CARDIOPULMONARY EXERCISE

TESTING(CPET) /EXERCISE
STRESS TESTING
Dr Arpita Panda
Associate Professor
ABSMARI
• It is a non invasive form of cardiovascular stress testing that uses
exercise with electrocardiography (ECG) and blood pressure
monitoring.
• This form of stress testing is usually performed with exercise
protocols using either a treadmill or bicycle.
• In addition, patients who are unable to exercise may benefit from the
administration of a pharmacologic agent that stimulates the heart's
activity, simulating exercise-induced changes.
• With treadmill stress testing, providers can determine:
- A patient's functional capacity
- Assess the probability and extent of coronary artery disease (CAD),
- Assess the risks, prognosis, and effects of therapy.
• The treadmill is the most widely used stress modality.
• The most commonly employed treadmill stress protocols are the
Bruce and modified Bruce.
• Upright bicycle exercise is preferable if dynamic first-pass imaging is
planned during exercise
EXERCISE PHYSIOLOGY
• Exercise is associated with sympathetic stimulation and changes in
the coronary vasomotor tone, which affects coronary blood flow.
• The coronaries dilate during exercise
• During exercise, the increase in myocardial oxygen demand and
coronary vasodilation allows for increased oxygen delivery which is
crucial to myocardial perfusion, thereby preventing ischemia. Through
this hyperemic effect, providers can identify ischemia, as stenotic
vessels do not vasodilate as well as normal vessels.
• Due to sympathetic stimulation and vagal inhibition, an increase in
stroke volume, heart rate, and cardiac output is noted.
• Alveolar ventilation and venous return also increase as a
consequence of selective vasoconstriction.
• The hemodynamic response depends on the amount of muscle mass
involved, exercise intensity, and overall conditioning.
• As exercise progresses, skeletal muscle blood flow increase and
peripheral resistance decrease leading to a rise in systolic blood
pressure (SBP), mean arterial pressure (MAP), and pulse
pressure. Diastolic blood pressure (DBP) may remain unchanged,
slightly increase, or slightly decrease.
• The age-predicted maximum heart rate is a useful measure for
estimating the adequacy of stress on the heart to induce ischemia.
• The goal is usually 85% of the age-predicted maximum heart rate,
calculated by subtracting the patient's age from 220.
METABOLIC EQUIVALENT(MET)
• One metabolic equivalent (MET) is defined as the amount of oxygen consumed while
sitting at rest
• It is equal to 3.5 ml O2 per kg body weight x min.
• The MET concept represents a simple, practical, and easily understood procedure for
expressing the energy cost of physical activities as a multiple of the resting metabolic
rate.
• The energy cost of an activity can be determined by dividing the relative oxygen cost of
the activity (ml O2/kg/min) x by 3.5.
• Also, the intensity levels (in METS) for selected exercise protocols are compared stage by
stage.
• In spite of its limitations, the MET concept provides a convenient method to describe the
functional capacity or exercise tolerance of an individual as determined from progressive
exercise testing and to define a repertoire of physical activities in which a person may
participate safely, without exceeding a prescribed intensity level.
VO2 MAX and FICK’S EQUATION
• This reflects the maximal ability of a person to take in, transport and
use oxygen.
• It defines that person’s functional aerobic capacity.
• VO2max has become the preferred laboratory measure of
cardiorespiratory fitness and is the most important measurement
during functional exercise testing.
• In healthy people, a VO2 plateau occurs at near maximal exercise.
• The Fick equation
• Understanding the Fick equation is of paramount importance for
appreciating the utility of functional exercise testing.
• At rest, the Fick equation states that oxygen uptake (VO2) equals cardiac
output times the arterial minus mixed venous oxygen content:
VO2 = (SV*HR) *(CaO2 - CvO2)
where SV is the stroke volume, HR is the heart rate, CaO2 is the arterial
oxygen content, and CvO2 is the mixed venous oxygen content.

• Oxygen uptake is often normalised for body weight and expressed in units
of ml O2/kg/min. One metabolic equivalent (MET) is the resting oxygen
uptake in a sitting position and equals 3.5 ml/kg/min.
• At maximal exercise, the Fick equation is expressed as follows:
VO2max = (SVmax * HRmax) * (CaO2max - CvO2max)
INDICATIONS
• Evaluating the patient with chest pain or dyspnea with other findings suggestive,
but not diagnostic of coronary artery disease (CAD)
• Risk stratification post-myocardial infarction
• Determining prognosis and severity of coronary artery disease
• Evaluating the effects of medical and surgical therapy
• Screening for latent coronary disease
• Evaluation of congestive heart failure
• Evaluation of arrhythmias
• Evaluation of functional capacity and formulation of an exercise prescription
• Evaluation of congenital heart disease
• Stimulus to a change in lifestyle
CONTRAINDICATIONS (ABSOLUTE)
• Very recent MI, < 3-4 days
• Unstable angina, not previously stabilized by medical therapy
• Severe symptomatic left ventricular dysfunction
• Life threatening dysrhythmias
• Severe aortic stenosis ( relative?)
• Acute pericarditis, myocarditis or endocarditis
• Acute aortic dissection
RELATIVE CONTRAINDICATIONS
• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities
• Severe arterial hypertension (SBP>200 mmHg or DBP>110 mmHg)
• Tachyarrhythmias or bradyarrhythmias
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Mental or physical impairment leading to inability to exercise adequately
• High-degree atrioventricular block
PREPARATIONS
• All persons conducting the treadmill stress test should be trained to
diagnose and manage complications should they arise.
• Emergency resuscitation equipment and drugs should also be readily
available.
• The patient should be explained about the procedure, and consent should
be obtained before the procedure.
• Patients should be instructed not to eat, drink, or smoke for at least three
hours before the examination, as this maximizes exercise capacity.
• The patient should bring comfortable exercise clothing and walking shoes
to the testing facility.
• The healthcare professional performing the test should explain the
benefits, risks, and possible complications to the patient before testing.
• Medications should be discussed with the patient beforehand, as
some drugs such as beta-blockers, calcium-channel blockers, digoxin,
and anti-arrhythmic medications can affect the maximal heart rate
achieved.
• An ischemic response can also be affected if patients are taking
nitrates.
• A thorough history and physical examination should be performed on
all patients before referral for exercise stress testing.
TECHNIQUE
• Treadmill stress testing is performed in a designated lab, supervised by a
trained healthcare provider.
• Electrodes are placed on the chest and attached to an ECG machine,
recording the heart's electrical activity.
• The resting ECG, heart rate, and blood pressure are obtained prior to
starting the exercise regimen.
• Once it is determined that there are no limiting factors based on baseline
ECG, the patient is placed on a treadmill with a designed protocol that
increases in intervals as they exercise.
• Blood pressure and heart rate are monitored throughout exercise, and the
patient is monitored for any developing symptoms such as chest pain,
shortness of breath, dizziness, or extreme fatigue.
Bruce protocol
• The Bruce protocol is the most common one used during treadmill
exercise stress testing.
• This protocol is divided into successive 3-minute stages, each
requiring the patient to walk faster and at a steeper grade.
• The testing protocol could be adjusted to a patient's tolerance, aiming
for 6 to 12 minutes of exercise duration.
The modified bruce protocol
• There is a modified Bruce protocol for those who cannot exercise
vigorously, adding two lower workload stages to the beginning of the
standard Bruce protocol, both of which require less effort than stage 1.
• There are a number of other protocols for patients with a limited
exercise tolerance; however, other methods that do not include
exercise are also available for such patients.
Modified bruce protocol
Balke’s protocol
• The Balke Treadmill Test was developed as a clinical test to determine
peak VO2 in cardiac patients, though it can also be used to estimate
cardiovascular fitness in athletes.
• The test involves walking on a treadmill to exhaustion, at a constant
walking speed while gradient/slope is increased every one or two
minutes.
• Target population: recommended for cardiac patients as the
elevation workload is moderate and even considered safe for patients
with severe LV dysfunction
• During the exercise test, data about heart rate, blood pressure, and
ECG changes should be obtained at the end of each stage.
• At any time, an abnormality is detected with cardiac monitoring.
• Heart rate and systolic blood pressure should rise with each stage of
exercise until a peak is achieved.
• Patients should be questioned about any symptoms they experience
during exercise.
• All patients should be monitored closely during recovery until heart
rate and ECG are back to baseline, as arrhythmias and ECG changes
can still develop.
Indications for early termination of exercise
stress testing
The American College of Cardiology (ACC)/American Heart Association
(AHA) guidelines have specified indications for the termination of
exercise testing. The following are the absolute indications for
termination of testing:
• A drop in systolic blood pressure of greater than 10 mmHg from
baseline when accompanied by other indications of ischemia.
• Moderate-to-severe angina
• Increasing neurologic symptoms, such as ataxia, dizziness, near-
syncope
• Signs of impaired perfusion, such as cyanosis or pallor
• Technical difficulties in monitoring ECG tracings or systolic blood
pressure
• Patient's desire to stop
• Sustained ventricular tachycardia
• ST-elevation of more than 1 mm in leads without diagnostic Q waves,
other than V or aVR
Relative indications
• A drop in systolic blood pressure of 10 mmHg or more from baseline in the
absence of other evidence of ischemia
• ST or QRS changes (excessive horizontal or downsloping ST depression of
more than 2 mm) or marked axis shift
• Arrhythmias, such as supraventricular tachycardia, multifocal premature
ventricular contractions (PVCs), heart block, or bradyarrhythmias
• Fatigue, shortness of breath, leg cramps, wheezing, or claudication
• Development of intraventricular conduction delay or bundle branch block
that cannot be differentiated from ventricular tachycardia
• Increasing chest pain
• Hypertensive response (systolic blood pressure of 250 mmHg, diastolic
blood pressure higher than 115 mmHg, or both)
Report
• At the conclusion of testing, a report should be included.
• This report should outline:
- The baseline ECG interpretation
- Baseline heart rate, and blood pressure
- ECG changes during exercise, including the presence of
arrhythmia/ectopy and the onset of such changes
- Maximal heart rate and blood pressure during exercise
- Estimated exercise capacity in metabolic equivalents of task (METs),
exercise duration and stage completed, symptoms experienced during
exercise and the reason for terminating the test.
Interpretation
• A normal test is when a patient's blood pressure and heart rate increase
appropriately to graded exercise.
• There should be no ECG changes suggestive of ischemia and no
arrhythmias during testing.
• Failure of the blood pressure to increase or decrease with signs of ischemia
has prognostic significance.
• Angina or significant ST depression (greater than 2 mm) before completing
stage 2 of the Bruce protocol and/or ST depressions that persist for more
than 5 minutes into recovery suggest severe ischemia and high risk for
coronary events.
• Exercise testing will either be positive, negative, equivocal, or
uninterpretable if there is a limiting factor such as heart rate.
BICYCLE ERGOMETRY
• Exercise on a cycle is less intense than on a treadmill due to the fact
that the cycle is actually weight bearing.
• Modern equipment is sophisticated and may accommodate the
resistance to the pedaling speed (resistance increases at lower speed,
and vice versa).
• The cycle ergometer is cheaper than the treadmill and it requires less
space in the laboratory.
• Measuring blood pressure is easier on cycle than on the treadmill.
• Importantly, the ECG is easier to record and there are fewer artefacts
on cycle as compared with treadmill.
• Exercise resistance is usually measured in Watts (W). It is conventional
to initiate exercise at 40 W for women and 50 W for men.
• Resistance is then increased with 15 W for females and 15–30 W for
males every other minute. Resistance can be increased faster for well-
trained subjects.
• The total duration of the exercise test should be 7 to 10 minutes.
• By then the patient should have reached the maximum capacity.
• METs may be calculated by dividing oxygen uptake per minute with
the product of 3.5 × bodyweight (kilograms)
Disadvantages
• A drawback of cycle ergometry is the dependency on the quadriceps
muscles, which usually limits exercise tolerance due to discomfort in
these muscles.
• Hence, the cycle runs the risk of terminating the test prematurely
before reaching the maximum oxygen uptake.
• This risk is greatest in persons not used to cycling; indeed, in those
persons the achieved oxygen uptake may be up to 20% lower than
the maximum oxygen uptake.
GOALS OF EXERCISE TESTING
• Improve long-term survival for patients after a cardiac
hospitalization (up to 50% long-term mortality reduction)
• Create exercise program to aid in:
• Increase exercise capacity à improved functional capacity
• Reduction of hospital admission
• Improve cardiac symptoms
• Improve psychological effects of disease burden on patient
• Stabilize or reverse progression of atherosclerosis
• Alter natural history of CAD
• Decrease risk of sudden death or reinfarction
PROTOCOLS USED IN EXERCISE TESTING
BRUCE PROTOCOL
• The Bruce Test is commonly used treadmill exercise stress test.
• It was developed as a clinical test to evaluate patients with suspected
coronary heart disease, though it can also be used to estimate
cardiovascular fitness.
• aim: to evaluate cardiac function and fitness.
• equipment required: treadmill, stopwatch, heart rate monitor
• procedure:
Exercise is performed on a treadmill. If required, the leads of the ECG
are placed on the chest wall. The treadmill is started at 2.74 km/hr (1.7 mph)
and at a gradient (or incline) of 10%. At three minute intervals the incline of
the treadmill increases by 2%, and the speed increases as shown in the table
Bruce Treadmill Test Stages

• Stage 1 = 1.7 mph at 10% Grade

• Stage 2 = 2.5 mph at 12% Grade
• Stage 3 = 3.4 mph at 14% Grade
• Stage 4 = 4.2 mph at 16% Grade
• Stage 5 = 5.0 mph at 18% Grade
• Stage 6 = 5.5 mph at 20% Grade
• Stage 7 = 6.0 mph at 22% Grade
• Stage 8 = 6.5 mph at 24% Grade
• Stage 9 = 7.0 mph at 26% Grade
The Bruce Protocol Formula for Estimating
VO2 Max
• For Men VO2 max = 14.8 - (1.379 x T) + (0.451 x T²) - (0.012 x T³)
• For Women VO2 max = 4.38 x T - 3.9T = Total time on the treadmill
measured as a fraction of a minute (ie: A test time of 9minutes 30
seconds would be written as T=9.5).
• Because this is a maximal exercise test, it should not be performed
without a physician’s approval and without reasonable safety
accommodations and supervision
Modified Bruce protocol
• It starts at a lower workload than the standard test, and is typically
used for elderly or sedentary patients.
• The fist two stages of the Modified Bruce Test are performed at a
1.7mph and 0% grade and 1.7 mph and 5% grade
• The third stage corresponds to the first stage of the Standard
Bruce Test protocol as listed above.
Modified bruce protocol
BALKE’S PROTOCOL
• The Balke Treadmill Test was developed as a clinical test to determine
peak VO2 in cardiac patients, though it can also be used to estimate
cardiovascular fitness in athletes.
• The test involves walking on a treadmill to exhaustion, at a constant
walking speed while gradient/slope is increased every one or two
minutes.
• Purpose : to determine peak VO2, particularly in cardiac patients.
• Equipment required: treadmill, stop-watch, electrocardiograph
(optional)
• Pre-test:
- Explain the test procedures to the subject.
- Perform screening of health risks and obtain informed consent.
- Prepare forms and record basic information such as age, height, body
weight, gender, test conditions.
- Measure out course and place marker cones.
- Perform an appropriate warm-up.
• Procedure :
- The athlete walks on a treadmill to exhaustion, at a constant walking speed
while gradient/slope is increased every one or two minutes.
- The assistant starts the stopwatch at the beginning of the test and stops it
when the subject is unable to continue.
- There are several modification or variation of the Balke test that are used,
with variations in the treadmill speed, time at each level and/or increase in
gradient.
❖For men the treadmill speed is set at 3.3 mph, with the gradient starting at
0%. After 1 minute it is raised to 2%, then 1% each minute thereafter.
❖For women the treadmill speed is set at 3.0 mph, with the gradient starting
at 0%, and increased by 2.5% every three minutes.
❖Walking speed constant at 3 km/hr whilst the grade was increased by 2.5
percent every two minutes.
Results :
- The test score is the time taken on the test, in minutes. Ideally this
should be between 9-15 minutes.
- The test time can also be converted to an estimated VO2max score
using the following formulas where the value "T" is the total time
completed (expressed in minutes and fractions of a minute e.g. 9
minutes 15 seconds = 9.25 minutes) (note: this is only applicable if
the same protocol is used as when these formula were developed) :
• for men: VO2max = 1.444 (T) + 14.99
• for women: VO2max = 1.38 (T) + 5.22
• Target population:
It is recommended for cardiac patients since the elevation in workload
is moderate and therefore considered safe even for patients with
severe LV dysfunction
NAUGHTON PROTOCOL
• The Naughton protocol is a sub-maximal exercise test designed to keep
the patient in a heart rate zone that is lower than the maximum heart rate.
• There are several stages, each one slightly more intense than the last. The
heart rate gradually increases throughout the test with an endpoint target
zone that is 80 to 90 percent of your maximum heart rate.
• More gradual increase in exertion with shorter stages
• Allows for diagnostic results in older & deconditioned patients
• 2 minutes per stage
• 7 stages (initial stage 1.0 MPH, Grade 0)
• The Naughton protocol is less intense than other testing procedures, such as
the more popular Bruce protocol. The test has a more gradual increase in
intensity and uses lower speeds. For this reason, the Naughton protocol is
used for diseased populations, those at high coronary risk.
Specifics
• The Naughton protocol starts with a 2 minute warm-up. The speed is set to 1
mph and the incline is set to 0. After the warm-up, the speed is set at 2 mph
and does not change for the remainder of the test. The test consists of six, 2
minute intervals. The grade starts at 0 for the first interval, and increases by
3.5 percent every 2 minutes.
• The Naughton protocol starts with a 2 minute warm-up.

• After the warm-up, the speed is set at 2 mph and does not change for the
remainder of the test.