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*CLINICAL EXERCISE PHYSIOLOGY > CH5- Graded Exercise Testing > Flashcards

CH5- Graded Exercise Testing Flashcards

1
Q

3 general uses of graded exercise testing (GXT)

A

-diagnostic
-prognostic
-therapeautic

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2
Q

diagnostic use of GXT

A

identify abnormal responses

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3
Q

prognostic use of GXT

A

identify future, given the presence of disease

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4
Q

therapeautic use of GXT

A

identify impact of intervention

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5
Q

which individuals need GXT prior to an exercise program

A

moderate + high risk
-low risk doesn’t need

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6
Q

who are considered low risk + therefore don’t need GXT prior to exercise program

A

individuals with fewer than 2 NET CV risk factors

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7
Q

who are moderate risk + need GXT prior to exercise program

A

individuals with 2 or more NET CV risk factors

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8
Q

who is high risk + therefore needs GXT prior to exercise program

A

individuals with 1 or more signs/symptoms of CV/pulmonary/metabolic disease
-net doesn’t matter for this one; if they have a diagnosis of disease they are automatically high risk

-ex: diabetic = automatically high risk due to having known metabolic disease
-another risk if having a known MI a year ago

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9
Q

can you still do GXT prior to exercise program for low risk individuals

A

yes, there are benefits but we don’t HAVE to

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10
Q

positive CV risk factors (diagram)

A

-age
-family history
-cigarette smoking
-physical inactivity
-obesity
-hypertension
-dyslipidemia
-diabetes

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11
Q

negative CV risk factors (diagram)

A

high density lipoprotein cholesterol (HDL-C)

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12
Q

how does the positive/negative CV risk factors diagram work

A

-any positive risk factor = +1
-negative risk factor = -1, cancels out positive
-we calculate the NET

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13
Q

CV risk factor diagram- age

A

-men greater or equal to 45 years
-women greater or equal to 55 years

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14
Q

CV risk factor diagram- family history

A

-MI
-coronary revascularization
-sudden death before 55 years in father or other male first-degree relative OR before 65 years in mother or female first-degree relative

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15
Q

CV risk factor diagram- cigarette smoking

A

-current cigarette smoker
-quit within the previous 6 months
-exposure to environmental tobacco smoke

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16
Q

CV risk factor diagram- physical inactivity

A

not participating in at least 30 min of moderate intensity on at least 3 days of the week for at least 3 months

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17
Q

CV risk factor diagram- obesity

A

-BMI greater or equal to 30
-waist girth greater than 102 cm (40 in) for men
-waist girth greater than 88 cm (35 in) for women

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18
Q

CV risk factor diagram- hypertension

A

-SBP greater or equal to 120 mmHg
-DBP greater or equal to 80 mmHg
(confirmed by measurements on at least 2 separate occasions)

-OR on antihypertensive medication

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19
Q

CV risk factor diagram- dyslipidemia

A

-LDL (low-density lipoprotein) cholesterol greater or equal to 130
-HDL (high-density lipoprotein) cholesterol less than 40

-OR on lipid-lowering medication

-if total serum cholesterol is all that is avilable, use greater or equal to 200

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20
Q

CV risk factor diagram- diabetes

A

-fasting plasma glucose greater or equal to 126
-2 hour plasma glucose levels in oral glucose tolerance test (OGTT) greater or equal to 200
-HbA greater or equal to 6.5%

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21
Q

CV NEGATIVE risk factor diagram- high-density lipoprotein cholesterol (HDL-C)

A

greater or equal to 60

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22
Q

types of GXTs

A

-stress ECG/EKG
-regular stress test
-cardiac stress test
-graded exercise test (GXT)
-sign + symptom-limited GXT (Sx-GXT)

KNOW that all these things essentially mean the same thing

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23
Q

elements for GXT

A

-appearance + quantification of symptoms
-test termination
-resting, exercise, + recovery ECG abnormalities
-assessment of functional capacity
-interpretation of findings + generation of final summary report

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24
Q

pre-test considerations for GXT

A

JUST AS IMPORTANT AS THE ACTUAL TEST

-testing personnel
-informed consent
-general interview + physical examinatin
-pretest likelihood for CHD
-prestest instructions + subject preparation for ECG
-selection of exercise protocol + modality

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25
Q

pre-test considerations- testing personnel

A

-in an ideal world, you would have 2 people conducting the test with 1 doing EKG/other data + the other doing the test
-physician won’t be present unless they are trying to push the limit with the patient
-what REALLY happens- only 1 technician managing EKG, protocol, changing equipment, measuring vitals, making sure patient is okay, etc.
-clinical ex physiologist, PT, RN, NP, PA can all do initial interpretation but not final
-regardless of who does the initial interpretation, the FINAL INTERPRETATION MUST BE DONE BY THE PHYSICIAN THAT ORDERED THE TEST

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26
Q

pre-test considerations- informed consent

A

-reason for tet
-test procedures
-explanation of risks, major + minor
-patient explains or verbalizes ALL of these back to test supervisor

-anyone who has gotten procedure/test has done this
-for legal purposes
-in extreme detail

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27
Q

what is the most important part of informed consent

A

explanation of risks
-every risk from most minor to most major should be listed, most major is typically death

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28
Q

pre-test considerations- general interview + examination

A

-refer back to ch4 for specifics
-must make sure no changes have occurred in the clinical status
-review medical record prior to testing
-determine indications vs contraindications

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29
Q

indications

A

reasons for Rx
-KNOW this
-if asked for ex of indication, she is asking why we are doing a test + the specific reason why the test was ordered

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30
Q

contraindications

A

reasons not to do a medical treatment

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31
Q

generally, how would the general interview/examination work in terms of GXT

A

ideally they would come in for first appointment to do general interview + examination so that you could have time to think about what protocol would be good for them
-SOMETIMES you must do this + GXT in the same appointment
-make sure medical records have not changed since previous appointment

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32
Q

pre-test considerations- indications

A

aka reasons for the test
-assess symptoms to assist in the diagnosis of coronary heart disease or other medical conditions
-identify a patient’s future risk or prognosis
-evaluate pacemaker, HR, or BP response to exertion
-evaluate for return-to-work guidelines + disability
-determine effectiveness of an intervention

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33
Q

indications- “assess symptoms to assist in the diagnosis of CHD or other medical conditions”

A

-one of the most common reasons why GXTs are done
-most GXTs are sign + symptom limited

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34
Q

indications- “identify a patient’s future risk or prognosis”

A

-where we identify future risk or prognosis
-this works because FUNCTIONAL CAPACITY is highly correlated to prognosis

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35
Q

functional capacity

A

how well someone performs on tests

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36
Q

functional capacity is highly correlated to ___

A

prognosis

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37
Q

indications- “evaluate for return-to-work guidelines + diability determination”

A

-if you have a job that is physically strenuous, the GXT will indicate how you will do back at work
-also helps confirm if people can apply for disability
-government uses GXTs to see if you truly have a disability

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38
Q

indications- “determine effectiveness of an intervention”

A

more of a therapeautic reason

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39
Q

pre-test considerations- absolute contraindications

A

-MI within prior 2 days or other acute cardiac event
-change in ECG suggesting MI or other acute event
-unstable angina
-symptomatic severe aortic stenosis
-uncontrolled symptomatic heart failure
-acute myocarditis or pericarditis
-acute infection

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40
Q

2 types of contraindications

A

-absolute
-relative

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41
Q

absolute contraindications

A

-black + white
-no room for interpretation
-if there are present you will absolutely not do exercise testing (absolute = NO exercise)
-doesn’t mean this can’t change + they will eventually be able (ex: infection can clear up)

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42
Q

aortic stenosis

A

when aortic valve narrows + blood cannot flow normally

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43
Q

acute myocarditis

A

condition causing inflammation of heart muscle (myocardium)

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44
Q

acute pericarditis

A

painful condition where fluid-filled pouch (pericardium) around heart is inflamed

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45
Q

relative contraindications

A

-the gray area
-specific to individual
-might have to delay testing but not always

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46
Q

pre-test considerations- relative contraindications

A

-left main coronary stenosis
-severe arterial hypertension at rest (SBP greater than 200 or DBP greater than 110)
-tachycardia at rest or marked bradycardia
-uncontrolled metabolic disease or electrolyte abnormality

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47
Q

left main coronary stenosis

A

serious condition when left main coronary artery narrows, causing reduction in blood flow to left ventricle of heart

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48
Q

relative contraindications- when might severe arterial hypertension at rest occur

A

if patient is incredibly nervous
-you could do things to calm them down but if it stays elevated, we cannot do the test

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49
Q

relative contraindications- high BP

A

pressure could be high because they forgot to take medication
-we would have them come back another day

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50
Q

pre-test considerations- subject preparation

A

-clothing + shoes
-continue medications? timing of medications?
-food + water
-substances to avoid
-skin preparation for ECG
-electrode placement

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51
Q

when does subject preparation occur

A

doesn’t just happen on day of test, happens on days leading up to it too
-ex: when you have surgery, you get directions for how to prep few days before surgery

-NEVER ASSUME THESE THINGS ARE COMMON SENSE, because they aren’t

52
Q

subject preparation- clothing + shoes

A

-comfortable workout wear
-appropriate shoes (no high heels, no sandals)

53
Q

subject preparation- medications

A

-continue medications? timing of medications?
-physician will be the one that determines this
-IF PHYSICIAN DOESN’T INCLUDE IN RX, YOU MUST CONTACT THEM TO MAKE SURE
-reason for test (diagnostic, prognostic, exercise program)

54
Q

subject preparation- food + water

A

-hydrate days leading up to the test
-avoid caffeine (stimulant so will affect BP + HR in response to exercise)
-small snack before test (ex: granola bar)

55
Q

subject preparation- substances to avoid

A

-ETOH (ethanol aka alcohol)
-cigarettes

56
Q

subject preparation- skin preparation for ECG

A

eliminate oils + hair, lotions, etc. (makes it difficult for electrodes to stay stuck to skin)

57
Q

subject preparation- electrode placement

A

-use standard lead placement OR alter site for pacer implant or ICD implant
-electrodes must be placed regardless of reason for test

-males- ask if they are okay shaving beforehand so we can put electrodes in those areas; hair will come off regardless when you take electrodes off

-DO NOT PUT ELECTRODES DIRECTLY OVER ANY TYPE OF IMPLANT

58
Q

pre-test considerations- select protocol

A

-steady state vs ramp? maximal vs submaximal?
-try to match work rate increments (in estimated METs) to patient capabilities (ex: walk a flight of stairs)
-test duration: 8-12 min
-use a common protocol
-use protocol appropriate for testing

59
Q

is steady state or ramp protocol more common

A

ramp

60
Q

submaximal vs maximal

A

submax is more on the safe side

61
Q

what protocol is #1

A

Bruce protocol
-most physicians know this one
-try to use this one because common in clinical setting + physician will better understand
-also easily modified- the standard values given by the protocol can be easily adjusted higher/lower based on patient needs

62
Q

what stage do we want patient to get to in protocol

A

stage 4-5ish
-if we only get to stage 2, you will probably never get a Rx from that physician again

63
Q

pre-test considerations- select mode

A

(treadmill, bike, arm ergometer, etc.)
-quantified, incremental, graded work
-athletes: specificity of testing + training
-occupational concerns
-accomodate patient needs (orthopedic, body habitus, gait + balance)

64
Q

body habitus

A

the shape of someone’s body

65
Q

2 commonly used protocols

A

-Balke
-Bruce

66
Q

which protocol is most common

A

Bruce protocol

67
Q

appearance + quantification of symptoms

A

-maintain regular communication between staff + patient
-rating of perceived exertion (RPE)
-use of handrails required?
-accomodate other common languages through translation

68
Q

appearance + quantification of symptoms- maintain regular communication between staff + patient

A

-use thumbs up/down
-these would be communicated BEFORE the test

69
Q

appearance + quantification of symptoms- RPE

A

RPE = rating of perceived exertion

70
Q

what is used to quantify RPE

A

Borg scale

71
Q

appearance + quantification of symptoms- use of handrails required?

A

ideally we don’t want patient to be reliant on the handrails
-if they rely on them more than not, make a note of this
-doesn’t mean it is fault in the test/us/patient BUT important to make note + let physician know

72
Q

Borg scale

A

MODIFIED Borg scale is more common due to numbers used
-0-10 is easier to use than 6-20

73
Q

numbers for Borg scale

A

6-20
-6 = light
-20 = hard

74
Q

numbers for modified Borg scale

A

0-10
-0 = rest
-10 = very,very hard

75
Q

what do we use RPE/Borg for

A

to see how well the person is doing throughout the test
-shows how suitable the protocol is for them

76
Q

MET level

A

a way to measure amount of energy the body uses during physical activity compared to resting

77
Q

2 types of test termination

A

-submaximal GXT
-symptom limited

78
Q

test termination- submaximal GXT

A

reaches a predetermined MET level

79
Q

test termination- symptom limited

A

terminated because of onset of symptoms

80
Q

most clinical GXT are submaximal or symptom limited

A

symptom limited
-the test is complete once the presence of a specific sign/symptom appears

81
Q

angina

A

chest pain or discomfort that occufrs when the heart muscle doesn’t receive enough oxygen-rich blood

82
Q

dyspnea

A

shortness of breath

83
Q

peripheral vascular disease

A

occurs when blood vessels narrow or become blocked, reducing blood flow to organs + limbs outside the heart + brain

84
Q

intermittent claudication

A

lower extremity skeletal muscle pain that occurs during exercise

85
Q

besides knowing when a symptom kicks in, what else is important

A

knowing their ability to do ADLs
-there are varying levels for angina/dyspnea, etc.

86
Q

angina scale

A

0- no symptom
1- light, barely noticable
2- moderate, bothersome
3- moderately severe, very uncomfortable
4- most severe or intense pain ever experienced

87
Q

dyspnea scale

A

0- no symptoms
1- mild, noticeable to patient but not observer
2- mild, some difficulty, noticeable to observer
3- moderate difficulty, but patient can continue
4- severe difficulty, patient cannot continue

88
Q

(not sure if you need to know) peripheral vascuar disease scale for assessment of intermittent claudication

A

0- no symptoms
1- definite discomfort or pain but only of initial or modest levels (established but minimal)
2- moderate discomfort or pain from which the patient’s attention can be diverted by a number of common stimuli (conversation, interesting TV show, etc.)
3- intense pain from which the patient’s attention cannot be diverted except by catastrophic events (fire, explosion, etc.)
3- excruciating + unbearable pain

89
Q

resting, exercise, + recovery ECG abnormalities- RESTING abnormalities

A

don’t need to know resting abnormalities
-KNOW that resting abnormalities listed here are things probably already identified in medical report + we are just confirming the presence of these

90
Q

resting, exercise, + recovery ECG abnormalities- abnormalities DURING the ECG

A

-ST-segment depression (presence of subendocardial ischemia)
-ST-segment elevation (stop test immediately)
-T-wave changes (concern when tied to ST-segment changes)
-arrhythmia

91
Q

abnormalities during the ECG- ST-segment depression

A

representative of myocardial ischemia
-physically the person would experience angina
-when patient says they are experiencing chest pain, you SHOULD be able to see ST-segment depression on ECG
-if you see on ECG but patient hasn’t reported, you know that angina is on the way

92
Q

myocardial ischemia

A

adequate oxygen isn’t reaching myocardia

93
Q

ST-segment depression indicates what

A

presence of subendocardial ischemia

94
Q

what to do if we see ST-segment elevation

A

stop test immediately

95
Q

when are T-wave changes a concern

A

when tied to ST-segment changes

96
Q

assessment of functional capacity

A

-exercise duration
-estimated METs
-VO2max

97
Q

what is functional capacity linked to

A

ability to do ADLs
-also linked to prognosis

98
Q

assessment of functional capacity- what might you need to define to the physician

A

METs
-also helpful to include normative data; take your patient + compare them to the norm

99
Q

how does VO2 max decline for healthy, inactive individual

A

5-10% per decade

100
Q

how does VO2 max decline for healthy, active individual

A

3-6% per decade

101
Q

interpretation of findings + generation of final summary report- 6 items to address

A

-angina status
-ECG findings (ischemia)
-ECG findings (arrhythmia)
-functional capacity
-HR response
-BP response

KNOW THAT THESE 6 ITEMS MUST BE SENT TO PHYSICIAN AS A MINIMUM EVERY SINGLE TIME!!!!!!
-even if the test had nothing to do with any of the 6 things, STILL MUST INCLUDE
-ex: if someone is being seen for pulmonary issues + not cardiac, they still may experience angina since it is associated with lack of oxygen to the heart

102
Q

interpretation- angina status

A

-typical angina, atypical/noncardiac angina, none
-time to onset, test limiting, time to resolution, therapies needed to help resolve

103
Q

what does TYPICAL angina look like

A

-when they begin to exert themselves, the angina begins
-when they stop + relax, the angina goes away

104
Q

ATYPICAL/NONCARDAIC angina

A

no rhyme or reason it when it onsets + stops

105
Q

test limiting

A

the symptom (ex: angina) made the patient say they couldn’t do the test any more

106
Q

interpretation- ECG findings ischemia

A

-ST segment depression for ischemia diagnosis
-time of onset, magnitude of change, + time to resolve

107
Q

for ischemia, what does magnitude of change refer to

A

the actual measured depression
-ECG will tell you this

108
Q

interpretation- ECG findings arrhythmia

A

-state findings
-time of onset, time to resolve
-important to note if it is an arrhythmia the person has all the time rather than an onset arrhythmia

109
Q

interpretation- functional capacity

A

-peak MET level + compare to normative data
-reason for stopped test

110
Q

interpretation- HR response

A

before, during, + after exercise

111
Q

interpretation- BP response

A

before, during, + after exercise

112
Q

if a patient cannot complete exercise or it is too high risk, what do we do

A

use chemicals to mimic the same reaction

113
Q

WHO decides if a patient is able to complete exercise or go drug route

A

the PHYSICIAN, NOT THE CEP

114
Q

what drugs are used to induce same effect as exercise

A

dobutamine
-increases HR + BP

115
Q

what does dobutamine do

A

increase HR + BP
-just like exercise does

116
Q

stress EKG with imaging is used for what

A

people who cannot complete exercise themselves

117
Q

2 types of stress EKG with imaging

A

-EKG with echocardiogram (stress echo)
-EKG with radionuclide imaging (nuclear stress test)

118
Q

EKG with echocardiogram (stress echo)

A

allows for assessment of wall motion abnormalities

119
Q

EKG with radionuclide imaging (nuclear stress test)

A

allows for assessment of distribution of blood flow
-uses radioactive tracer to see how blood flows through the heart

120
Q

who would administer the dobutamine

A

NURSE, not the CEP

121
Q

see slides 36 + 37 for images of echo vs nuclear stress test

A
122
Q

nuclear stress test provides which images

A

slices of the heart from different angles
-illumination of the radioactive tracer through the heart

123
Q

in an abnormal nuclear stress test, what could be indicated

A

plaque buildup could cause blockage
-an individual would need surgery to go + clear out the plaque

124
Q

biggest takeaway about GXT

A

do what is safest for the patient
-NEVER sacrifice this
-we want to find the balance of getting the best/safest effort of the patient to fulfill the needs of the physician

125
Q

GXT conclusion

A

-GXT is a useful + often the first diagnostic tool used to assess the presence of significant CAD with or without nuclear perfusion or echo imaging
-can be used for diagnosis but also PROGNOSIS + help design an exercise training program

*CLINICAL EXERCISE PHYSIOLOGY (5 decks)

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