Physiology and Protocol, Indications and Contraindications DN EXERCISE STRESS TEST Physiology and Protocol, Indications and Contraindications DN

Essential ET Terminology Performance of the E S T Assess Exercise Test Responses Interpretation Of The Exercise Stress Test

Exercise Test Terminology Vo2max METs Myocardial Oxygen Consumption

Maximal Oxygen Uptake (VO2max) Greatest amount of oxygen an individual utilizes with maximal exercise (ml O2 /kg/ min) “Gold Standard” for cardiorespiratory fitness Fick Equation Vo2max = (HRmax x SVmax) x (CaO2max - CvO2max)

VO2max = (HRmax X SVmax) X (CaO2max - CvO2max) FICK EQUATION Diffusion Ventilation Perfusion (220 - Age) Sinus Node Dysfunction Drugs (e.g., B - blockers) PaO2 Hgb [ ] SaO2 VO2max = (HRmax X SVmax) X (CaO2max - CvO2max) Genetic Factors (Heart Size) Conditioning Factors Contractility/Afterload/Preload Disease Factors Wall Motion/Ventricular Fn, Valve Stenosis or Regur Skeletal Muscles Aerobic Enzymes Fiber Type Muscle Disease Cap density

MET Metabolic Equivalent Term 1 MET = "Basal" aerobic oxygen consumption to stay alive = 3.5 ml O2 /Kg/min inf- thyroid status, post exercise, obesity, disease states

MET Values 1 MET = "Basal" = 3.5 ml O2 /Kg/min 2 METs = 2 mph on level < 5METs = Poor prognosis if < 65;

13 METs = Excellent prognosis 10 METs = prognosis with med therapy = CABG 13 METs = Excellent prognosis 16 METs = Aerobic master athlete

Calculation of METs on the Treadmill METs = Speed x [0.1 + (Grade x 1.8)] + 3.5 3.5 Calcul automatically by device Speed in meters/minute = MPH x 26.8 Grade expressed as a fraction

Myocardial (MO2) Accurate measurement - cardiac catheterization Coronary Flow x Coronary (a – v)O2 diff HR, SBP, LVEDV, CONTRACTILITY, WALL THICKNESS .

Myocardial Oxygen Consumption Indirectly measured as the “Double Product” “Double Product” = HR x SBP A normal value is greater than 20,000 – 25,000 < 20,000 is low heart work load > 29,000 indicates high heart work load Angina & ST↓occur at the same DP for an individual

Types of Exercise Isometric (Static) Isotonic (Dynamic) Mixed -weight-lifting -pressure work for heart, limited cardiac output Isotonic (Dynamic) -walking, running, swimming, cycling -Flow work for heart -↑CO,↓ TPR Mixed

Exercise physiology Sympathetic activation Parasympathetic withdrawal Vasoconstriction, except in- Exercising muscles Cerebral circulation Coronary circulation ↑norepinephrine and renin

Exercise physiology ↑ventri contractility ↑O2 extraction(upto 3) ↓peripheral resistance ↑SBP,MBP,PP DBP –no significant change Pulm vasc bed can accommodate 6 fold CO CO - ↑ 4-6 times

Exercise physiology Isotonic exercise(cardiac output) Early phase- SV+HR Late phase-HR

peak oxygen consumption- age, sex, & training level of the person performing the exercise The plateau in peak oxygen consumption- Vo2 max Vo2 max is limited by 1)the ability to del O2 to sk. muscles 2) muscle oxidative capacity . V02 peak Oxygen consumption (liters/min) (VO2max) Work rate (watts)

Respiration during exercise dynamic exercise- ventilation increases linearly over the mild to moderate range, then > rapidly in intense exercise workload at which rapid ventilation occures is called the ventilatory breakpoint (together with lactate threshold) Lactate acidifies the blood, driving off CO2 and increasing ventilatory rate

BP rise in exercise (SBP) ↑up to 150-170 mm Hg during dynamic exercise; diastolic rarely alters isometric - SBP may ≥250 mmHg, and DBP can reach 180

Intense exercise  Glycolysis>aerobic metabolism  ↑ blood lactate lactic acid (mM) Lactate threshold; endurance estimation Relative work rate (% V02 max)

Age Pred Max HR APMHR=220 - age in years\ APMHR=200-1/2 age MHR ↓ with age Lower/higher than actual value(+/_12beats) Not used as an indicator of max exertion in EST/ Indi to terminate test

.

Post exercise phase Vagal reactivation -Imp-cardiac decceleration mech ↑in well trained athletes Blunted in CCF

ENERGY REQ ACTIVITY 4 METS >4-<10 METS >10 METS TAKING CARE OF SELF WALKING INDOORS WALK AT 2-3 mph 4 METS LIGHT WORK AROUND THE HOUSE WALKING AT 3-4 mph >4-<10 METS CLIMB 1 FLIGHT OF STAIRS/UP HILL WALK>4 mph, SHORT RUNNING SCRUBBING FLOOR,MOVING FURNITURE >10 METS RUNNING> 6-7 mph HEAVY LABOUR SWIMMING,FOOTBALL

Exercise Stress Testing Pathophysiology: At rest- adequate coronary blood flow with exercise-supply\demand mismatch -ST segment changes 70-80%occlusion - detection by EST Sign CAD can exist with a -VE Exercise Stress Test.

Treadmill protocol EST- stand protocols to progressively ↑ cardiovascular work load in a uniform and reproducible way Bruce protocol Naughton protocol Weber protocol ACIP(asymptomatic cardiac ischemia pilot) Modified ACIP

The Bruce protocol 1949 by Robert A. Bruce, considered the “father of exercise physiology”. Published as a standardized protocol in 1963. gold-standard for detection of myocardial ischemia when risk stratification is necessary.

BRUCE Protocol Stage Time (min) M/hr Slope 1 1.7 10% 2 3 2.5 12% 6 3.4 1.7 10% 2 3 2.5 12% 6 3.4 14% 4 9 4.2 16% 5 12 5.0 18% 15 5.5 20%

PROTOCOL USES COMMENTS BRUCE Normally used large↑Vo2 bet stages\running≥st 3 NAUGHTON&WEBER Limited ex tolerance-CCF 1-2 min stages\1 MET increment ACIP Established CAD 2 min stages\> linear ↑ in HR & Vo2 MOD-ACIP Short elderly individuals Peak Vo2 is the same regardless of the protocol used diff – rate at which it is achieved

Procedure Standard 12 lead ECG- leads Torso ECG + BP HR ,BP ,ECG Supine and Sitting / standing HR ,BP ,ECG Before,after,stage Onset of ischemic response Each min recovery(5-10 mints)

Procedure- Lead systems Mason-Liker modification-extremity electrodes moved to torso 2 ↓ motion artifacts RAD ↑inf lead voltage Loss of inf lead q New Q in AVL

Contraindications to Exercise Testing Absolute A/c MI (< 2 d) High-risk unstable angina Uncontrolled cardiac arrhythmias causing symptoms or hemo compromise Symptomatic severe AS Uncontrolled symptomatic CCF Acute pulmonary embolus or pulmonary infarction A/c myocarditis or pericarditis A/c Ao dissection

Contraindications to Exercise Testing Relative LMCA stenosis Mod- stenotic VHD Electrolyte abnormalities Sev HTN Tachyarrhythmias or bradyarrhythmias HOCM and other outflow tract obstructions Mental or physical impairment leading to inability to exercise adequately High-degree AV block

SAFETY & RISKS In nonselected pat pop-mortality- .01% -morbidity-.05% In k/c CAD- 1 C.arrest/59000 person hours -AMI in 1.4 / 10000 tests Arrythmias-AF-Mc-9/10,000 tests -VT-6/10,000 tests -VF- .6/10,000 tests Deaths& MI estimated occur in 1 of 25000 tests

Bayes' theorem A theory of probability The post test probability is proportional to the pretest probability To diagnose, test sensitivity ,specificity& prevalence in the population being tested req

Sensitivity- a person with the disease having a positive test. Specificity-person without the disease having a negative test. Prevalence- % in the population having disease.

Pretest Probability Based on the pat's h/o ( age, gender, chest pain ), phy ex and initial testing, and the clinician's experience. Typical or definite angina →pretest probability high - test result does not dramatically change the probability. Diag power maximal when the pretest probability is intermediate-30-70%

Classification of chest pain Typical angina Atypical angina Noncardiac chest pain Substernal chest discomfort with characterstic quality and duration Provoked by exertion or emotional stress Relieved by rest or NTG Meets 2 of the above characteristics Meets one or none of the typical characteristics

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

INTERMEDIATE CATEGORY AGE GROUP GENDER & SYMPTOMS 30-39 YEARS M& F + TYPICAL ANGINA M + ATYPICAL/ PROBABLE ANGINA 40-49 YEARS F + TYPICAL ANGINA M + ATYPICAL/ NON ANGINAL CP 50-59 YEARS F+ TYPICAL ANGINA M&F + ATYPICAL NAGINA M+ NON ACP 60-69 YEARS M& F+ ATYPICAL/PROB ANGINA M&F + NACP

E T TO DIAGNOSE OBSTRUCTIVE CAD Class I Adult (including RBBB or <1 mm of resting ST↓) with intermed pretest probability of CAD Class IIa Patients with vasospastic angina.

E T TO DIAGNOSE OBSTRUCTIVE CAD Class IIb 1. Patients - high pretest probability of CAD 2. Patients - low pretest probability of CAD 3. Patients with <1 mm of baseline ST ↓and on digoxin. 4. Patients with LVH and <1 mm baseline ST ↓. Class III Patients with the following baseline ECG abnormalities: • Pre-excitation syndrome • Electronically paced ventricular rhythm • >1 mm of resting ST depression • Complete LBBB

SVD(LAD>RAD>LCX) 25-71% EST SENSITIVITY SPECIFICITY OVERALL 68% 77% SVD(LAD>RAD>LCX) 25-71% MULTIVESSEL DIS 81% 66% LMCA/3-VD 86% 53%

Exercise Testing in Asymptomatic Persons Without Known CAD Class I None. Class IIa Evaluation of asymP DM pts - plan to start vigorous exercise ( C) Class IIb 1. Eval of pts with multiple risk factors - guide to risk-reduction therapy. 2. Eval of asymptomatic men > 45 yrs and women >55 yrs: Plan to start vigorous exercise Involved in occupations which impact public safety High risk for CAD(e.g., PVOD and CRF) Class III Routine screening of asymptomatic

RISK ASSESS AND PROG IN PAT WITH SYMP OR A PRIOR HISTORY OF CAD Class I 1. Initial evalu with susp/known CAD +/- RBBB or <1 mm of resting ST Depression 2.Susp/ known CAD, previously evaluated-+ signi change in clinical status nw 3. Low-risk UA pts >8 to 12 hrs & free of active ischemia/CCF 4. Intermed-risk UApts > 2 to 3 days & no active ischemia/ CCF Class IIa Intermed-risk UA pts – initial markers (N),rpt ECG –no signi change, and markers >6-12 hrs (N) & no other evidence of ischemia during observation.

AFTER MYOCARDIAL INFARCTION Class I 1. Before discharge (submaximal --4 to 6 days). 2. Early after discharge (symptom limited --14 to 21 days). 3. Late after discharge if the early exercise test was submaximal (symptom limited --3 to 6 weeks). Class IIa After discharge as part of cardiac rehabilitation in patients who have undergone coronary revascularization.

AFTER MYOCARDIAL INFARCTION Class IIb 1. Patients with the following ECG abnormalities: • Complete LBBB • Pre-excit synd • LVH • Dig therapy • >1 mm of resting ST-segment dep • paced ventricular rhythm 2. Periodic monitoring in patients who continue to participate in exercise training or cardiac rehabilitation. Class III 1. Severe comorbidity likely to limit life expectancy and/or candidacy for revascularization. 2. any time to eval pts with AMI with uncompensated CCF, arrhythmia, or noncardiac exercise limiting conditions. 3. Before discharge to evaluate pts who have already been selected for, or have undergone, cardiac cath. .

Submaximal protocols predetermined end point, often a peak HR 120 bpm, or 70% predicted max HR or peak MET – 5 Symptom-limited tests to continue till signs or sympt needing termination (i.e., angina, fatigue, ≥ 2 mm of ST↓,v. arrhy, or ≥10-mm Hg drop in SBP from the resting blood pressure)

The incidence of fatal cardiac events(inclu fatal MI & cardiac rupture)-- 0.03% Nonfatal MI and successfully resuscitated cardiac arrest -- 0.09% Complex arrhythmias, including VT --1.4%. Symptom-limited protocols have an event rate that is 1.9 times that of submaximal tests

High risk predischarge Present Absent Cardiac cath strategy 2 strategy3 symp lim EST(14-21d) sub max (4-7d)

Symp lim EST(14-21 days) Markedly ab mildly ab negative Card cath Ex imaging Reversible ischemia no rev ischemia Med Rx

Sub max (4-7 days) Markedly ab mildly ab negative Ex imaging Rev ischemia no rev isch symp lim ex(3-6wks) card cath markedly ab mildly ab negative rev isch no rev isch Med Rx

E S T Before and After Revascularization Class I 1. Demo of ischemia before revascularization. 2. Eval rec symps suggesting ischemia aft revascularization. Class IIa Aft discharge for activity counseling and/or exercise training as part of rehabilitation in pts aft revascularization. Class IIb 1. Detection of restenosis in selected, high-risk asymptomatic pts < first 12 months aft PCI. 2. Periodic monitoring of selected, high-risk asymptomatic ps for restenosis, graft occlusion, incomplete coronary revascularization, or disease progression. Class III 1. Localization of ischemia for determining the site of intervention. 2. Routine, periodic monitoring of asymptomatic pts after PCI or CABG without specific indications.

Investigation of Heart Rhythm Disorders Class I 1. Identification of appropriate settings in pts with rate-adaptive pacemakers. 2. Evaluation of cong CHB in pts considering ↑activity/competitive sports. (C) Class IIa 1. Evaluating known or suspected exercise-induced arrhythmias. 2. Evaluation of medical, surgical, or ablative therapy in exercise-induced arrhythmias

Investigation of Heart Rhythm Disorders Class IIb 1. Isolated VPC in middle-aged pts without other evidence of CAD. 2. Prolonged 1˚AV block or type I-2˚AV block , LBBB, RBBB, or VPC in young pts considering competitive sports. (C) Class III Routine investigation of isolated VPC in young pts.

IN VALVULAR HEART DISEASE Class1- c/c AR-Fun capacity & symp resp in pats with equivocal sympt Class 2A c/c AR- FN capacity- athletic activity prog in c/c AR before AVR

Stress Testing Modality Sensitivity Specificity Exercise test 68% 77% Nuclear Imaging 87-92% 80-85% Stress Echo 88-95%

EST RESPONSES & INTERPRETATIONS

Normal Response to Stress Testing Heart rate increases Blood pressure increases Cardiac output increases Total peripheral resistance decreases Dysrhythmias – isolated unifocal PVC’s and PAC’s (suppressed at increased heart rate) Oxygen consumption increases

Abnormal Response to Stress Testing Heart rate fails to rise above 120 or unable to attain THR of 85% of max SBP shows a drop Physically unable to complete test Marked hypertension, >260/115 Chest Pain and/or unusual shortness of breath

Normal Response of ECG to Stress Testing ECG Changes QRS complex ↓ in size PR,QRS,QT shorten J point ↓, resulting in up sloping of ST segment ST segment returns to baseline by 80 milliseconds PR segment may down slope(Inf leads– baseline PQ junction) R amplitude may decr at rates > 130 P ampl ↑ T wave decreases

The Electrocardiographic Response

The Exercise ECG 1 = Iso-electric 2 = J point 3 = J + 80 msec FIGURE 10-8 Magnified ischemic exercise– induced electrocardiographic 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 0.2mV (2mm) and ST 80 is 0.24mV (24mm). The average slope measurement from the J point to ST 80 is −1.1 mV/sec. 1 = Iso-electric 2 = J point 3 = J + 80 msec

ST 60 -- HR > 130/min ST 80 -- HR ≤ 130/min

Criteria for Reading ST-Segment Changes on the Exercise ECG ST DEPRESSION: Measurements made on 3 consecutive ECG complexes ST level is meas rel to the P-Q junction When J-point is dep rel to P-Q junction at baseline: Net diff from the rest J junction - amount of deviation When the J-point is ↑ rel to P-Q junction at baseline and becomes ↓ isoel with exercise: Mag of ST dep - P-Q junction and not the resting J point

Abnormal and Borderline ST-Segment Depression 1.0 mm or > horizontal or downsloping ST dep at 80 msec after J point on 3 consecutive ECG complexes BORDERLINE: 0.5 to 1.0 mm horizontal or downsloping ST dep at 1.5 mm or > upsloping ST dep at 80 msec after J point on 3 consecutive ECG complexes

ECG changes during stress test

Normal Rapid Upsloping Minor ST Depression Slow Upsloping

Horizontal Downsloping Elevation (non Q lead) Elevation (Q wave lead)

ECG Patterns Indicative of Myocardial Ischaemia ECG Patterns Not Indicative of Myocardial Ischaemia

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. severe ischemic response.

The J point at peak exertion is depressed 2 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. “slow upsloping” ST segment at peak exercise indicates an ischemic pattern in patients with a high coronary disease prevalence pretest. 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.

abnormal at 9:30 minutes ES test and resolves in the immediate recovery phase. 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.

ST Elevation Abnormal response J ↑ ≥0.10mV(1 mm) ST 60 ≥0.10mV(1 mm) Three consecutive beats Q wave lead (Past MI) Severe RWMA, ↓EF, ↓Prognosis Non Q wave lead (Past MI) Severe ischemic response Localise the culprit Non Q wave lead (No past MI)-1% Transmural reversible myocardial ischemia- ----vasospasm, ↑coronary narrowing

ST segment elevation 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 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 coronary vasospasm produces this result in the absence of significant intraluminal atherosclerotic narrowing

Confounders of EST Interpretation Digoxin abnormal ST-segment response to exercise. occurs in 25% to 40% directly related to age. LVH ↓ specificity of EST, sensitivity unaffected. still the first test Ab test- ref to add tests Resting ST ↓ Resting ST-segment ↓ -even otherwise adverse

LBBB Ex-induced ST ↓ -no asso with ischemia no level of ST-seg dep - diag RBBB do not ↓ sensitivity, specificity, or predictive value β- # THERAPY routine- unnecessary- to stop beta-blockers-† symp in patients taking -↓ diag & prog value - inadequate HRR

ERS and resting ST↑ Return to the PQ Jn –nl ST↓ meas from PQ jn Not from the elevated J point before ex.

Duke Treadmill Score Treadmill Score = Ex.tme (min) -5х (ST-seg dev in mm)- 4х ex.angina index (0-no angina, 1 angina, 2 if angina stops test) High Risk= -11, mortality - >5% annually Low Risk= +5, mortality - 0.5% annually

DUKE TM SCORE Independent prog information =y good in males & females Not as effective in age≥ 75 yrs

high-risk test result- mortality ≥ 4%/yr→ for cardiac cath ACC/AHA Guidelines: high-risk test result- mortality ≥ 4%/yr→ for cardiac cath Intermediate-risk result -mortality 2- 3%/yr→ additional testing- cardiac cath, exercise imaging study

Pseudo normalization pattern of T No prior MI Nondiagnostic finding Prior MI Sugg Reversible myocardial ischemia Needs - rev myo perfusion defect

R Wave amplitude LVH Voltage criteria ST seg – less reliable to ∆ CAD even in the absence of LV strain pattern Loss of R wave (MI) ↓Sensitivity of ST response in that lead

U inversion Occ in precordial leads at HR<120 Relatively insensitive but Relatively specific 4 CAD

ST/HR SLOPE MAESUREMENTS HR adj of ST seg dep-↑ sensitivity ST/HR slope of 2.4 mV/beats/min-abnormal >6mV/beats/min -3 vessel disease CORNELL protocol-gradual inc in HR ST seg/HR index-av change of ST dep with HR through out the course of ex test > 1.6 -abnormal Linear reg analysis rel the meas amt of st dep in indi leads to hr at the end of each sstage of ex Better prognosticator than std crit im MRFITrial

Abnormal BP Response Failure to ↑SBP >120 mmHg Sustained ↓(15 secs) >10mmHg ↓SBP below resting BP during progressive exe Inadequate ↑ of CO Hypo episode 3- 9% of symp pats Extensive CAD & perfusion defects LMCA/ 3 VD

Exercise Capacity Stage 2 = 6 - 8 METS Stage 3 = 8 -10 METS VO max = (mph x 26.8) x (0.1 + [% grade X 1.8] + 3.5 Stage 1 = 5 METS Stage 2 = 6 - 8 METS Stage 3 = 8 -10 METS 2 2 Aerobic cost or oxygen consumption.MET=oxygen comsuption at rest.The strongest predictor of death in normal&CAD,1MET=17% reduction in all cause mortality.Data from large study from Mayo (3K pts)& St. James Women Take Heart project.

1-MET ↑in exercise capacity, the survival improved by 12 % FIGURE 10-12 Age-adjusted relative risks of all-cause mortality by quintile of exercise capacity in 2534 subjects with a normal exercise test result and no history of cardiovascular disease and 3679 subjects with an abnormal exercise test result or history of cardiovascular disease. The mean duration of follow-up was 6.2 ± 3.7 years. Quintile 5 was used as the reference category. For each 1-MET increase in exercise capacity, the survival improved by 12 percent (From Myers J, Prakash M, Froelicher V, et al: Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 346:793, 2002 N Engl J Med 346:793, 2002.) 1-MET ↑in exercise capacity, the survival improved by 12 % N Engl J Med 2002

Heart rate response Chronotropic incompetence-adv prog Inability to attain THR OR Ab HRR (<80%) {%HR Reserve=(HRpeak-HRrest)/(220-age- HRrest)} Chronotropic index ANS dysfunction,SN dysfuntion, drugs, myocardial ischemia ↑long term mortality-< 80%CI (not on β blockers) CI-hr increments/stage that is below nl-inability to use all hrr

Heart Rate Recovery -Rapid reactivation of vagal tone - ↓ in heart rate post ex- nl -Slow decceleration post ex -↓ vagal tone HRR=HR (peak)-HR (1 min later)

TMT (upright) < 12 bpm TMT (supine) < 18 bpm upright value <22 bpm at 2 minutes is abnormal Prognostic power independent of other factors Inde of ex level, beta bl, sev of cad,lv fn, CI, DTMS,

HRR Predicts Outcome in CAD

Exercise induced Chest discomfort Usually after ischemic ST changes +/-↑DBP chest discomfort –only sgn of CAD In CSA, CP less freq than ST↓ Angina with no ST ↓- MPI to assess ischemic severity. (+) Stress Test with angina → 5%/yr.( mortality) (+) Stress Test, no angina → 2.5%/yr. Circ 1984;70:547-551

Adverse prognosis & multivessel CAD Symptom limiting exercise < 5METs Abnormal BP response ST↓ ≥2mm or downsloping ST↓→ <5METs, ≥5 leads, persisting ≥5 mins into recovery ST↑( except aVR) Angina at low exercise work loads Reproducible sustained/symptomatic VT

Indications for Terminating Exercise Testing Absolute indications ↓ SBP >10 mm Hg fm baseline +other evidence of ischemia Mod - severe angina ↑ CNS sympts (ataxia, dizziness, or near-syncope) Signs of poor perfusion (cyanosis or pallor) Technical diff in monitoring ECG or systolic BP Subject’s desire to stop Sustained VT ST ↑ (≥1.0 mm) in leads without Q-waves (other than V1 or aVR)

Relative indications ↓ in S BP (≥10 mm Hg) in the absence of other evidence of ischemia ST or QRS changes - excessive ST↓ (>2 mm of horizontal or downsloping ST↓ ) or marked axis shift Arrhythmias other than sustained VT, including multifocal PVCs, triplets of PVCs, SVT, heart block, or bradyarrhythmias Fatigue, shortness of breath, wheezing, leg cramps, or claudication Devp of BBB or IVCD that cannot be distinguished from VT Increasing chest pain Hypertensive response(250/115 mm hg)

Sub maximal ex test Signs & sympt of ischemia Att of a work load of 6 METS 85% of APMHR HR of 110 beats / min –on β blockers BORG score 17

THANK YOU