Cardio Exercise stress test & Exercise contraindication/precaution

Question 1

BP response with exercise

Answer 1

SBP: Increase
DBP: may decrease/same
–>decrease peripheral vascular resistance due to vasodilation

Post exercise: BP decrease quickly & remain hypotensive for 12 hr post exercise

Arm exercise: higher SBP & DBP–>arm vasculature offer greater resistance to blood flow

Question 2

Exercise post MI

Answer 2

Stable condition first:
- No new/recurrent chest pain in past 8hr
- Creatine kinase and/or troponin levels are not rising
- No new signs of uncompensated heart failure
- No new significant abnormal rhythm on ECG

Phase 1 Inpatient:
Frequency:
early mobilisation 2-4x/day
D1: start SOOB

Intensity:
- RPE: BORG<13
- HR: <120 bpm/Resting HR+20 bpm

Time:
- Intermittent bouts: lasting 2-5 mins

Question 3

Phase 2 CR

Answer 3

*undergo a symptom-limited maximal exercise tolerance test
*Termination of exercise with ST depression
*HR guideline may not be applicable (e.g. B-blocker–>slow down heart rate)

Frequency:
▪ Aerobic : 3-5x/wk
▪ Resistance: 2-3x/wk

Intensity:
▪ Aerobic: 60-85% of HR max
▪ Resistance: Moderate

Time:
▪ Aerobic: 20-60 mins
▪ Resistance: 10-15 reps; 3 sets of 8-10 different exercises for both upper and lower body

Question 4

Resistance exercise Contraindication and types to avoid

Answer 4

Contraindication:
- symptomatic congestive heart failure
- uncontrolled hypertension
- severe valvular disease
- unstable symptoms

Types to avoid:
- no valsalva
- extensive upper body activity
- isometric/static exercises

Question 5

Contraindication to cardiopulmonary exercise

Answer 5

Heart related:
- Acute myocardial infarction
- Unstable angina
- Severe aortic stenosis
- Uncompensated CHF
- Active pericarditis, myocarditis, or endocarditis

Vessel related:
- Acute DVT
- Aortic aneurysm

Blood pressure related:
- Uncontrolled systemic hypertension
- Resting systolic BP (SBP) >200 mm Hg or resting diastolic BP (DBP) > 110 mm Hg that should be evaluated on a case by-case basis
- Orthostatic BP drop of >20 mm Hg with symptoms

ECG related:
* Resting ST-segment depression or elevation (>2mm)
* Third-degree atrioventricular (AV) block without pacemaker
* Uncontrolled atrial or ventricular dysrhythmias
* Uncontrolled sinus tachycardia (>120 beats per minute)

Systemic related:
* Acute systemic illness or fever
* Uncontrolled diabetes mellitus
* Recent embolism
* Thrombophlebitis
* Severe orthopaedic conditions that would prohibit exercises
* Other metabolic conditions

Neuro related:
- ICP > 20 mmHg

Question 6

Precautions to cardiopulmonary exercise

Answer 6

Heart related:
* Pulmonary hypertension
* Bradycardia/ Tachycardia
* Moderate valvular disease

Repiratory related:
* Unstable asthma

Systemic related:
* Diabetic patient with autonomic denervation of heart

Question 7

Contraindication to exercise testing

Answer 7

Heart-related:
* Recent complicated MI (unless the patient is stable and pain free)
* Unstable angina
* Acute CHF
* Severe aortic stenosis
* Active or suspected pericarditis or myocarditis

Vessel related:
* Suspecting or known dissecting aneurysm

ECG related:
- Third degree AV heart block without pacemaker
- recent significant change in the resting ECG suggesting infarct or other acute cardiac event

Systemic related:
* Acute infections
* Significant emotional distress
* Thrombophlebitis or intracardiac thrombi
* Recent systemic or pulmonary embolus

Question 8

Precautions to exercise testing

Answer 8

Heart-related:
* Resting diastolic BP > 115 or resting systolic BP > 200
* Moderate valvular heart disease
* Fixed-rate pacemaker (rarely used)

Vessel related:
* Ventricular aneurysm

ECG related:
* Frequent or complex ventricular ectopy

Systemic related:
* Known electrolyte abnormalities (hypokalemia, hypomagnesemia)
* Uncontrolled metabolic disease (e.g. DM)
* Chronic infectious disease (e.g. AIDS, hepatitis)
* Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
* Advanced or complicated pregnancy

Question 9

Absolute indications for terminating exercise testing

Answer 9

Symptoms:
* Moderately severe angina
* Increasing nervous system symptoms (e.g. ataxia, dizziness or near syncope)
* Subject’s desire to stop

Signs:
* A fall of SBP of > 10 mm Hg from baseline blood pressure despite an increase in workload when accompanied by other evidence of ischemia
* Signs of poor perfusion (cyanosis or pallor)

ECG Change:
* ST elevation (+1.0 mm) in leads without diagnostic Q-waves
* Sustained ventricular tachycardia
* Technical difficulties monitoring the ECG or systolic blood pressure

Question 10

Relative indications for terminating exercise testing

Answer 10

Symptoms:
* Fatigue, shortness of breath, wheezing, leg cramps, or claudication
* Increasing chest pain

Signs:
* A fall of SBP of > 10 mm Hg from baseline blood pressure despite an increase in workload in the absence of other evidence of ischemia
* Hypertensive response (SBP of > 250 mmHg and/or DBP of > 115 mmHg)

ECG Change:
* ST or QRS changes such as excessive ST depression (>2mm horizontal or down sloping ST-segment depression)
* Arrythmias other than sustained ventricular tachycardia
* Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia