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

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

3. Exercise Test Terminology
Vo2max
METs
Myocardial Oxygen Consumption

4. 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)

5. 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

6. 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

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

8. 13 METs = Excellent prognosis
10 METs = prognosis with med therapy = CABG
13 METs = Excellent prognosis
16 METs = Aerobic master athlete

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

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

11. 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

12. 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

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

14. 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

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

16. 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)

17. 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

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

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

20. 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

21. .

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

23. 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

24. 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.

25. 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

26. 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.

27. 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%

28. 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

29. 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)

30. 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

31. 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

32. 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

33. SAFETY & RISKS
In nonselected pat pop-mortality- .01%
-morbidity-.05%
In k/c CAD- 1 C.arrest/59000 person hours
-AMI in 1.4 / 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 tests

34. 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

35. 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.

36. 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%

37. 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

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

39. 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

40. 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.

41. 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

42. 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%

43. 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

44. 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.

45. 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.

46. 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. .

47. 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)

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

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

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

51. 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

52. 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.

53. 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

54. 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.

55. 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

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

57. EST RESPONSES & INTERPRETATIONS

58. 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

59. 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

60. 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

61. The Electrocardiographic Response

62. 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

63. ST HR > 130/min
ST HR ≤ 130/min

64. 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

65. 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

66. ECG changes during stress test

67. Normal
Rapid Upsloping
Minor ST Depression
Slow Upsloping

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

69. ECG Patterns Indicative of Myocardial Ischaemia
ECG Patterns Not Indicative of Myocardial Ischaemia

70. 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.

71. 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.

72. 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.

73. 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

74. 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

75. 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

76. 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

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

78. 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

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

81. 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

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

83. 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

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

85. 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

86. 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

87. 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 = METS
Stage 2 = METS
Stage 3 = 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.

88. 1-MET ↑in exercise capacity, the survival improved by 12 %
FIGURE 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

89. 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

90. 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)

91. 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,

92. HRR Predicts Outcome in CAD

93. 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 → %/yr.
Circ 1984;70:

94. 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

95. 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)

96. 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)

97. 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

98. THANK YOU