The ESC Textbook of Cardiovascular Medicine (3 edn)

A. John Camm (contributor) et al.

https://doi.org/10.1093/med/9780198784906.001.0001
Published: 2018 Online ISBN: 9780191827143 Print ISBN: 9780198784906

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CHAPTER

Chapter 8.17 Exercise ECG testing

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Krzysztof Kaczmarek, Iwona Cygankiewicz

https://doi.org/10.1093/med/9780198784906.003.0808
Published: July 2018

Abstract
Exercise electrocardiogram (ECG) stress test was the rst standardized functional test for diagnosing
myocardial ischaemia. However, its position has been importantly challenged by recent advancement
in functional non-invasive imaging techniques. It is particularly useful in evaluation of pathologies, in
which physical e ort constitutes an important provocative factor (ischaemic heart disease,
hypertrophic cardiomyopathy, exercise-induced arrhythmias). Nevertheless, exercise ECG test should
be considered also to objectively assess symptoms in patients with suspected chronotropic
incompetence, including those with cardiac pacemakers or other cardiac devices with pacing features.
This chapter describes test performance and its interpretation, as well as summarizes the current
position of exercise testing according to the European Society of Cardiology (ESC) guidelines.

Keywords: exercise electrocardiographic test, treadmill test, functional capacity, exercise tolerance
Collection: Oxford Medicine Online

Introduction

Physical e ort is one of the most common physiological stressors, which can provoke the occurrence of
symptoms related to the cardiovascular system. Popular scales use a range of physical e ort for staging
severity of illness, including the Canadian Cardiovascular Society grading system for angina or the New York
Heart Association scale for heart failure. Therefore, standardized exercise-based functional testing was
logically developed and is widely applied in medicine, particularly in cardiology.

Exercise electrocardiogram testing (EET) was the rst standardized functional test for diagnosing
myocardial ischaemia. However, its position has been importantly challenged by recent advancement in
functional non-invasive imaging techniques, including stress echocardiography, stress cardiac magnetic
1
resonance, single-photon emission computerized tomography, and positron emission tomography.
Exercise testing

The EET is based on continuous recording of electrical activity of the heart and repeatedly acquired arterial
blood pressure measurements during controlled and standardized physical e ort and thereafter during
2
recovery. Two standard methods for provocation of physical e ort are routinely used in clinical practice—
the treadmill test and the cycle ergometer, of which the most commonly used and preferable is the treadmill
exercise test. However, cycle ergometers are considered as acceptable alternatives, especially for patients
3
with diseases that cause limitations of movement (e.g. orthopaedic, neurological, or others). Maximal
4,5
oxygen uptake is approximately 5–20% lower on the cycle ergometer, as compared to the treadmill.

Standard EET equipment consists of a computerized central unit connected to an electrocardiography (ECG)
system and ergometer (treadmill or bicycle). The central unit integrates all the peripheral devices, which

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include: acquisition and processing of ECG recordings, steering of the ergometer according to the
programmed protocol, and acquisition of blood pressure measurements. Manual blood pressure
measurements frequently replace automatic modules. Treadmills are usually automatized and controlled by
a computer in terms of speed and slope adjustment. For safety reasons, treadmills should be equipped with
rails at the front and on both sides, as well as safe stopping systems (including an emergency stop button)
for protection against falls. Dedicated sets of all components for EET are commercially available worldwide.
Nonetheless, although they o er an automatically controlled course of the EET and full analysis of the
results, a critical and thorough supervision by an experienced physician is still obligatory and crucial for
6
appropriate diagnosis.

ECG recordings are acquired with a 12-lead system usually with electrodes placed in modi ed positions
7,8
(Mason–Likar torso-mounted limb lead system). This modi cation includes shifting the right arm and
left arm electrodes to the right and left infraclavicular fossae; the right leg and left leg electrodes are placed
in the right and left iliac fossae, respectively. Precordial electrodes remain in the same positions as they are
for standard ECG. The Mason–Likar system provides ECG recordings very similar to the standard ECG, but
slight di erences can be noted. These discrepancies include: (1) higher amplitudes of R and T waves in II,
III, and aVF; (2) lower amplitude of R and T waves in I and aVL; (3) smaller Q wave in II, III, and aVF; and (4)
rightward change of the QRS axis of approximately 20°. Importantly, the ST segment in the Mason–Likar
modi ed ECG remains unchanged, as compared to standard electrode placement.

In general, three main groups of parameters are assessed during EET: (1) clinical—symptoms and signs (i.e.
chest pain, low e ort capacity); (2) ECG abnormalities (i.e. ST segment abnormalities, arrhythmias); and (3)
haemodynamic response (i.e. exertional hypotension). Physical activity is de ned as power calculated in
9
Watts (W) or metabolic equivalents (METs) which approximate exertional oxygen uptake. One metabolic
equivalent is de ned as uptake of 3.5 mL of oxygen/kg/minute. The relationship between MET demands and
common daily activities is shown in Table 8.17.1.
Table 8.17.1 Metabolic equivalents for selected physical activities

Metabolic equivalents (METs) Physical activity

1–2 Eating, getting dressed, sedentary work

Walking slowly downward or on flat surface

Having shower

3–4 Doing light housework and/or gardening

Walking leisurely up to two blocks

5–6 Performing light sports (dancing, golf, curling)

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Walking at a moderate pace (approximately 5 km/hour)

Doing heavier housework (chopping wood)

7–9 Performing heavy outdoor work

Performing a low-level skill sport discipline (tennis, cycling leisurely, jogging slowly)

10–12 Swimming, running, skiing, playing basketball and soccer

13 or more Fast running and any competitive physical activity

1 MET equals approximately 17.5 W for a 70-kg person.

When an EET is prescribed, the patient should be informed about the test, including a discussion not only
about the purpose and bene ts, but also about potential complications secondary to the EET. Exercise-
induced brady- and tachyarrhythmias, ischaemia leading to acute coronary syndrome, exacerbation of
heart failure, hypotension, syncope, or even death have been reported as a result of exercise testing. Non-
cardiac complications, such as musculoskeletal injury, soft tissue injury, body aches, persistent fatigue, and
dizziness, can also occur. Furthermore, all patients should be instructed how to prepare adequately for the
test, which basically includes remaining at least 3 hours at fasting and non-smoking state. If an EET is
performed to diagnose myocardial ischaemia, patients should be o beta-blockers for at least ve half-life
periods of the drugs, if possible. The test on beta-blockers has signi cantly lower sensitivity in disclosing
10
ischaemic abnormalities. Additionally, which is obvious but sometimes forgotten, each patient ought to be
instructed to come for this exam with comfortable clothing and shoes. Immediately before performing an
EET, written informed consent for the test has to be con rmed or retaken and thereafter a medical history
and physical examination should be conducted. If any contraindication is revealed (Table 8.17.2) or the
purpose of the EET is not clear, the referring physician should be contacted or informed. Adequate skin
preparation and use of special electrodes and cables are all important for reducing potential electrical
noises. A dynamic development of the technology allows applying novel wireless ECG systems which
facilitate preparation to the test. As there is a risk of cardiac arrest during an EET (>1:10,000), a fully
equipped resuscitation set must be available.
Table 8.17.2 Contraindications for EET

Absolute

Lack of patientʼs consent

Physical disability

Early phase of acute coronary syndromes (<2–4 days)

Decompensated heart failure

Severely symptomatic and/or life-threatening arrhythmias

Severe symptomatic aortic stenosis

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Acute myocarditis and/or pericarditis and/or endocarditis

Acute aortic syndrome

Acute pulmonary embolism

Relative

Severe le main coronary stenosis or its equivalent

Severe arterial (>200/110 mmHg) or pulmonary hypertension

Recent cerebral ischaemia (stroke or transient ischaemic attack)

Uncontrolled arrhythmias (tachy- and bradyarrhythmias)

Moderate or severe le ventricular outflow tract obstruction (aortic stenosis or hypertrophic cardiomyopathy)

Unstable non-cardiac medical state (dyselectrolytaemia, anaemia, thyrotoxicosis, fever, infection, etc.)

At the beginning of the ETT, resting blood pressure and standard ECG are to be taken. Thereafter, baseline
‘torso’ ECG recordings in the supine and standing positions are obtained. Although ECG monitoring is
performed continuously during the test, computerized comparative analysis of ECG tracings, especially ST
segment changes, is performed at the end of each stage of a particular protocol. Blood pressure
measurements are to be taken at each stage of the protocol either manually by a physician or automatically.
Work increments and a particular protocol ought to be adjusted to the capabilities of each patient in the way
that allows for the patient to reach the maximal or, in the case of ischaemic heart disease, submaximal heart
rate and predicted maximal exercise capacity (Table 8.17.3). A variety of exercise protocols have been
designed for the EET. However, generally, they can be divided into two groups: graded and ramp protocols
(Table 8.17.4). The Bruce protocol is the ‘gold standard’ for myocardial ischaemia detection in mildly
symptomatic/asymptomatic younger (<65 years old) and t patients, while its modi ed version is
considered as the most popular and universal test, less intensive than the standard protocol and therefore
more suitable for the majority of diagnosed patients. The Cornell, Naughton, and modi ed Naughton
protocols are usually used for the elderly and/or patients with heart failure, while the Costill protocol serves
for highly trained athletes. A preparation phase, warm-up, and a recovery period are common for both types
of exercise protocols, but an increase of exercise workload is continuous in ramp protocols, while in graded
protocols, the workload is augmented at each stage (Figure 8.17.1). Ramp protocols are more adjustable for
each individual; however, the graded tests are used more often, probably due to more intuitive
standardization, a vast literature to compare, and an established routine. E ort time during the EET lasts
usually approximately 8–12 minutes, and recovery duration 6–8 minutes. The EET is stopped when the
maximal or submaximal heart rate is achieved. Nevertheless, in certain situations, the EET should be
stopped before reaching these time durations (Table 8.17.5).

Table 8.17.3 Selected equations used in EET

#
Predicted maximal exercise capacity (METs) at Male: 18 – (0.15 × age )
treadmill
#
Female: 14.7 – (0.13 × age )
## #
Predicted maximal workload (W) at cycle Male: (20.4 × height + 8.74 × age − 1909) × 0.1634
ergometer
## #
Female: (20.4 × height + 8.74 × age − 2197) × 0.1634
###

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Relative exercise capacity/workload (%) Achieved maximal exercise capacity (METs)/predicted maximal exercise
###
capacity (METs)
# 11
Traditional predicted maximal heart rate (bpm) 220 − age (historical data)
12
Predicted maximal heart rate (bpm) 208 − (0.7 × age) (more recent data)

Predicted maximal heart rate (bpm) CAD on 164 − (0.7 × age)

beta-blockers

Predicted submaximal heart rate (bpm) 85% of predicted maximal HR

#### ####
Duke treadmill score Maximal exercise time − 5 × ST segment depression − 4 × angina
####
index
##### #### #####
VA score 5 × (CHF/Dx) + ST segment depression + SBP score − METs

Heart rate reserve (bpm) Maximal HR − resting HR

Chronotropic index (%) (Peak HR − resting HR) × 100/HR reserve

Double product Peak HR × peak systolic blood pressure

# Age given in years.

## Height given in centimetres.
### Workload for cyclometer, instead of METs, calculated in watts.
#### Time given in minutes, ST depression given in millimetres, and angina index given as follows: 0, no angina; 1, not limiting
angina; 2, exercise-limiting angina.
##### CHF/Dx: 0, no history of heart failure or receiving digoxin; 1, history of heart failure or/and receiving digoxin. SBP score:
SBP rise greater than: 40 mmHg, 0; 30 mmHg, 1; 20 mmHg, 2; 10 mmHg, 3; 4 mmHg, 0; 5, drop below resting SBP.
CAD, coronary artery disease; HR, heart rate; METs, metabolic equivalents.
Table 8.17.4 Selected protocols for exercise ECG testing

Type of protocol Protocol Maximal workload at 12 minutes – stages – stage duration

Graded: treadmill Bruce 16 METs – 7 – 3 min

Modified Bruce 7 METs – 8 – 3 min

Cornell 8 METs – 10 – 2 min

Naughton 8 METs – 7 – 2 min

Modified Naughton 6.5 METs – 10 – 2 min

ACIP

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Costill 20 METs – 11 – 2 min

Low-level Bruce 3.5 METs – 4 – 3 min

Graded: cycle 50 W/3 min-stage 200 W/12 min

25 W/2 min-stage 150 W/12 min

25 W/3 min-stage 100 W/12 min

Ramp: treadmill BSU/Bruce ramp 14 METs

ACSM 10.7 METs

AAVPR 10.1 METs

Ramp: cycle 30 W/min 360 W/12 min

25 W/min 300 W/12 min

15 W/min 180 W/12 min

10 W/min 120 W/12 min

5 W/min 60 W/min

ACIP, Asymptomatic Cardiac Ischaemia Pilot; ACSM, American College of Sports Medicine; AAVPR, ; BSU, Ball State University.
Table 8.17.5 Indications for early termination of exercise ECG test

Absolute

1. ST segment elevation of >1 mm in leads without pre-existing Q waves of prior myocardial infarction (other than aVR, aVL,
and V1)
2. Drop of systolic blood pressure of >10 mmHg with concomitant evidence of myocardial ischaemia (clinical or ECG)
3. Typical angina—at least moderate
4. Symptoms of reduced perfusion (cyanosis or pallor)
5. Important ventricular arrhythmias (sustained or numerous non-sustained) which reduce significantly cardiac output
6. Advanced bradyarrhythmias, especially atrioventricular blocks (second- or third-degree)
7. Symptoms of central nervous system dysfunction (vertigo, ataxia, dizziness, presyncope, syncope)

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8. Equipment or testing malfunction
9. Patientʼs request to stop

Relative

1. ST segment depression of >2 mm typical for myocardial ischaemia (horizontal or downsloping)

2. Reduction of systolic blood pressure of >10 mmHg with no signs of ischaemia
3. Increasing angina
4. Ventricular and/or supraventricular arrhythmias which have potential influence on haemodynamic stability
5. Bradyarrhythmias that have the potential to become more advanced and/or result in reduced cardiac output
6. Hypertensive overresponse (systolic >250 mmHg or diastolic >115 mmHg)
7. Wide QRS complex—di icult to distinguish between intraventricular conduction abnormalities or ventricular
rhythm/tachycardia
8. Important physical symptoms: shortness of breath, fatigue, wheezing, claudication, etc.

Figure 8.17.1

Workload in relation to time of test in graded and ramp ETT protocols.

Indications

An ETT is particularly useful in the evaluation of pathologies, in which physical e ort constitutes an
important provocative factor (ischaemic heart disease, hypertrophic cardiomyopathy, exercise-induced
arrhythmias). Nevertheless, an EET should be considered also to objectively assess symptoms in patients
with suspected chronotropic incompetence, including those with cardiac pacemakers or other cardiac
devices with pacing features. An EET can be useful for risk strati cation before cardiac and non-cardiac
surgery. Patients complaining of low exercise capacity of unknown cause can also be evaluated with an EET
(Table 8.17.6).
Table 8.17.6 The role of exercise ECG test in various clinical scenarios

Disease Purpose

Coronary artery disease Establishing a diagnosis of chronic coronary syndrome

Evaluation of coronary reserve

Risk stratification

Hypertrophic cardiomyopathy Risk stratification

Heart failure (valvular heart disease, Assessment of exercise capacity and exercise-induced symptoms
cardiomyopathies)

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Evaluation before non-cardiac surgery Risk stratification

Exercise-induced arrhythmias Establishing a diagnosis

Evaluation of treatment e ect Assessment of exercise capacity and exercise-induced symptoms

Sports (amateur/competitive) and Assessment of exercise capacity and risk stratification in patients with diagnosed or
physical training suspected cardiovascular disease

Restriction of exercise tolerance of Establishing a diagnosis and/or assessment of exercise capacity

unknown cause
Table 8.17.7 Recommendations for performing exercise ECG test according to ESC guidelines

Recommendations Class Level

1
Chronic coronary syndromes

Use of exercise electrocardiogram in the initial diagnostic management of patients with suspected
coronary artery disease

Exercise ECG is recommended for the assessment of exercise tolerance, symptoms, arrhythmias, blood I C
pressure response, and event risk in selected patients

Exercise ECG may be considered as an alternative test to rule in and rule out CAD when non-invasive IIb B
imaging is not available

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Exercise ECG may be considered in patients on treatment to evaluate control of symptoms and ischaemia IIb C

Exercise ECG is not recommended for diagnostic purposes in patients with ≥0.1 mV ST segment depression III C
on resting ECG or who are being treated with digitalis

Risk assessment in patients with suspected or newly recognized chronic coronary syndrome

Risk stratification, preferably using stress imaging or coronary computerized tomography angiography I B
(CCTA) (if permitted by local expertise and availability), or alternatively exercise stress ECG (if significant
exercise can be performed and the ECG is amenable to the identification of ischaemic changes), is
recommended in patients with suspected or newly diagnosed CAD

Patients with a long-standing diagnosis of chronic coronary syndromes

Risk stratification is recommended in patients with new or worsening symptom levels, preferably using I B
stress imaging or, alternatively, exercise stress ECG

Screening for coronary artery disease in asymptomatic subjects

In asymptomatic adults (including sedentary adults considering starting a vigorous exercise programme), IIb C
an exercise ECG may be considered for cardiovascular risk assessment, particularly when attention is paid
to non-ECG markers such as exercise capacity
11
Patients with syncope

Exercise testing is indicated in patients who experience syncope during or shortly a er exertion I C

There are no data supporting routine exercise testing in patients with syncope
12
Supraventricular arrhythmias

Exercise tolerance testing may be considered as an optional test in the initial evaluation of patients with
supraventricular tachycardia

In patients with inappropriate sinus tachycardia, exercise test might be considered to document the
exaggerated heart rate or blood pressure response to minimal exercise

In patients with Wol –Parkinson–White syndrome, identification of an abrupt and complete normalization
of the PR interval with loss of delta wave during exercise testing has been considered a marker of low risk
13
Atrial fibrillation

The ventricular rate while exercising with AF should be evaluated in every athlete (by symptoms and/or by IIa C
monitoring), and titrated rate control should be instituted
14
Ventricular arrhythmias

In diagnostic work-up of family members of sudden unexplained death syndrome or sudden arrhythmic
death syndrome victims
Exercise stress testing is recommended in adult patients with ventricular arrhythmia who have an I B
intermediate or greater probability of having CAD by age and symptoms to provoke ischaemic changes or
ventricular arrhythmia

Exercise stress testing is recommended in patients with known or suspected exercise-induced ventricular I B
arrhythmia, including catecholaminergic polymorphic ventricular tachycardia (CPVT), to achieve a
diagnosis and define prognosis

Exercise stress testing should be considered in evaluating response to medical or ablation therapy in IIa C
patients with known exercise-induced ventricular arrhythmia

In patients with suspected of CPVT, an exercise stress test that elicits atrial arrhythmias and ventricular
arrhythmia (bidirectional or polymorphic ventricular tachycardia) is recommended to establish the
diagnosis

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15
Chronic heart failure

Exercise testing in patients with heart failure:

• Is recommended as a part of the evaluation for heart transplantation and/or mechanical circulatory I C
support (cardiopulmonary exercise testing)

• Should be considered to optimize prescription of exercise training (preferably cardiopulmonary exercise IIa C
testing)

• Should be considered to identify the cause of unexplained dyspnoea (cardiopulmonary exercise testing) IIa C

• May be considered to detect reversible myocardial ischaemia IIb C

16
Valvular heart diseases

Exercise testing is recommended in physically active patients for unmasking symptoms and for risk
stratification of asymptomatic patients with severe aortic stenosis

EET in indications for surgical valve replacement in asymptomatic patients with severe aortic stenosis:

• Abnormal exercise test showing symptoms on exercise clearly related to aortic stenosis
• Abnormal exercise test showing a decrease in blood pressure below baseline

17
Hypertrophic cardiomyopathy

Cardiopulmonary exercise testing, with simultaneous measurement of respiratory gases (or standard I B
treadmill or bicycle ergometry when unavailable), should be considered in symptomatic patients
undergoing septal alcohol ablation and septal myectomy to determine the severity of exercise limitation

Irrespective of symptoms, cardiopulmonary exercise testing with simultaneous measurement of respiratory IIa B
gases (or standard treadmill or bicycle ergometry when unavailable) should be considered to assess the
severity and mechanism of exercise intolerance and change in systolic blood pressure

Cardiopulmonary exercise testing, with simultaneous measurement of respiratory gases (or standard IIa C
treadmill or bicycle ergometry when unavailable), should be considered in symptomatic patients
undergoing septal alcohol ablation and septal myectomy to determine the severity of exercise limitation

A 12-lead ECG, upright exercise testing, resting and exercise two-dimensional and Doppler
echocardiography, and 48-hour ambulatory ECG monitoring are recommended in patients with
unexplained syncope to identify the cause of their symptoms
18
Cardiovascular prevention

Clinical evaluation, including exercise testing, should be considered for sedentary people with IIa C
cardiovascular risk factors who want to engage in vigorous physical activities or sports
Knuuti J, Wijns W, Saraste A, et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of
chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407–477. doi: 10.1093/eurheartj/ehz425. © The European Society of
Cardiology. Reprinted by permission of Oxford University Press.

Table modified based on ESC guidelines: references 1, 11, 12, 13, 14, 15, 16, 17, 18.

In clinical practice, an ETT is most frequently used for diagnosing myocardial ischaemia. Recent European
Society of Cardiology (ESC) guidelines on chronic coronary syndromes shifted importance of initial
1
screening from ECG testing towards imaging techniques. Pretest probability of coronary disease used in
older guidelines has been replaced by ‘clinical likelihood of CAD’ which additionally includes evaluation of
di erent risk factors. The guidelines recommend that the choice of the initial non-invasive diagnostic test
should be based on the clinical likelihood of coronary disease and other patient characteristics that

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in uence test performance, local expertise, and the availability of tests. Figure 8.17.2 shows the ranges of
clinical likelihood of coronary artery disease (CAD) in which a given test can rule in or rule out disease. Table
8.17.7 displays ESC recommendations for exercise stress test in initial evaluation of patients with suspected
and newly diagnosed CAD, as well as in patients with stable symptoms associated with long-lasting chronic
coronary syndrome, including those after revascularization procedures. An EET might be also considered in
asymptomatic patients screened for CAD, including those who importantly want to increase their physical
activity from sedentary to vigorous.

Figure 8.17.2

Ranges of clinical likelihood of coronary artery disease in which a given test can rule in (red) or rule out disease.

Knuuti J, Wijns W, Saraste A, et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of
chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407–477. doi: 10.1093/eurheartj/ehz425. © The European Society of
Cardiology. Reprinted by permission of Oxford University Press.

Patients with heart failure, cardiomyopathies, and valvular heart disease constitute the second important
group of patients referred for exercise testing. In this case, stress testing is mostly aimed at evaluating
exercise tolerance and haemodynamic response to exercise. It is worth emphasizing that it is not a standard
exercise ECG, but more preferably cardiopulmonary testing that is recommended.

Exercise testing is also useful in patients with arrhythmias. The ventricular rate during physical e ort
should be evaluated in every athlete with atrial brillation (AF), while in other patients with AF, it is simply
to evaluate the adequacy of a rate control strategy. Similarly, patients with inappropriate sinus tachycardia
might undergo this test for documentation of their heart rate while exercising. An EET can serve for risk
assessment in patients with Wol –Parkinson syndrome, as well as in those su ering from ventricular
arrhythmias. In this latter group, in certain populations, this test may be additionally used for establishing a
diagnosis (i.e. catecholamine-induced polymorphic ventricular tachycardia).

An adjustment of settings of cardiac implantable electronic devices with cardiac pacing facilities can be
challenged with exercise testing and, if not providing enough chronotropic response, reprogrammed to
achieve a better response.

Table 8.17.7 summarizes the current position of exercise testing according to ESC
1,11,12,13,14,15,16,17,18
guidelines.

Interpretation of EET

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Exercise induces physiological changes in every healthy individual, which include increase in heart rate
(chronotropic) and systolic blood pressure, but also increase in inotropic, bathmotropic, lusitropic, and
dromotropic cardiac properties. Some of these processes are re ected in the ECG, which reveals changes in
duration and morphologies of ECG waves. Shortening of the RR interval, increase in P and S wave amplitude
in II, III, and aVF, shortening of the P wave and QRS complex, and increase in Q wave amplitude in I, aVL,
and V5–V6, as well as decrease in R wave amplitude in II, III, and aVF, can be physiologically observed.

On the other hand, patients with cardiovascular diseases may respond pathologically to exercise. Such
pathological reaction may consist of: (1) manifestation of symptoms (chest pain, limited e ort, dizziness,
syncope, palpitations, dyspnoea, claudication); (2) exertional hypotension or excessive blood pressure
increase; and (3) exercise-induced ECG abnormalities. Clinical measures obtained from EET are
summarized in Table 8.17.8.
Table 8.17.8 Measures obtained during exercise ECG test

Type Measure
*
Clinical Chest pain: timing of occurrence and recovery, ESC type and intensity

Exercise tolerance: maximal exercise capacity/workload (METs/W); exercise duration; protocol stage
achieved

Perceived exertion level, i.e. Borg scale (6–20 or 0–10 grades)

Non-anginal symptoms: type—dyspnoea, cyanosis, pallor, vertigo, ataxia, syncope, etc., timing and
*
intensity if appropriate

Haemodynamic Systolic and diastolic blood pressure at each stage

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Heart rate at each stage, peak heart rate, heart rate reduction during recovery (heart rate recovery)

Chronotropic response (chronotropic index, chronotropic reserve)

Double product

Electrocardiographic ST segment changes at each stage and recovery:

• Type: elevation, depression (upsloping, horizontal, downsloping)

• Number of leads with ST segment changes
• Timing of ST segment changes, occurrence, and recovery

ST/HR slope and index

Arrhythmias and conduction abnormalities:

• Type and intensity

• Timing of occurrence and recovery

Combined Duke treadmill score = METs – 5 × (EI-STD) − 4 (TM APi)

VA score = 5 × (CHF/Dx) + EI-STD + SBP score − METs

7
* Intensity of angina and dyspnoea is classified traditionally in 1–4 grade severity scales:

Angina: 1 – onset of discomfort; 2 – moderate; 3 – severe; 4 – very severe;

Dyspnoea: 1 – mild, not noticeable for observer; 2 – mild, noticeable for observer; 3 – moderate; 4 – severe, patient cannot
continue test;

EI-STD—exercise-induced ST depression (in millimetres).

TM Api—treadmill angina pectoris index: 0, no angina; 1, angina during the test; 2, angina during the test was reason for
stopping.

CHF/Dx: 0, no history of heart failure or receiving digoxin; 1, history of heart failure or/and receiving digoxin.

SBP score: SBP rise greater than: 40 mmHg, 0; 30 mmHg, 1; 20 mmHg, 2; 10 mmHg, 3; 4 mmHg, 0; 5, drop below resting SBP.
Myocardial ischaemia
Several parameters may suggest CAD. Among them, the most classical are exercise-induced chest pain and
ST segment abnormalities. Therefore, routinely, the results of an ETT in CAD screening include information
on clinical and/or ECG features. Intuitively, an EET is clinically positive if exercise-induced chest pain is
observed. In particular, typical angina that occurs at low exercise intensity (<5 METs) is characteristic for
CAD. ECG abnormalities provoked by myocardial ischaemia are frequently observed as ST segment changes
—depression and/or elevation. ST segment deviation, as compared to the isoelectric line, is measured
between 60 and 80 ms from the J point, which can increase with a growing exercise load. A standard
abnormal response during an EET, which indicates myocardial ischaemia, is de ned as either horizontal or
downward depression of the ST segment of 0.1 mV or more. Upsloping ST segment depressions observed at
e ort or during tachycardia may be seen in healthy individuals. However, if these changes have amplitudes

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of ≥0.2 mV and moreover are correlated with chest pain, the EET should be interpreted as positive for
myocardial ischaemia (Figures 8.17.3 and 8.17.4). The majority of EET machines calculate relatively novel
parameters which are an index of ST depression in relation to the heart rate. Results of uncertain value, but
not excluding myocardial ischaemia, are those in which ST segment depressions are horizontal or
downsloping with an amplitude of 0.05–0.1 mV or upsloping and 0.1–0.2 mV below the isoelectric line. In
some patients, the pretest ECG reveals ST segment depression or elevation. These ST segment changes can
become more profound or get normalized during an EET. Therefore, in selected patients, an EET has to be
interpreted in careful relation to the pretest ECG. Exercise-induced ST elevation is always important, and if
observed in leads with no Q wave, should be alarming as it is frequently related to critical proximal stenosis
of the coronary artery. The abovementioned ST segment abnormalities are suggestive of myocardial
ischaemia if observed in two parallel leads. In the majority of cases, exercise-induced abnormalities of the
ST segment disappear during the recovery phase. Interpretation of ST segment changes is not diagnostic if
patients have persistent left bundle branch block, pretesting signi cant ST segment depression (≥0.1 mV),
overt pre-excitation syndromes (with descending conduction via an accessory pathway), ventricular pacing,
or digitalis-induced ST abnormalities. Parameters of most diagnostic value for CAD are summarized in Box
8.17.1. If the EET gives both clinically and electrocardiographically positive results, the risk of
angiographically important coronary stenosis is signi cant (approximately 90%). The ETT is less predictive
for CAD if only one of these factors is positive. However, in some patients with a normal EET, in both clinical
and ECG aspects, coronary artery stenosis might be identi ed by coronary angiography. It should not be
forgotten that there are conditions which can mimic ST segment depression similar to that seen in CAD (Box
8.17.2). Additionally, some authors have pointed out that exercise-induced ventricular arrhythmia,
especially ventricular tachycardia (both non-sustained and sustained), is seen more frequently in patients
with CAD.
Box 8.17.1 ECG parameters of most diagnostic value for coronary artery disease

1. ST segment depression (horizontal or downsloping) of >2 mV

2. ST segment elevation

3. ST segment depression occurrence at low exercise level (<5 METs)

4. ST segment depression in ve or more leads

5. Prolonged ST segment depression late in recovery (>5 min)

6. ST segment depression/heart rate slope >2.4 mcV/bpm (>6 mcV/bpm—for multivessel coronary

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stenosis)

7. Average ST segment depression/heart index >1.6 mcV/bpm

Box 8.17.2 Non-coronary causes of ST segment depression

Aortic stenosis

Hypertension

Cardiomyopathies

Anaemia

Hypokalaemia

Hypoxia

Digitalis

Wol –Parkinson–White syndrome

Bundle branch block

Supraventricular tachycardia

Sudden excessive exercise in untrained patient

Figure 8.17.3

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Interpretation of ST segment changes.

Reproduced from Fletcher GF, Ades PA, Kligfield P, et al; American Heart Association Exercise, Cardiac Rehabilitation, and
Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on
Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a
scientific statement from the American Heart Association. Circulation. 2013 Aug 20;128(8):873–934. doi:
10.1161/CIR.0b013e31829b5b44 with permission from Wolters Kluwer.

Figure 8.17.4

Example ECG changes during a positive exercise treadmill test performed in a 64-year-old male (181 cm/81 kg). Maximal
workload 150 W (6.4 METs). Exercise duration 8.03 minutes. Maximal heart rate obtained 146 bpm (93% of age-predicted).
Maximum ST change: −3.25 mm. ST/HR index 4.17 mcV/bpm. Double product 25,200 mmHg/bpm. (1) Baseline; (2) maximal ST
change; (3) Peak e ort; (4) Recovery.
Chronotropic incompetence
Chronotropic incompetence is traditionally de ned as an inability to achieve at least 85% of the maximum
heart rate predicted for age and gender. Some authors use more sophisticated measures to evaluate cardiac
chronotropy, i.e. chronotropic response, chronotropic index, and chronotropic reserve. They suggest
diagnosing chronotropic incompetence if a patient reaches <80% of the normal chronotropic response. For
patients on beta-blockers, the cut-o value for chronotropic response is 62%. Another measure of heart
rate reaction for exercise is heart rate recovery de ned as the di erence between the heart rate at peak
e ort and the heart rate after 1 or 2 minutes of recovery. Normal values for heart rate recovery are a
reduction of 12 bpm or 18 bpm during the rst minute of upright cool-down recovery or when immediate
19
supine position is obtained, respectively.

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Patients who had cardiac implantable electronic devices implanted can complain of chronotropic
incompetence mainly due to underlying disease (sinus node dysfunction). An appropriate adjustment of
pacing parameters which should provide the exercise rate response can be assessed with the EET. Unusual
problems related to heart rate response for exercise can be observed in patients with cardiac dysautonomias.
20
In this population, exercise tolerance may be limited by excessive heart rate increase. Whether this
phenomenon is due to inappropriate sinus node function or sympathovagal imbalance is still a matter of
21
debate.

Exercise intolerance
Functional capacity is strongly related to age and gender and is therefore calculated individually with
respect to these parameters (Table 8.17.3). Exercise intolerance is de ned as inability to achieve age- and
gender-related functional capacity; however, the predictive value is below 85% of the relative exercise
22
capacity or workload. Important functional capacity impairment is historically deemed <5 METs for
23
women and <7 METs for men. Abnormal functional capacity is a strong predictor of unfavourable
cardiovascular prognosis, as well as all-cause death.

Exercise-induced arrhythmias
Physical e ort impacts on homeostatic mechanisms, the dysregulation of which may be proarrhythmic.
Among them, cardiac sympathovagal imbalance and ion changes, provoking shortening of ventricular and
atrial refractory periods, increasing conduction velocity, and incrementing amplitude of after-potentials,
24,25
are of utmost importance.

26
Exercise-induced atrial arrhythmias are seen in approximately 28% of patients undergoing an EET. In the
vast majority (>95%), atrial ectopy was recorded, followed by supraventricular tachycardia and AF or atrial
utter in approximately 3.5% and 1% of patients, respectively. Occurrence of atrial arrhythmias during the
EET did not a ect prognosis.

Ventricular arrhythmias observed during exercise testing are considered as an important risk factor for
unfavourable prognosis in patients with structural disease. Approximately 10% of patients referred for an
27
EET due to suspected CAD had exercise-induced ventricular tachycardia. Frequent ventricular premature
beats (VPBs) de ned as >7 VPBs/minute, as well as more complex arrhythmias (bi- and trigeminy, and
28
non-sustained ventricular tachycardias), were associated with more cardiovascular events. Sustained
ventricular tachycardia or ventricular brillation is rarely seen during exercise testing and is always
considered as alarming. Usually it is seen in patients with structural heart disease (i.e. after myocardial
infarction, ischaemic cardiomyopathy, or arrhythmogenic right ventricular cardiomyopathy). However, if
seen in a normal heart, it should raise suspicion of channelopathy (catecholaminergic polymorphic
cardiomyopathy, long QT syndrome). Exercise-induced sustained monomorphic ventricular tachycardia is a
risk factor in patients with structural heart disease or channelopathies, but not in some idiopathic
ventricular arrhythmic syndromes such as right/left out ow tract ventricular tachycardia or fascicular
25
tachycardia.

Exercise-induced hypotension or exaggerated hypertensive response

Systolic blood pressure normally increases with intensifying e ort. Therefore, a drop of systolic blood
pressure below pre-exercise values during an EET is deemed as exercise-induced hypotension. An abnormal
reaction is also observed if the increase in systolic blood pressure during an EET is lower than 44 mmHg in
the general population, lower than 30 mmHg in post-infarction patients, or lower than 20 mmHg in
individuals with hypertrophic cardiomyopathy. An excessive increase in systolic blood pressure is diagnosed

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if it reaches values higher than 210 mmHg in men or 190 mmHg in women. Diastolic blood pressure during
an EET remains unchanged or is slightly elevated (usually up to 90 mmHg).
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