Presents

TREADMILL
TESTING
Presented by- Mr.jeet ghosh
Resource person-Healthcare
sector
introduction
• Exercise electrocardiographic testing is among the most
fundamental and widely used tests for the evaluation
of patients with CVD
• It is easy to perform, and interpret; it is flexible and
adaptable; and it is reliable, inexpensive, and readily available
in hospital or practice settings.
• The exercise test has been used by clinicians for more than
half a century, and its durability can be attributed to its
evolution over time
 3

INDICATIONS OF EXERCISE TESTING

• Elicit abnormalities not present at rest

• Estimate functional capacity
• Estimate prognosis of CAD
• Likelihood of coronary artery disease
• Extent of coronary artery disease
• Effect of treatment
• Evaluation and management of patients with a wide variety of
cardiovascular conditions, including valvular heart disease,
congenital heart diseasearrhythmias, and peripheral arterial
disease (PAD).
 4

METHODS

• General concerns prior to performing an exercise test include

• Patient preparation
• Choosing a test type
• Choosing a test protocol
• Patient monitoring
• Reasons to terminate a test
• Post test monitoring
 5

PRETEST PREPARATION

∙ Any history of light headed or fainted while exercising sholud

be asked.
∙ The physician should also ask about family history and general
medical history, making note of any considerations that may
increase the risk of sudden death.
∙ A brief physical examination should always be performed prior
to testing to rule out significant outflow obstruction
 Preparation for exercise testing include the
following
-
1. The subject should be instructed not to eat or smoke atleast 2 hours prior to the test .
2. Unusual physical exertion should be avoided before testing.
3. Specific questioning should determine which drugs are being taken. The labeled
medications should be brought along so that medications can be identified and
recorded.
4. A written informed consent form is usually required. The indication for the test should
be known.
5. The supervising physician should be made aware of any recent deterioration in the
patient's clinical status.
6. although diagnostic exercise tests in patients without known CAD are best performed by
withholding cardioactive medications on the day of the test to better assess for an
ischemic response, functional testing in patients with known CAD might best be
performed with patients having taken their usual medications to evaluate the effects
7. The test should not be performed on subjects who are markedly hypertensive (e.g.,
EXERCISE PROTOCOLS
1. Isotonic or dynamic exercise,
2. isometric or static exercise,
3. resistive (combined isometric and isotonic) exercise.
• Dynamic protocols are most frequently used to assess
cardiovascular reserve, and those suitable for clinical testing
should include a low-intensity warm-up phase.
• In general, 6 to 12 minutes of continuous progressive exercise
during which the myocardial oxygen demand is elevated to the
patient's maximal level is optimal for diagnostic and
prognostic purposes.
• The protocol should include a suitable recovery or cool-
down period.
DYNAMIC EXERCISES
• Arm Ergometry
• Bicycle Ergometry
• Treadmill test
• Walk Test
Arm Ergometry
•Involve arm cranking at
incremental workloads of
10 to 20 watts for 2- or 3-
minute stages
HR & BP responses to a
give
n
wor
kloa
d>
leg
exer
cise

Pea
k
 Treadmill Protocols
• Bruce
• Modified Bruce
• Cornell
• Blake ware
• Naughton and Weber
• ACIP (Asymptomatic cardiac ischemia pilot)
• Modified ACIP
13
 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 and Modified Bruce Protocol
Bruce:There are 7
stages, but most
individuals are
unable to
complete all of
the stages. This
protocol starts at
5 METs in stage 1
and then each
stage is increased
by approximately
2 – 3 METs
modified
bruce:the first 2
stages occur at
workloads of 2.9
and 3.7 METs.
Stage three is
equal to the first
stage (5METs)
 PROTOCOL USES COMMENTS

BRUCE Normally used 3min stages

NAUGHTON&WEBER Limited ex tolerance-CCF 1-2 min stages\1 MET

increment

ACIP Established CAD 2 min stages

1.5-MET increments
between stages after two
1-minute warm-up
stages.\> linear ↑ in HR &
Vo2

MOD-ACIP Short elderly individuals who cannot keep up with a

walking speed of 3 mph

where grade is expressed as a fraction (e.g., 5% grade = 0.05). can be

converted to METS by dividing by 3.5.
The peak is usually the same regardless of treadmill protocol used;
the difference is the rate of time at which the peakis achieved
 17

The 6-Minute Walk Test

⮚Used for patients who have marked left ventricular

dysfunction or peripheral arterial occlusive disease and
who cannot perform bicycle or treadmill exercise.
⮚Patients are instructed to walk down a 100-foot
corridor at their own pace, attempting to cover as much
ground as possible in 6 minutes.
⮚At the end of the 6-minute interval, the total distance
walked is determined and the symptoms experienced by
the patient are recorded.
ECG
MEASUREMENTS
ECG LEAD SYSTEM
Mason –Likar modification
⮚Adequate
skin
prepartion
⮚Extremity electrodes
moved to the torso to
reduce motion artifact
•Arm electrodes- lateral
aspects of infraclavicular
fossae
•Leg electrodes-above
the anterior iliac crest
Mason –Likar modification
⮚It results in
• Right axis shift
• Increased voltage in inferior leads
• May produce loss of inferior Q waves and development of new Q
waves in lead aVL
⮚Thus, the body torso limb lead positions cannot be used
to interpret a diagnostic rest 12-lead ECG
Types of ST Segment Displacement

⮚In normal persons

•The PR, QRS, and QT intervals shorten as heart rate
increases
•P amplitude increases
•PR segment becomes progressively more downsloping
in the inferior leads
•J point or junctional depression will occur
J point depression of 2 to 3 mm in leads V4 to V6, with rapid upsloping ST segments
depressed approximately 1 mm 80 milliseconds 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.
Types of ST Segment Displacement

⮚In patients with myocardial ischemia

• ST segment usually becomes more horizontal
(flattens) as the severity of the ischemic response
worsens.
• With progressive exercise, the depth of ST segment
depression may increase, involving more ECG leads, and
the patient may develop angina
•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 2.5 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.
Types of ST Segment Displacement

⮚In the immediate postrecovery phase

•ST segment displacement may persist, with downsloping
ST segments and T wave inversion, gradually returning
to baseline after 5 to 10 minutes
• Ischemic response ---only in the recovery phase
⮚Occur in 10 percent of patients
⮚Prevalence is higher in asymptomatic
populations compared with those with
symptomatic CAD
MEASUREMENT OF ST SEGMENT
DISPLACEMENT
⮚True isoelectric point ----TP segment
•For purposes of interpretation--- PQ junction is
usually chosen as the isoelectric point
⮚Abnormal response
•The development of 1 mm or greater of J point
depression
•with a relatively flat ST segment slope (<1 mV/sec)
• depressed greater than or equal to 0.10 mV 80 msec
after the J point (ST 80) in three consecutive beats with
a stable baseline
Ischemic exercise-induced ECG
MEASUREMENT OF ST SEGMENT
DISPLACEMENT
⮚When the ST 80 measurement is difficult to
determine at rapid heart rates (e.g., >130 beats/min),
the ST 60 measurement should be used.
⮚The ST segment at rest may occasionally be depressed.
When this occurs, the J point and ST 60 or ST 80
measurements should be depressed an additional 0.10
mV or greater to be considered
⮚When the degree of resting ST segment depression is
0.1 mV or greater, the exercise ECG becomes less
specific, and myocardial imaging modalities should be
considered
MEASUREMENT OF ST SEGMENT
DISPLACEMENT
⮚In early repolarization
• Normal response---Resting ST segment elevation returns to the PQ
junction
• Magnitude of exercise-induced ST segment depression should be
determined from the PQ junction and not from the elevated
position of the J point before exercise
 MEASUREMENT OF ST SEGMENT
DISPLACEMENT
⮚Localization of site of myocardial ischemia
• ST segment depression do not localize the site of myocardial ischemia
and which coronary artery is involved
• ST segment elevation is relatively specific for the territory of
myocardial ischemia and the coronary artery involved.
UPSLOPING ST SEGMENTS
⮚Normal response
• J point depression
• Rapid upsloping ST segment (>1 mV/sec)
•depressed less
than 1.5 mm at ST
80

⮚Abnormalresponse
Depression of ST segment > 1.5 mm at ST80
✔Patients with a high CAD prevalence---
abnormal.
ST SEGMENT ELEVATION
⮚ST segment elevation may occur in
• an infarct territory where Q waves are present
• in a noninfarct territory.
⮚Abnormal response
1 mm elevation at ST60 for 3 consecutive beats with a stable
baseline.
 ST SEGMENT ELEVATION
⮚ST segment elevation in leads with abnormal Q
waves
• Occur in 30% of anterior MI & 15% of inferior MI
• Have a lower ejection fraction
• greater severity of resting wall motion abnormalities
• worse prognosis.
• not a marker of more extensive CAD
• rarely indicates myocardial ischemia.
 ST SEGMENT ELEVATION
⮚ST segment elevation in leads without Q waves
⮚Indicates transmural myocardial ischemia caused by
coronary vasospasm or a high-grade coronary narrowing
⮚Occurring in a 1 percent of patients with obstructive CAD.
⮚Site of ST segment elevation is relatively specific for the
coronary artery involved
ST SEGMENT ELEVATION
T WAVE CHANGES
⮚ Pseudonormalization of T waves
• T-waves inverted at rest and becoming upright with exercise
• Nondiagnostic finding --- in low CAD prevalence
populations
• In rare instance--- marker for myocardial ischemia
Pseudonormalization of T waves
OTHER ECG MARKERS
⮚Changes in R wave amplitude
⮚Relatively nonspecific and are related to the level of
exercise performed
⮚In LVH the ST segment response cannot be used reliably
to diagnose CAD
⮚U wave inversion
⮚may occasionally be seen in the precordial leads at heart rates
of 120 beats/min
⮚Relatively specific and relatively insensitive for 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 depression with HR

through out the course of exercise test
• > 1.6 -abnormal
NONELECTROCARDIOGRAPHIC
OBSERVATIONS
 Blood Pressure
⮚Normal Exercise response
• SBP - Increase to 160 to 200 mm HG
• DBP - Does not change significantly
⮚In LV dysfunction (or) an excessive reduction in systemic
vascular resistance
• Failure to increase SBP> 120 mm HG
• (or) Sustained decrease > 10 mm HG repeatable within 15 seconds
• (or) Fall in SBP below standing rest values
Exertional Hypotension
⮚Ranges from 3 to 9 %
⮚Higher in patients with TVD (or) Left main
CAD
⮚Cardiomyopathy
⮚Cardiac arrhythmias
⮚Vasovagal reactions
⮚LVOT Obstruction
⮚On Antihypertensive drugs
⮚Hypovolemia
⮚Prolonged Vigorous Exercise
 Work Capacity

⮚Limited work capacity

Associated with increased risk of cardiac events in known(or) suspected CAD
⮚In estimating functional capacity, the amount of work
performed (or exercise stage achieved ) should be the
parameter measured and not the number of minutes of
exercise
 1-MET ↑in exercise capacity, the survival improved by
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.)
Cumulative 20-year survival rates in 6749 black and 8911 white male U.S. veterans with
and without cardiovascular disease. Survival is significantly reduced with each decrement
in peak aerobic capacity. The relationship was similar for those with and without
cardiovascular disease and for blacks and whites.(From Kokkinos P, Myers J, Kokkinos JP,
et al: Exercise capacity and mortality in black and white men. Circulation 117:614, 2008.)
Heart rate response
Sinus rate increases progressively with exercise.
Inappropriate increase in heart rate at low work loads -
• Atrial fibrillation
• Physically deconditioned
• Hypovolumic
• Anemia
• Marginal left ventricular function
• When the heart rate fails to incraese appropriately with
exercise it is associated with adverse prognosis
Maximum Heart Rate
• The maximum heart rate with exercise is a fundamental physiologic
parameter that provides the clinician relevant information concerning the
intensity of exercise, the adequacy of the exercise test, the effect of
medications that influence heart rate, the poten- tial contribution to
exercise intolerance, and the patient’s progno- sis
• The maximum achievable heart rate (HRmax) is unique for each patient
but can be estimated by using regression equations that adjust for the
patient’s age. The most familiar equation, which was developed principally
in middle- aged men, is
HRmax = 220 − Age
• Although easy to apply and calculate, there is considerable variability with
this equation, especially in patients with CAD who are taking beta blockers.
Newer equations have been proposed to replace the 220 − age rule to
generate the age-predicted maximum heart rate:
Men: HRmax = 208 − (0.7 × Age)
Women: HRmax = 206 − (0.88 × Age)
CAD with beta blockers: HRmax = 164 − (0.7 × Age)
Sub-Maximal Exercise
• when the peak heart rate achieved is below the age-predicted maximum heart
rate.
• An inadequate study is defined by failure to achieve a predefined goal, such
as 85% of the age-predicted maximum heart rate.
• If a patient without known CAD has an inadequate study, the term
nondiagnostic study is often applied. As with all things, this “nondiagnostic”
status is relative.
 52

∙ Chronotropic incompetence is determined by decreased heart

rate sensitivity to the normal increase in sympathetic tone
during exercise and is defined as inability to increase heart
rate to atleast 85 percent of age predicted maximum.
∙ Heart rate reserve is calculated as follows –
% HRR used = (HRpeak- HRres) / (220-age-Hrres)
Heart Rate Recovery(HRR)
• Abnormal HRR refers to a relatively slow deceleration of heart
rate following exercise cessation

• Reflects decreased vagal tone - associated with increased

mortality
• When the postexercise phase includes an upright cool-down, a
value of 12 beats/min or less is abnormal.
• For patients undergoing stress echocardiography or
otherwise assuming a supine position immediately after
exercise, a value of 18 beats/min or less is abnormal.
• When HRR is measured 2 minutes into recovery, a value of 22
beats/min or less is abnormal.
• The prognostic value of abnormal HRR is independent of the
oexercise level attained,
o beta blocker usage,
o severity of CAD,
oleft ventricular function,
o chronotropic incompetence,
o Duke treadmill score, and presence of exercise-induced
angina or ischemic electrocardiographic abnormalities.
• Abnormal HRR is associated with increased abnormal and
high-risk myocardial perfusion scans, even in patients
without exercise test results that would normally warrant
further testing
Rate-Pressure Product
⮚Heart rate x Systolic BP Product
⮚Indirect measure of myocardial oxygen demand
⮚increases progressively with exercise
⮚used to characterize cardiovascular
performance
⮚Normal - 20 to 35 mm HG x beats/m x 10-3
⮚In CAD - < 25 mm HG x beats/m x 10-3
Chest discomfort
⮚It occurs usually after the onset of ischemic ST
segment depression
⮚In some patients , it may be the only signal of obstructive
CAD
⮚In CSA , Chest discomfort occurs less frequently than
ischemic ST segment depression
Diagnostic Use of Exercise Testing
• Approximately 75% to 80% of the diagnostic information on
exercise-induced ST-segment depression in patients with a
normal resting ECG is contained in leads V4 to V6.
• The exercise ECG is less specific when patients in whom
false- positive results are more common are included, such
as those with valvular heart disease, left ventricular
hypertrophy, marked resting ST segment depression, or
digitalis therapy.
Noncoronary causes of ST
segment
depression
⮚Severe aortic stenosis
⮚Severe hypertension
⮚Cardiomyopathy
⮚Anemia
⮚Hypokalemia
⮚Severe hypoxia
⮚Digitalis use
⮚Sudden excessive exercise
Noncoronary causes of ST
segment depression
⮚Glucose load
⮚Left ventricular hypertrophy
⮚Hyperventilation
⮚Mitral valve prolapse
⮚Interventricular conduction disturbance
⮚Preexitation syndrome
⮚Severe volume overload (aortic,mitral
regurgitation)
⮚Supraventricular tacyarrhythmias
Bayes’ Theorem
• Incorporates pretest risk of disease & sensitivity and specificity
of test to calculate post-test probability of CAD

• Clinical information and exercise test results are used to make

final estimate about probability of CAD

• Diagnostic power maximal when pretest probability of CAD is

intermediate (30% to 70%)
 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.
 Classification of chest pain

• Typical angina
1. Substernal chest discomfort with characterstic quality
and duration
2. Provoked by exertion or emotional stress
3. Relieved by rest or NTG

• Atypical angina
Meets 2 of the above characteristics

• Noncardiac chest pain

Meets one or none of the typical characteristics
Pre Test Probability of Coronary Disease by Symptoms,
Gender and Age

Age Gender Typical/Definit Atypical/Probab Non- Asymptomatic

e Angina le Angina Anginal
Chest
Pectoris Pectoris 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 = Intermediate = 10- Low = <10%
>90% 90% Very Low
= <5%
 INTERMEDIATE CATEGORY
AGE GROUP GENDER & SYMPTOMS

30-39 YEARS M& F + TYPICAL ANGINA

M + ATYPICAL/ PROBABLEANGINA
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
 EXERCISE PARAMETERS ASSOCIATED WITH
ADVERSE PROGNOSIS AND
MULTIVESSEL CAD
• Duration of symptom-limiting exercise < 5 METs

• Abnormal BP response

• Angina pectoris at low exercise workloads

• ST-depression ≥ 2 mm - starting at <5 METs

down sloping ST - involving ≥5
leads,
- ≥5 min into recovery
• Exercise-induced ST- elevation (aVR excluded)

• Reproducible sustained or symptomatic VT

. Exercise Testing in Determining
Prognosis
• Asymptomatic population
• Prevalence of abnormal TMT in asymptomatic
middle aged men - 5-12%.
• Risk of developing a cardiac event-
approximately nine times when test
abnormal
• Future risk of cardiac events is greatest if test
strongly positive or with multiple risk factors
• Appropriate asymptomatic subjects for test -
 Prognostic Value of the Exercise
Electrocardiogram

• Prognostic Variables
The strongest predictor of prognosis derived from
the exercise test is exercise capacity.
• The weakest predictor is ST-segment depression.
• All other variables, such as the heart rate
achieved, HRR, blood pres- sure response,
ventricular arrhythmias, and exercise-induced
angina, fall between these two extremes. This
prognostic hierarchy is similar in both men and
women.
Symptomatic patients

• Exercise ECG should be routinely performed in

patients with chronic CAD before CAG

• Patients with good effort tolerance (>10 METS)

have excellent prognosis regardless of anatomical
extent of CAD.

• Provides an estimate of functional significance of

CAG documented coronary stenoses
 RISK ASSESSMENT AND PROGNOSIS in PATIENTS
WITH SYMPTOMS OR PRIOR HISTORY OF CAD

CLASS INDICATION ACC/AHAGuidelines 2002

I 1. Patients undergoing initial evaluation

Exceptions
a. Preexcitation syndrome

b. Electronically paced ventricular rhythm

c. >1 mm of ST-segment depression at rest
d. Complete left bundle branch block
2. Patients after a significant change in cardiac symptoms
3. Low-risk unstable angina patients 8 to 12 hr after presentation who have been
free of active ischemic or heart failure symptoms

4. Intermediate-risk unstable angina patients 2 to 3 days after presentation who

have been free of active ischemic or heart failure symptoms

Patients with severe comorbidity likely to limit life expectancy or prevent

III revascularization
 Duke tread mill score

• Developed by Mark and co-workers

• Provide survival estimates based on results from

exercise test
• Provides accurate prognostic & diagnostic information

• Adds independent prognostic information to that

provided by clinical data & coronary anatomy

• Less effective in estimating risk in subjects > 75

 Duke tread mill score - RISK

Score Risk 5 yr survival % CAD

>5 Low risk 97 Nil / SVD

- 10 to +4 Moderate risk 91

< -11 High risk 72 TVD/LMCA

 Duke tread mill score
• Exercise time - (5 ˣ ST deviation) - (4 ˣ treadmill
angina index)

• Angina index

1 if no angina
2 if typical angina occurs during exercise
3 if angina was the reason pt stopped exercise
SEX SPECIFIC SCORES
 POST MI STATUS
• Since 2002, when the last full set of exercise testing guidelines was
updated,21 treatment of myocardial infarction and evaluation of
post– myocardial infarction patients have evolved greatly. In those
guidelines, exercise testing carried class I indica- tions before
hospital discharge (sub- maximal 4 to 7 days), 14 to 21 days after
discharge (symptom limited if not performed before discharge), and
3 to 6 weeks after discharge (symptom limited if predischarge
submaxi- III mal performed). These recommendations were based
largely on the then existing ACC/AHA guidelines for the
management of acute myo- cardial infarction. In this setting the
exercise test was found to be safe, with a reported mortality rate of
0.03% and a nonfatal event rate of 0.09%.
• Present clinical environment, realistic goals of
exercise testing in the post–myocardial
infarction setting, whenever it is per- formed,
should be threefold: to provide (1) a
functional evaluation to guide the exercise
rehabilitation prescription, (2) a basis for
advice concerning return to work and other
physical activities, and (3) an evaluation of
present therapy.
Thank you