Exercise Testing In

Cardiology
Absolute Contraindications
Acute myocardial infarction, within 2 days

High-risk unstable angina

Uncontrolled cardiac arrhythmia with

hemodynamic compromise

Active endocarditis

Symptomatic severe aortic stenosis

0-2 Low
2-4 Intermediate
5-7 High risk
Decompensated heart failure

Acute pulmonary embolism or pulmonary

infarction

Acute myocarditis or pericarditis

Physical disability that precludes safe and

adequate testing
Relative Contraindications
 Known left main coronary artery stenosis

 Moderate aortic stenosis with uncertain relation to

symptoms

 Tachyarrhythmias with uncontrolled ventricular rates

 Acquired complete heart block

 Hypertrophic cardiomyopathy with severe resting

gradient

 Mental impairment with limited ability to cooperate

Exercise Test Modality and
Protocols
 The testing modality and protocol should be
selected in accordance with the patient’s estimated
functional capacity based on age, estimated physical
fitness from the patient’s history, and underlying
disease

 Several exercise test protocols are available for both

treadmill and stationary cycle ergometers

 Patients who have low estimated fitness levels or

are deemed to be at higher risk because of underlying
disease (e.g., recent MI, heart failure) should be
tested with a less aggressive exercise protocol
Treadmill and cycle ergometers may use
stepped or continuous ramp protocols

Work rate increments (stages) during

stepped protocols can vary from 1 to 2.5
METs

Ramp protocols are designed with stages

that are no longer than 1 minute and for
the patient to attain peak effort within 8 to
12 minutes
TREADMILL
 Treadmill testing provides a more common form of
physiologic stress (i.e., walking) in which patients
are more likely to attain a higher oxygen uptake
and peak HR than during stationary cycling

 Cycling may be preferable when orthopedic or

other specific patient characteristics limit treadmill
testing or during exercise echocardiographic testing
to facilitate acquisition of images at peak exercise

 The most frequently used stepped treadmill

protocols are the Naughton, Bruce, and modified
Bruce
BRUCE SUBMAXIMAL
TREADMILL TEST
The test is administered in three-minute
stages until the client achieves 85% of his
or her age-predicted maximum heart
rate (MHR)

In a clinical setting, the test is typically

performed to maximal effort, to evaluate
both fitness and cardiac function

Given the degree of difficulty with this test,

it is generally not appropriate for
deconditioned individuals or the
 Pre-test procedure
 Measure pre-exercise HR, sitting and standing, and
record the values on a testing form or data sheet

 Estimate the submaximal target exercise HR

 Each of the stages is three minutes in length with a goal

to achieve steady-state HR (HRss) at each workload

 As long as HRss has been achieved, the speed and

incline will increase at the end of each three-minute
interval
Secure the blood pressure (BP) cuff on the client’s
arm (tape the cuff in place with medical tape to
avoid slippage)

Allow the client to walk on the treadmill to warm

up and get used to the apparatus (≤1.7 mph)

He or she should avoid holding the handrails. If

the client is too unstable without holding onto the
rails, consider using another testing modality

The results will not be accurate if the client must hold

on to the handrails the entire time
 Modified Bruce Protocol
The modified Bruce protocol employs 2 initial low
level 3-minutes stages at a speed of 1.7 mph and
grades 0 % and 5%, respectively, and then
continues into the full Bruce protocol
NAUGHTON PROTOCOL
The Naughton protocol is a sub-
maximal exercise test designed to
keep you in a heart rate zone that is
lower than your maximum heart rate

Your heart rate gradually increases

throughout the test with an endpoint target
zone that is 80 to 90 percent of your
maximum heart rate
NAUGHTON PROTOCOL
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
NAUGHTON PROTOCOL
 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
Patient Monitoring
During Exercise
Testing
During the Exercise Period
12-lead ECG during last minute of each
stage, or at least every 3 min

Blood pressure during last minute of each

stage, or at least every 3 min

Symptom rating scales as appropriate

for the test indication and lab protocol
During the Recovery Period
 Monitoring for a minimum of six minutes after exercise
in sitting or supine position, or until near baseline heart
rate, blood pressure, ECG and symptom measures are
reached

 A period of active cool-down may be included in the

recovery period, particularly following high levels of
exercise in order to minimize the post-exercise
hypotensive effects of venous pooling in the lower
extremities

 12-lead ECG every minute

Heart rate and blood pressure
immediately after exercise, then every one
or two minutes thereafter until near-
baseline measures are reached.

Symptomatic ratings every minute as long

as they persist after exercise

Patients should be observed until all

symptoms have resolved or returned to
baseline levels.
 BICYCLE ERGOMETER
The rate of workload progression is somewhat
arbitrary, although it has been suggested that
optimal exercise duration for func tional
assessment on the bicycle is between 8 and 17
minutes

Bicycle work is quantified in watts (W) or in

kilopod metres (kpm/min; 1 W = 6kpm/min)

The initial workload for patients with patients with

CHF is usually 20–25 W and increased by 15–25 W
every 2 minutes until maximal exertion is reached
 MODIFIED ASTRAND RHYMING
CYCLE ERGOMETER PROTOCOL
 Allow the subject to warm‐up on the cycle ergometer for 2 to 3 minutes with a
resistance of 0 kg and at a cadence of 50

 Following this, the subject pedals for 6 minutes at a workload chosen to try and elicit
a steady-state heart rate between 125 and 170 bpm

 As a guide, the initial workload for men is between 300-600 kp/m/min (unconditioned)
and 600-900 (conditioned)

 For women, 300-450 kp/m/min (unconditioned) and 450-600 (conditioned)

 Record heart rate every minute during the test

 If the heart rate at 5 and 6 minutes is not within 5 beats/min, continue for one extra
minute

 If the steady-state heart rate achieved is not between 125 and 170 bpm, adjust the
workload appropriately and continue for a second 6 minute period

 Otherwise, the test is completed

6-MINUTE WALK TEST
SIX-MINUTE WALK TEST
The 6-minute walk test can be used as a
surrogate measure of exercise capacity when
standard treadmill or cycle testing is not available

Distance walked is the primary outcome of the

test

It is not useful in the objective determination of

myocardial ischemia and is best used in a serial
manner to evaluate changes in exercise capacity
and the response to interventions that may affect
exercise capacity over time
Testing Site
 The Six Minute Walk Test Protocol should be performed
indoors, along a long, flat, straight, enclosed corridor with a
hard surface that is seldom traveled

 The walking course must be 30 m in length

 A 100-ft (30.4 m) hallway is required and its length should be

marked every 3 m

 The turnaround points should be marked with a cone (such as

an orange traffic cone)

 A starting line, which marks the beginning and end of each 60-
m lap, should be marked on the floor using brightly colored
tape
Measurements
Assemble all necessary equipment (lap
counter, timer, clipboard, worksheet) and
move to the starting point

Set the lap counter to zero and the timer to 6

min. Position the patient at the starting line

As soon as the patient starts to walk, start the

timer

Do not talk to anyone during the walk

 Use an even tone of voice when using the standard phrases
of encouragement

 Each time the patient returns to the starting line, click the
lap counter once (or mark the lap on the worksheet)

 At the end of 6 min, tell the patient to stop walking, and

measure the total distance traveled (meters)

 Heart rate, blood pressure and oxygen saturation should be

measured at rest and at the end of exercise as well

 The main outcome of this test is total distance

traveled
Functional Capacity
Functional capacity is a strong predictor of
mortality and nonfatal cardiovascular
outcomes in both men and women with and
without CAD

Even though exercise capacity is most

accurately measured by CPX, a reasonable
estimate can be obtained from treadmill
testing alone
 The best methods for estimating predicted METs are
the following simple regression equations

 Men : Predicted METs = 18 − (0 . 15 × Age)

 Women : Predicted METs = 14 . 7 − (0 . 13 ×

Age)

 The reported exercise time can be translated into

METs or METs based on the exercise test protocol

 The reported METs can then be expressed as a

percentage of the predicted METs
Functional capacity is often expressed in
terms of metabolic equivalents (METS),
where 1 MET is the resting or basal oxygen
consumption of a 40–year-old, 70-kg man

Functional capacity is classified as

Excellent (>10 METS)

Good (7 METs to 10 METS)
Moderate (4 METs to 6 METS)
Poor (<4 METS)
Peak Heart Rate
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 maximum age-predicted heart rate
(MPHR)
Men HRmax 208 – (0.7×Age)
Women HRmax 206 – (0.88 ×Age)
CAD with Beta HRmax 164 – (0.7×Age)
Blockers
Chronotropic Incompetence
The inability of the heart to increase its rate
to meet the demand placed on it is termed
chronotropic incompetence

It is considered an independent predictor

(including the well-established Duke
treadmill score) of cardiac or all-cause
mortality
An inadequate study is defined by failure to
achieve a predefined goal, such as 85% of MPHR

If a patient without known CAD has an inadequate

study, the term nondiagnostic study is often
applied

In the presence of any other diagnostic

endpoints, such as 2-mm or greater ST-segment
depression, exercise-induced hypotension, or
exercise-induced anginal chest pain, the heart
rate adequacy question becomes irrelevant
 CHRONOTROPIC INDEX
(HR Max – HR Rest)
× 100
(220 – Age – HR Rest)

• Failure to achieve a chronotropic index higher

than 80% defines the presence of chronotropic
incompetence

• In patients taking nontrivial doses of beta

blockers who are compliant with their
medication, a value lower than 62% is considered
chronotropic incompetence

• Criteria for assessing chronotropic incompetence

HEART RATE RESERVE
Maximum HR – Resting Heart Rate
Heart Rate Recovery
Abnormal heart rate recovery (HRR) has
been defined by many methods, but the
most commonly accepted include:

Less than 12 beats/min after 1 minute with

postexercise cool down

Less than 18 beats/min after 1 minute with

immediate cessation of movement into
either the supine or sitting position

Less than 22 beats/min after 2 minutes

Blood Pressure Responses
 Exercise BP responses, as with those for HR, reflect the
balance between sympathetic and parasympathetic
influences

 Systolic blood pressure

 Pulse pressure (difference between systolic and diastolic BP)
 HR-BP product (also called the double product), and
 Double-product reserve (change in double product from peak to
rest) all increase steadily as workload increases

 Diastolic BP increases only minimally or may fall

 In most normal individuals, systolic BP will increase to

higher than 140 mm Hg and the double product to higher
than 20,000
Hypertensive Systolic Pressure
Response
This response is usually defined as greater
than 210 mm Hg in men and greater than
190 mm Hg in women

Even though these exercise responses are

considered abnormal, they are not
generally reasons to terminate exercise

Such responses may be indicative of the

future development of hypertension or
adverse cardiac events
Exercise-Induced Systolic
Hypotension
 This has been variably defined but most frequently as
systolic pressure during exercise falling below
resting systolic pressure

 Another definition is a 20 mm Hg fall after an initial rise

 Either of these definitions would be an absolute reason to

terminate the exercise test

 The former definition is more predictive of a poor prognosis

and is usually related to severe multivessel CAD with LV
dysfunction, especially when noted with other signs of
ischemia, such as ST depression or angina at a low
workload
Pseudo–Exercise-Induced
Hypotension
 This response occurs in patients who are anxious
about the exercise study and begin exercise with a
somewhat elevated systolic pressure

 As exercise proceeds in the first stage, this elevated

BP usually settles down or “falls” toward its
customary resting level

 As exercise continues, continued observation reveals

a gradual upward trend in BP

 Considerable judgment needs to be used when

interpreting this response
Low Maximum Systolic
Pressure Peak
This is defined as a rise to less than 140
mm Hg or a lower than 10 mm Hg rise
overall

After excluding poor exercise effort, this

response is often associated with severe
CAD and worse cardiovascular outcomes in
persons with and without known CAD and
warrants further evaluation
ECG Changes
ST Depression
1 mm or greater or 0.1 mV or greater of
horizontal or downsloping ST-segment
depression in three consecutive beats
Sensitivity of 68% and specificity of 77%.
This assumes that the PQ point (not the TP
segment) is used as the isoelectric reference
and that the point of ST-segment measurement
is 60 to 80 milliseconds after the J point

The 60-millisecond post–J point criterion is used

at HR higher than 130 beats/min

This criterion should be added to and not

included with existing resting ST-segment
depression
 Unlike ST-segment elevation, exercise-induced ST-
segment depression does not localize
ischemia to a precise region or vascular bed

 The lateral precordial leads are the best for

defining positive responses. However, the inferior
leads can be helpful in assessing the extent of
ischemia when the lateral leads are abnormal as
well

 Isolated inferior ST depression is frequently

falsely abnormal because of the influence of atrial
repolarization in these leads
ST ELEVATION
 1 mm or greater or 0.1 mV of ST-segment elevation above the PQ
point at 60 milliseconds after the J point in three consecutive beats

 The J point may or may not be elevated as well

 Without pathologic Q waves, exercise-induced ST elevation usually

indicates either significant proximal coronary stenosis or epicardial
coronary spasm

 ST-segment elevation precisely localizes the transmural

ischemia to a particular vascular region

 In contrast, when pathologic Q waves are present, ST-segment

elevation is usually indicative of an LV aneurysm or significant wall
motion change. Ischemia may be involved in this process, and
myocardial perfusion imaging is generally required to determine this
 Indications for
Terminating the
Exercise Test
Absolute Indications
ST elevation (>1.0 mm) in leads without Q
waves due to prior MI (other than aVR, aVL, or
V1)

Drop in systolic BP of >10 mm Hg, despite

an increase in workload, when accompanied by
any other evidence of ischemia

Moderate to severe angina

Central nervous system symptoms (e.g.,

ataxia, dizziness, or near syncope)
Signs of poor perfusion (cyanosis or pallor)

Sustained ventricular tachycardia or other

arrhythmia that interferes with normal
maintenance of cardiac output during
exercise

Technical difficulties monitoring the ECG or

systolic BP

Patient’s request to stop

Relative Indications
Marked ST displacement (horizontal or
downsloping of >2 mm) in a patient with
suspected ischemia

Drop in systolic BP of >10 mm Hg (persistently

below baseline) despite an increase in workload, in
the absence of other evidence of ischemia

Increasing chest pain

Fatigue, shortness of breath, wheezing, leg

cramps, or claudication
Arrhythmias other than sustained ventricular
tachycardia, including multifocal ectopy,
ventricular triplets, supraventricular tachycardia,
atrioventricular heart block, or bradyarrhythmias

Exaggerated hypertensive response (systolic

blood pressure >250 mm Hg and/or diastolic blood
pressure >115 mm Hg)

Development of bundle branch block that

cannot be distinguished from ventricular
tachycardia
Pharmacologic
Influences on
Interpretation
Digitalis Glycosides
 That digitalis can have an adverse effect on ST-segment
interpretation is generally common knowledge

 The principal issue has been false-positive results

and reduced specificity

 The absence of ST-segment change at rest does not

eliminate the effect occurring during exercise

 Sensitivity is not affected by digitalis

 Therefore, a negative ST-segment response with digitalis

is still reliable
Beta Adrenoreceptor
Blockers
Beta blockers clearly reduce the rate-
pressure product in most patients receiving
adequate doses

Evidence indicates that the diagnostic

sensitivity and NPV of exercise testing are
adversely affected

For those without established CAD who are

undergoing a diagnostic-level exercise ECG,
beta blockers should ideally be withheld to
allow an adequate HR response
Men HRmax 208 – (0.7×Age)
Women HRmax 206 – (0.88 ×Age)
CAD with Beta HRmax 164 – (0.7×Age)
Blockers
Prognostic Value
The strongest predictor of prognosis
derived from the exercise test is
functional capacity

A weaker predictor is ST-segment

depression

All other variables, such as the HR

achieved, HRR, BP response, ventricular
arrhythmias, and exercise-induced angina,
fall between these two extremes
DUKE’S TREADMILL
SCORE
 The Duke Treadmill Score (DTS) is a weighted index
combining treadmill exercise time using standard
Bruce protocol, maximum net ST segment deviation
(depression or elevation), and exercise-induced
angina
DTS = Exercise time (minutes) - (5 x ST
deviation in mm) - (4 x angina index)

Risk Score Angina Index

High < -11 0 No Angina
Intermed -11 to +5 1 Angina
iate 2 Angina leading to stoppage
Low > +5 of test
Physiologic Principles of
Exercise Echocardiography
 During exercise, increases in myocardial oxygen demand results
in augmented systolic function with increased myocardial
thickening

 With a hemodynamically significant coronary stenosis, the

relative disparity in oxygen delivery to the distal coronary bed
cannot meet increases in myocardial oxygen demand

 Transient hypoperfusion results in mechanical dysfunction of

affected myocardium

 Stress echocardiography is well suited to assess this ischemic

response by visualizing global and regional myocardial motion,
allowing for localization of coronary lesions, given that coronary
artery anatomy and myocardial distribution are relatively similar
among patients
Myocardial ischemia generally progresses in a
defined sequence of events, termed
the ischemic cascade

Ischemia is initiated by regional hypoperfusion of

a distal coronary bed

After resultant metabolic changes within affected

myocardium, alterations in function occur; initially
with abnormalities in myocardial relaxation
(diastolic dysfunction), and subsequently with
systolic dysfunction of affected segments
 Only in the later stages of ischemia are characteristic
ECG changes, such as ST segment depression, and
frank angina manifest

 However, because endocardial myocardial oxygen

demand is higher, only moderate ischemia is needed
to produce visually identifiable contractile dysfunction

 With exercise ECG testing, ischemia diagnosis occurs

with onset of angina or ECG changes, occurring in the
later stages of the ischemic cascade , contributing to
acknowledged limitations in diagnostic accuracy for
exercise ECG testing
In contrast, stress testing with integrated
cardiac imaging identifies ischemia earlier,
at onset of regional hypoperfusion (nuclear
perfusion stress) or with systolic
dysfunction (echocardiography)

With stressor cessation and restoration of

adequate coronary flow, induced
abnormalities typically recover rapidly, but
may persist if ischemia is severe
 In the absence of a physiologically significant coronary
narrowing, the myocardial response to stress is
augmented systolic function with increased
inward hyperdynamic motion

 In the presence of ischemia, myocardial responses include the

following:

 Hypokinesis, myocardial thickening with inward motion less

than 5 mm or relatively less than the rest of the myocardium

 Akinesis, absence of thickening or inward motion

 Dyskinesis, thinned myocardium with paradoxical outward

systolic motion, a passive myocardial response to increased
intraventricular pressure
 Upper
Right: Apical
four-chamber
view during
rest

Upper Left:
Apical four-
chamber view
after exercise
stress

Lower
Right: Apical
four-chamber
view during
rest

Lower Left:
At rest, LV chamber size is normal. After exercise, there is Apical four-
hyperdynamic function of all segments with a decrease in chamber
chamber view
size after exercise
stress
The patient exercised 7
minutes and 30 seconds on
a standard Bruce protocol
and developed angina at
peak stress

Top: Apical two-chamber

view atrest during systole

Middle: After exercise, there

is thinning and hypokinesis
of the entire apex and distal
inferior wall in the apical
two-chamber view (arrows)

Bottom: On the apical four-

chamber stress view, there
is thinning and dyskinesis of
the entire apex and distal
inferoseptum (arrows). All
other segments became
hyperdynamic.
Exercise Testing
in Non-
Atherosclerotic
Heart diseases
Aortic Stenosis
Patients with symptoms provoked by exercise
testing should be considered symptomatic, even
if the clinical history is equivocal

Exercise-induced angina, excessive dyspnea

early in exercise, dizziness, and syncope are
consistent with symptoms of AS

However, exercise testing is avoided in

symptomatic patients with AS because of a high
risk of complications, including syncope,
ventricular tachycardia, and death
 Hypertrophic
Cardiomyopathy
 LVOT gradients can be dynamic, and maneuvers
performed during a resting TTE to provoke an LVOT
gradient (such as Valsalva) can be variable because of
inconsistencies in instruction and patient effort

 Stress echocardiography, representing the most

physiologic form of provocation, can be most helpful for
those patients where the presence or severity of LVOTO is
uncertain after the baseline echocardiogram

 LV outflow gradients in the postprandial state are

higher than when fasting and treatment with beta-
blockers often reduces the severity of exercise-induced
LVOTO
Although there are few data comparing
treadmill and bicycle ergometry, both
are acceptable when performed in
experienced laboratories

Exercise testing is only useful in older

children, typically >7 to 8 years of age,
because young children are often unable to
cooperate with exercise testing
Mitral Stenosis
Mitral Regurgitation