DISEASE SEVERITY (PROGNOSIS) Symptoms, functional capacity and ischemia during exercise are evaluated Magnitude of ischemic response and at what replicable point does it occurr Double-Product --SBP x HR= myocardial oxygen consumption

5. TESTING AFTER AN INSULT Prior to hospital discharge Submax tests may be used Symptom limited tests done 4 day post MI Use to gage activity level and therapy

6. FUNCTIONAL TESTING Used for exercise prescription, activity counseling, or disability limitations Usually described in terms of a percentage of “normal” in units of METS

7. CLINICAL TEST MODALITIES Treadmill--yields the highest VO2 and HR Hand rails--needs and purposes Stop belt--Stop exercise Additional directions for the novice like???

8. MORE Cycle ergometers--lower VO2 (5-25%) and HR Better HR and BP measures Less expensive, less noise, less space Driven by patient motivation Localized fatigue Arm ergometery-lower VO2 (20-30%)

9. PROTOCOLS Based on purpose of test, desired outcomes and the individual Bruce, Ellestad--larger incremental changes- for healthy Naughton, Balke-Ware, USAFSAM--smaller incremental changes--for older and deconditioned Submax tests-used for individuals that are too unstable or high risk to take to max

10. PROTOCOLS Submax tests are usually terminated based on a predetermined end point like 120 bpm or a MET level of 5 Even so, most end points are patient specific Ramp Protocol-- increasingly popular--based on constant and continuous increase in workload-seemingly more accurate in estimations and more individualized

11. TESTING FOR RETURN TO WORK POST INSULT 15-20% of MI survivors do not return to work Medical and nonmedical factors contribute to outcome Job demands, timelines for return to work, rehab based on job demands, and to determine special work related needs GXT can provide necessary info but specialized tests can be used also

12. SPECIALIZED TESTS Weight carrying tests-evaluates tolerance for dynamic and static lifting Repetitive lifting--evaluates tolerance to bouts of lifting

13. MEASURES DURING TESTS Pretest--ECG, HR, BP, RPE--supine, sitting, standing Exercise--3-lead ECG every min., 12- lead ECG last 15 sec, of each stage, BP last min. of each stage, RPE last min. of each stage--BP, 12-lead ECG, and RPE at MAX Posttest--same as during the exercise portion

14. MEASURING EXPIRED GASES The most accurate way of determining VO2, functional capacity and VT Not necessary for all clinical testing Most appropriate for: evaluating a therapeutic intervention, in research, when cause of exercise limitation is uncertain, evaluation for prognosis and need for transplantation, and exercise prescription for cardiac rehab

15. ECG MONITORING Quality of ECG very important Skin prep is essential shave alcohol abrasion Electrode placement in supine position 10 electrodes for 12 lead

16. SUBJECTIVE RATINGS RPE- 0-10 or 6-20 scale Note instructions on p. 105-6 Symptomatic scales are different rating for angina rating for leg pain rating for dyspnea

17. POST EXERCISE PERIOD Healthy individuals do an active and passive recovery Symptomatic individuals may require supine recovery Test termination based on absolute or relative indications

18. EXERCISE TESTING WITH IMAGING Used to determine extent or distribution of disease An additional confirmation when ECG changes are hard to interpret Echocardiography-cheaper than nuclear testing but operator dependent identifies wall abnormalities for ischemia

19. Nuclear Imaging -limitations include exposure to radiation, additional equipment and personnel and physician training in nuclear medicine and interpretation advantages include sharper and improved images over 180 degrees rotation--depicts heart in 3 dimensions so multiple myocardial segments can be viewed separately

20. PHARMACOLOGIC TESTING For patients not able to do an exercise test--to establish diagnosis of CAD or evaluating efficacy of CABG Dobutamine and Thallium are the most used tests Images obtained are similar to echocardiography

21. CONSIDERATIONS FOR PULMONARY PATIENT Degree of dyspnea Cause of dyspnea Distinguish between cardiac or pulmonary limitations Deconditioning factors such as obesity, anxiety Exercise induced oxygen desaturation

22. TESTING SUPERVISION Physician supervision Physician in the immediate vicinity Paramedical personnel Expertise versus physician presence Implications for Costs