Overview of Exercise Stress Testing:

Choosing the Right Protocol and Right

Modality for the Right Patients

Astri Kurniati Martiana., MD

Cardiovascular Prevention and Rehabilitation Division
Introduction
• Clinical exercise testing has been part of the differential diagnosis of patients with
suspected ischemic heart disease (IHD) for more than 50 yr
By 1956, he used the treadmill to establish guidelines for the
grouping of cardiac patients into New York Heart Functional
Class I through IV. Bruce's early use of the treadmill was a
single‐stage test with a fixed rate of 1.7 miles per hour at a
10% grade. Dr. Bruce quickly realized the limitations of the
single‐stage exercise test, and so he developed a multistage
treadmill test that required each individual to attain a
self‐determined point of maximal exertion.

“You would never buy a used car without taking it out for a drive
and seeing how the engine performed while it was running, and
the same is true for evaluating the function of the heart.”
Robert Arthur Bruce,
Father of Exercise Cardiology

Circulation. 2013;128:873-934, Ann Noninvasive Electrocardiol. 2004 Jul; 9(3): 290

During this time additional purposes for testing have evolved. Exercise testing now is used widely
for the following:

1. Detection of coronary artery disease (CAD) in patients with chest pain (chest discomfort)
syndromes or potential symptom equivalents

2. Evaluation of the anatomic and functional severity of CAD

3. Prediction of cardiovascular events and all-cause death

4. Evaluation of physical capacity and effort tolerance

5. Evaluation of exercise-related symptoms

6. Assessment of chronotropic competence, arrhythmias, and response to implanted device therapy

7. Assessment of the response to medical interventions

FUNCTIONAL CAPACITY
• Exercise capacity are usually expressed in METS (Metabolic Equivalent
of Task). Based on metabolic equivalents (MET) achieved.
• One MET is defined as 3.5 mL O2 uptake/kg per min, which is the
resting oxygen uptake in a sitting position).
• Energy cost: multiples of resting/basal metabolic rate.
• FC I : capable of achieving 7-8 METs.
• FC II: limited by symptoms at workloads 5-6 METs.
• FC III: symptomatic at workloads 3-4 METs.

Ann Saudi Med. 2006 Jan-Feb; 26(1): 1–6

 Estimated Functional Capacity

Tighe DA. Pocket Guide to Stress Testing, Second Edition. Edited by Dennis A. Tighe and Bryon A. Gentile. 2020 John Wiley & Sons Ltd
 Indication
Diagnostic Purposes
• Assesment of chest pain
• Diagnosis of coronary artery disease
• Diagnosis of exrcise induced arrythmias

Evaluation purposes
• Exercise capacity and functional evaluation
• Efficacy of medical therapy for CAD (anti-anginal therapy, etc)
• Efficacy of revascularization therapy for CAD
• Prognostication by aerobic capacity
• Evaluation of dyspnea

Rehabilitation purposes
• Cardiac and vascular rehabilitation
 Pre-test probability

ESC 2019 Guidelines Management of Chronic Coronary Syndrome. European Heart Journal (2020) 41, 407-477.
Contraindications

Circulation. 2013;128:873-934
Contraindications

Circulation. 2013;128:873-934
Selection of Exercise Stress Test Modes

4 – 5 METs

Mampu tes selama

6 – 12 menit

• Duke Activity Status Index (DASI)

• Compendium Physical Activity
• Veteran Specific Activity Questionnaire
• Specific Activity Scale of Goldman
 Exercise Testing
Graded exercise testing
• Used to observe the dynamic relationship between exercise workload and
the integrated cardiovascular, pulmonary, musculoskeletal, and
neuropsychological systems.
• The gold standard in exercise testing is the incremental exercise test
e.g: Treadmill test, Ergocycle test, CPET

Field Test
• Constant workload endurance test, are used to investigate the effects of
interventions that alter submaximal or endurance exercise capacity
• Used for patient who marked left ventricular dysfunction or peripheral
arterial occlusive disease, who cannot performed bicycle or treadmill exercise
• The outcome of these walk tests is able to more closely mimic the functional
abilities needed in everyday life
e.g: 6- or 12-minute walk test (6- or 12MWT), shuttle walk test (SWT)

breathe.ersjournals.com/content/breathe/1/2/120.full.pdf
Treadmill Test
• The treadmill should have front rails, side rails, or both to aid in subject
stability.
• Subjects should be encouraged not to tightly grasp the front or side
rails because this action supports body weight and thus reduces the
workload at any given stage, leading to the potential for a significant
overestimation of oxygen uptake.
• Work intensity is generally higher than cycle ergometer.
• Subjects must capable of running.
• Risk of falling.

circ.ahajournals.org/content/128/8/873
 Treadmill Protocols
• Bruce protocols

• The Bruce protocol is most widely used.

• There are 7 stages, This stage start at 4 METs in stage 1 and then increase by approximately 2-3 METs
• A disadvantage is the large interstage increments in workload between stages that can make estimation of V̇o2max less
accurate. Some subjects, especially those who are elderly, obese, or have gait difficulties, are forced to stop exercising
prematurely because of musculoskeletal discomfort or an inability to tolerate the high workload increments

circ.ahajournals.org/content/128/8/873
 Estimated Functional Capacity

Less than 5 METS Poor

5–8 METS Fair

9–11 METS Good

12 METS or more Excellent

• An inability to exercise >6 minutes on the Bruce protocol, or an inability to increase heart rate (HR) to
>85% of maximum predicted heart rate (MPHR) are significant indicators of increased risk of coronary
events with a 5-year survival ranging from 50% to 72%.

Ann Saudi Med. 2006 Jan-Feb; 26(1): 1–

 Treadmill Protocols
• Modified Bruce protocols

• The first stages occur at worklad of 2-4 METs, Stage 3 equal to the first stage of Bruce protocol
• Often use in older individuals or those whose exercise capacity is limited by cardiac disease

circ.ahajournals.org/content/128/8/873
Cycle Ergometer
• Less expensive, occupies less space, and is less noisy than a treadmill.
• Cycle ergometers are calibrated in kiloponds or watts (W); 1 W is equivalent
to ≈6 kilopondmeters per minute (kpm/min).
• The highest values of V̇o2 and HR are obtained with pedaling speeds of 50
to 80 rpm.
• Leg fatigue in an inexperienced sub- ject could cause early test termination
before reaching a true V̇o2max.
• Thus, V̇o2max is 10% to 20% lower in cycle versus treadmill testing in those
not accustomed to cycling.

circ.ahajournals.org/content/128/8/873
Cycle Ergometry Protocols
• Ramp incremental (left panel)
Red dashed lines represent protocols reaching an equal
work rate of 150 W after 10 minutes of exercise; blue
solid lines represent protocols reaching an equal work
rate of 100 W after 10 minutes of exercise.

• 2-minute incremental (right panel)

Protocols for cycle ergometry. The work rate increment is
added at the start of each 2-minute stage for the
conventional incremental test, whereas the increment is
equal to 1 W every 6 seconds and 1.5 W every 6 seconds
for the 10 W/min and 15 W/min ramp protocols,
respectively, beginning from Time 0 of the exercise
period.

Alessandro Mezzani; Annals ATS 14S3-S11.

Protokol Uji Latih Jantung
yang sering digunakan

ACSM’s Guidelines for Exercise Testing and Prescription 10th Ed.

Protocols of Exercise Stress Testing
• Initial warm-up period → successive (graded) increase in workload →
recovery period.
• Workloads should be increased gradually & maintained for a
sufficient length of time.
 6 Minutes Walking Test

• The 6MWT is easy to administer, better tolerated, and more reflective of activities of daily living than the
other walk tests”
• This test measures the distance that a patient can quickly walk on a flat, hard surface in a period of 6
minutes (the 6MWD).
• The self-paced 6MWT assesses the submaximal level of functional capacity. Most patients do not achieve
maximal exercise capacity during the 6MWT.

ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. “ATS statement: guidelines for the six-minute walk test.” American journal of respiratory and critical care medicine vol. 166,1 (2002): 111-7. doi:10.1164/ajrccm.166.1.at1102
 INDICATIONS AND LIMITATIONS
• Strongest indication 6MWT: measuring the response to medical
interventions in patients with moderate to severe heart or lung
disease.
• The 6MWT does not determine peak oxygen uptake, diagnose the
cause of dyspnea on exertion, or evaluate the causes or mechanisms
of exercise limitation.
• The information provided by a 6MWT should be considered
complementary to cardiopulmonary exercise testing, not a
replacement for it.

ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. “ATS statement: guidelines for the six-minute walk test.” American journal of respiratory and critical care medicine
vol. 166,1 (2002): 111-7. doi:10.1164/ajrccm.166.1.at1102
 Conclusion
• An exercise test commonly used for the CAD detection in patients with chest pain or
dyspnea on exertion, impaired exercise tolerance, to investigate how much exercise
is appropriate/safe in a patient; and to determine the response to treatment.
• Maximal incremental exercise testing has its main emphasis on the diagnosis of
exercise impairment and the mechanisms related to this impairment.
• Field tests are most important in the longitudinal assessment of exercise
performance, such as in the evaluation of treatment.
• Choosing appropriate protocol, and observing precautions are essential to ensuring
patient safety
THANK YOU